&?> .•»3 7#? ■'***• '/&£• Mr>- ^■tte m. ~^ v.'i S?#': lij -*c.v -:Jfc 'S&Cff iD'OOu Qr;p ipriDD^) LffliOO O^-OfM JP # Surgeon General's Office \ No! >^ / D/?C^a"dcC e^QOO 3Q*?QOQiCTaO< •>, i i-i' ' V I IM. THE INSTITUTES AND PRACTICE OF SURGERY: BEING THE OITTLIHBS OF BY WILLIAM GIBSON, M. D. PBOFISSOR OP SUBGEBY IN THE UNIVERSITY OP PENNSYLVANIA, SURGEON AN CLINICAL LECTUBEB TO THE PHILADELPHIA HOSPITAL--BLOCEXEY. Segnius irritant animos demissa per aurem, Quam quae sunt oculis subjecta fidelibus.—Ilor. \ ------------ FIFTH EDITION, ENLARGED. VOL.. I. PHILADELPHIA: CAREY, LEA & BLANCHARD. 1838. ViO 183S v.l Eastern District of Pennsylvania, to wit: BE IT REMEMBERED, that, on the twentieth day of January, in the forty- eight year of the Independence of the United. States of America, A. D. 1824, William, Gibson M. D., of the said district, hath deposited in this office the title of a book, the right whereof he claims as Author, in the words follow- ing, to wit:— "The Institutes and Practice of Surgery: being the Outlines of a course of Lec- tures, by William Gibson, M. D., Professor of Surgery in the University of Pennsylvania, Surgeon and Clinical Lecturer to the Aims-House Infirmary, &c. Segnius irritant animos demissa per aurem, Quam quae sunt oculis subjecta fidelibus.—Hor." In conformity to the Act of the Congress of the United States, entitled, "An Act fo'r the Encouragement of Learning, by securing the Copies of Maps, Charts, and Books, to the Authors and Proprietors of such Copies, during the times therein mentioned"—And also to the Act, entitled, "An Act supplemen- tary to an Act, entitled, * An Act for the Encouragement of Learning, by se- curing the Copies of Maps, Charts, and Books, to the Authors and Proprietors of such Copies, during the times therein mentioned,' and extending the bene- fits thereof to the arts of designing, engraving, atid etching Historical and other Prints." D. CALDWELL, Clerk of the Eastern District of Pennsylvania. GRIGGS & CO., PBINTEBS. \ > TO HIS PUPILS, THIS TEXT BOOK IS INSCRIBED, AFFECTIONATELY, BY THE AUTHOR. ♦ I) PREFACE TO FIRST EDITION. Unaccustomed, in my Lectures, to follow the exact arrangement of any systematic writer, my pupils have felt the want of a text book, and at different times have expressed a wish that I should compose one for their use. Long ago I ventured to give them a pledge so to do : a variety of engagements, however, prevented me from commencing the task until a few months past; since then severe and protracted indisposition has ren- dered the undertaking very oppressive, and so far pre- vented the execution of my design as to oblige me to offer, at present, a part only of the work. But this, I hope, as far as it goes, will answer the purpose for which it is expressly intended, and serve as a guide to those who now and may hereafter honour our school with their presence, whilst it will tend to revive the recol- lections of former pupils. As expressed in the title, the work must be considered a mere outline of the Lectures, which will be filled up by numerous illustrations, derived chiefly from an ex- tensive collection of models, morbid preparations, mag- VI PREFACE. nified drawings, and imitations of disease on the dead subject. The last two modes of instruction I consider peculiarly my own. Be this as it may, I have long been convinced of the importance, in addition to descrip- tion, of exhibiting as much as possible to the eye—being well aware that what is merely told is soon effaced from the memory, whilst an impression received through the sight is comparatively indelible. Upon this principle, my system of teaching is chiefly founded, and to a pro- per comprehension of it the present work will, I be- lieve, greatly contribute. Having enjoyed, whilst abroad, ample opportunities of collecting the best ancient and modern surgical writings, and possessing free access to the extensive and valuable library of the Aims-House Infirmary, I have seldom ventured to cite an authority or recommend a publication, without having minutely examined its contents. The reference,, therefore, given at the end of almost every section, may be relied upon, as containing the most precise, and accurate information on the va- rious topics embraced within the work. This, to the student, I hope will prove valuable, especially as great care has been taken to exclude from the reference every publication of equivocal merit. As an exception to these remarks, it gives me pleasure to acknowledge the assistance I have derived, in many instances, from the " Surgical Dictionary " of Mr. Samuel Cooper, a book replete, particularly the sixth, or last English, edition, with every variety of surgical information. This I have seldom referred to, intending to commend it in ge- PREFACE. Vii neral terms in this place. For the same reason, I have not invited particular attention to the " Elements of Surgery" by the late lamented and distinguished Pro- fessor Dorsey; a work which cannot be too highly ap- preciated, and which should be possessed by every American practitioner. For the fidelity of the sketches accompanying the present volume I can with confidence vouch, some of them having been executed by myself, and others by the masterly pencil of Mr. Sulley. I should prove un- grateful, did I not acknowledge the solicitude displayed by the engravers—Messrs. Tiebout, Kneass, Yeager, and Childs—that their work should equal the spirit and accuracy of the original drawings. I do not presume to offer these " Outlines " to expe- rienced members of the profession. They are designed exclusively for those young friends in whose concerns I take a lively interest, and from whom I have received so many tokens of kindness and respect. February 1st, 1824. / / PREFACE TO SECOND EDITION. A second edition of the Institutes and Practice of Surgery being called for, and in a much shorter time than, under particular circumstances, could have been expected, is a convincing proof of the importance which my pupils have attached to the work. In every point of view, indeed, I have reason to congratulate myself for having engaged in the undertaking, especially, as I have found from experience, that during the short and limited term of a four months' course of lectures, it was impossible, in noticing every surgical disease, to give a full account of each. This difficulty has been obviated in a measure, inasmuch as I have been enabled to do ample justice to the most important diseases, by refer- ring the class, in some instances, for an account of the comparatively unimportant ones, to the text book. By this it is not intended to imply that any department of the course is neglected, but merely to give assurance of particular attention being paid to the pathology and Vol. I B X PREFACE. treatment of such diseases as are of frequent occurrence, and intricate in their nature. The praises which have been bestowed on the work by European and American critics, though far beyond, in many instances, any merit I should be entitled to claim, have so far proved grateful as to encourage me to add such matter to the present edition as I have thought would be most likely to meet approbation, and increase the usefulness of the work—which is still de- voted to the particular service of the numerous and re- spectable pupils who attend our ancient and flourish- ing school. Nov. 1st, 1827. PREFACE TO THIRD EDITION. This book has been pronounced by hypercritics, " a book on the practice of medicine." A greater com- pliment could not have been paid to it; yet it argues very narrow views on the part of those who strive to af" fix limits to sciences which " blend, soften, and unite " in every possible way. True, it has been customary, in Europe, for sake of professional convenience and subdi- vision of labour, to separate the practice of surgery from that of medicine; but the result has never proved satis- factory to practitioners, and rarely, if ever, to patients. In some countries the mass of business is in the hands of surgeons and apothecaries, who prescribe for all com- mon complaints, while the mere physician is consulted in extraordinary cases, and is content, with his " otium cum dignitate." In this country, on the contrary, the physician is invested with the management of all com- mon medical and surgical cases, and, in general, is Xii PREFACE. willing enough, where the cases are simple, and the re- sponsibility'inconsiderable, to officiate to any extent— but equally prompt to avoid the more difficult cases, or such as require delicate or important operations. By individuals, thus situated, attempts have-been made to confine the duties of the surgeon to intricate and capital operations, and reserve for themselves the whole practice of physic and medical surgery. Fortunately, however, such projects have hitherto failed, and the good sense of the community has established the point —that a good surgeonmust be of necessity a good phy- sician, (though a good physician need not always be a good operator,) and that a mere " cutter" is the most humble of all professional creatures. Yet I am often told by pupils—that they delight in operative sur- gery, that it is the most interesting of all the branches, that it belongs to the exact sciences, that they mean to devote themselves exclusively to this department. Let them, I entreat, pause and hear the declaration of the most eminent surgeon and physician this country has ever seen—that " the whole operative surgery of one of our largest towns would barely be sufficient to support a single individual.'' Then they will be able to appreciate the motives of some insinuating medical politician,* * Strangers resort to this city in great numbers, and often from very remote places, with a view of putting themselves under care of some practitioner of their own choosing. They are told, however, not unfrequently, that the physician they seek is indisposed or out of town, and advised to consult Dr.----, who is, perhaps, a relation of the tavern keeper, and represented as very eminent, quite as much, if not more so, than the one they desire. The trick has often been played successfully, but latterly has so frequently failed, that there is every rea- son to believe it will soon be abandoned—especially, as the patients, when they PREFACE Xlll when he says "Dr.----is always out of town, is too independent to want business, is frequently indisposed, and cannot go out at night, does not practise medicine, but only operative surgery,"—then they will set the pro- per value on a text book, which embraces not merely the operative department, but the whole range of pathologi- cal and medical surgery—then they will be prepared to exclaim, Medicine and surgery are indissolubly inter- twined, and a book on surgery ought to be, to a certain extent, " a book on the practice of medicine." K The style of this work has been objected to—as not sufficiently diffuse ; but, on the contrary, condensed be- yond reasonable conciseness. That I have studied to retrench superfluities, both in expression and matter, I freely acknowledge, and so far plead guilty to the charge. Amplification, however, has not been con- sidered, I believe, cither by ancient or modern scholars, as peculiarly adapted to works of science, and-1 only fear that if subjected to rigid scrutiny by such critics, I should be condemned upon the score of diffuseness; for " to say much in a few words is certainly a great ex- cellence, and at the same time a great difficulty in com- position." Medio tutissimus ibis, would, perhaps, be a safe motto for most medical writers; for without imita- find it out, are very apt to change their quarters, and inform their friends of the imposition. By similar manoeuvres, patients are often kidnapped at towns a hun- dred miles off. For the honour of the profession, however, it is to be hoped that the charge so often made of a per-centage being allowed by the doctor for the "run of a hotel" is, in a great measure, untrue. I am very sure that nine- tenths of the physicians and surgeons of this city would scorn such an action; and I know instances where certain respectable hotel keepers have refused to cater upon any terms, for doctors mean enough to make them such offers. XIV PREFACE., ting the", prolixity of Cicero, or the brevity of Sallusf or of the ancient king, who said to his soldiers on the eve of battle, " I am your general—'you are French- men—there are the enemy:" it should be sufficient to avoid, on the one hand, all lengthened periods, and on the other, the simple affirmative or negative, of the " plain-dealing truth-loving quaker." Though mainly designed as a pioneer to the lectures in the university, this work will be found useful to stu- dents whilst attending clinical surgery in our Aims- House Infirmary. In proof of this, I may remark, that formerly the custom prevailed, (and still prevails in* other similar institutions in this country and Europe) among the surgeons and physicians of that establish- ment, of perambulating the wards, and making to the pupils who followed them desultory remarks upon, such cases as seemed most worthy of notice. Sensi- ble of the little benefit,derived by pupils from such a plan, and of the many inconveniences, and even in- juries, sustained by patients, from being sometimes jostled and even trodden upon inadvertently or un- avoidably, I resolved, when appointed, many years ago, to the Infirmary, to change the system entirely, and to institute a regular system of clinical instruction in sur- gery. Accordingly, I began by collecting, from the different wards, the most interesting cases, which, were then placed in one or more rooms, and after- wards individually presented to the class—previous- ly assembled in the operative theatre. A regular lecture was then delivered on some particular surgical PREFACE. XV subject, (as aneurism, hernia, cataract,) which the cases were calculated to illustrate in every possible way. My colleagues in the medical department soon perceived the advantage this system possessed oyer the one in common use, and determined to adopt it. For many years past, it has been pursued by all of us, and with immense advantage to the large class of students who every winter attend the clinical lectures, and with- out detriment to the numerous patients with which this great hospital is filled. To guard against injury, or in- convenience, to which the patient might be sometimes subjected, particular care is taken to select such cases only as may be transported on a bed, or otherwise, to the lecture room, and without danger of being exposed to inordinate'heat, or cold, or shocks, or movements, calculated to give pain, or interfere, in any way, with the treatment. The additions to the present edition, though not very considerable, will be found important, I trust, and apposite. If I have apparently overlooked, however, in some instances, the claims of surgeons whose general merits are aknbwledged by the profession, the omission must be imputed not to illiberality, or inadvertence, but to the difficulty of introducing into an elementary work of this description, matter which properly belongs to a comprehensive system of surgery. Nov. 1st, 1831. PREFACE TO FOURTH EDITION. To render a text book particularly useful, it is neces- sary to keep pace with improvements, or to record, from time to time, new, or important, facts and observations. I have endeavoured, therefore, to make this edition as complete as possible, by adapting it to the present con- dition of surgery, and to supply the deficiencies of for- mer editions by adding chapters and sections on sub- jects not hitherto treated of. With the same view I have added certain essays published by myself, at dif- ferent periods, (in the Philadelphia Journal of Medical Sciences, a work of great repute and extensively cir- culated, but not always accessible to students,) to which I have often occasion to refer in the lectures. These consist, chiefly, of observations on fractures of the thigh, exostosis, osteo-sarcoma, luxated shoulder, and bron- chocele. On diseases of the rectum and testicle, li- thotrity, diseases of the nerves, Caesarian operation, fis- sure of the palate, &c, new sections will be found; be- Vol. I. C Xvhi PREFACE. sides numerous other details not hitherto introduced into the work. I have thought it necessary, moreover, to alter the arrangement of the work—by transposing parts of the second volume to the first, and by changing, entirely, the order of subjects in the second volume. This has been done for the purpose of making the surgical course in the University, correspond with the anatomical lec- tures, so that the account of surgical diseases may fol- low, immediately, the anatomy of the parts. Upon the whole, I am persuaded—that the work, deficient, as it still may be, in some respects, will be found enhanced in value, and that the present edition cannot fail to prove acceptable to the student. Philadelphia, June 1st, 1835. CONTENTS OF VOLUME I. CHAPTER I. INFLAMMATION........Page 17 Treatment of Inflammation......20 Sect. 1. Suppurative Inflammation...... 23 Treatment of Suppurative Inflammation 25 2. Ulcerative Inflammation...... 26 Treatment of Ulcerative Inflammation - - - 26 3. Mortification........ 27 Treatment of Mortification .....28 4. Chronic Mortification....... 31 Treatment of Chronic Mortification ... - 32 5. Dry Mortification....... 34 Treatment of Dry Mortification.....37 CHAPTER II. VARIETIES OF INFLAMMATION .... - 39 Sect. 1. Erysipelas.........39 Treatment of Erysipelas ------ 40 2. Furunculus or Bile --------43 Treatment of Furunculus..... 43 3. Anthrax or Carbuncle.....- - .44 Treatment of Anthrax...... 44 4. Pernio or Chilblain........46 Treatment of Pernio...... 46 5. Frost-bite.........48 Treatment of Frost-bite...... 48 6. Burns..........50 Treatment of Burns...... 5* CHAPTER III. WOUNDS.......... M Sect. 1. Incised Wounds ------- Treatment of Incised Wounds..... 55 2. Punctured Wounds.......60 Treatment of Punctured Wounds - 61 3. Penetrating Wounds.......62 Treatment of Penetrating Wounds - 62 XX CONTENTS. Sect. 4. Contused Wounds.......Page 64 Treatment of Contused Wounds.....64 5. Lacerated Wounds -...... 66 Treatment of Lacerated Wounds.....67 6. Poisoned Wounds.....-- 70 Treatment of Poisoned Wounds ----- 81 7. Gun-shot Wounds....... 90 Treatment of Gun-shot Wounds.....93 8. Wounds of the Head and Face..... 98 Treatment of Wounds of the Head and Face - - - 102 9. Wounds of the Neck.......106 Treatment of Wounds of the Neck ... - 107 10. Wounds of the Chest....... 109 Treatment of Wounds of the Chest - 112 11. Wounds of the Abdomen...... 115 Treatment of Wounds of the Abdomen ... ng 12. Wounds of the Joints...... 122 Treatment of Wounds of the Joints ... - 124 CHAPTER IV. ABSCESSES.......... 128 Sect. 1. Abscess of Antrum Maxillare.....128 Treatment of Abscess of Antrum Maxillare - - 129 2. Mammary Abscess - - - - - - . 131 Treatment of Mammary Abscess - 132 3. Hepatic Abscess - ... 134 Treatment of Hepatic Abscess .... 13Q 4. Lumbar Abscess........j3g Treatment of Lumbar Abscess .... J39 5. Femoral Abscess -.......141 Treatment of Femoral Abscess - 142 6. Paronychia or Whitlow.......143 Treatment of Paronychia..... I44 CHAPTER V. ULCERS..........- 146 Seot. 1. Simple Ulcer......._ 140 Treatment of Simple Ulcer.....149 2. Irritable Ulcer...... 1P.n 150 Treatment of Irritable Ulcer.....151 3. Indolent Ulcer...... lco m " 15«J Treatment of Indolent Ulcer.....154 CHAPTER VI. SPECIFIC DISEASES........ 158 Sect. 1. Scrofula...... ,-0 _ .....158 Treatment of Scrofula...... 1R1 CONTENTS. XXI Sect. 2. Cancer .... Treatment of Cancer 3. Cancer of the Eye Treatment of Cancer of the Eye 4. Cancer of the Lip Treatment of Cancer of the Lip 5. Cancer of the Tongue . Treatment of Cancer of the Tongue 6. Cancer of the Breast . Treatment of Cancer of the Breast 7. Cancer of the Uteru3 . Treatment of Cancer of the Uterus 8. Cancer of the Rectum . Treatment of Cancer of the Rectum 9. Cancer of the Penis Treatment of Cancer of the Penis 10. Cancer of the Testicle Treatment of Cancer of the Testicle 11. Fungus Hsematodes Treatment of Fungus Hsematodes 12. Gonorrhoea .... Treatment of Gonorrhoea 13. Syphilis .... Treatment of Syphilis . CHAPTER VII. FRACTURES ..... Treatment of Fractures Sect. 1. Fracture of the Nose, &c. Treatment of Fracture of the Nose 2. Fracture of the Lower Jaw Treatment of Fracture of the Lower Jaw 3. Fracture of the Vertebrae Treatment of Fracture of the Vertebra? 4. Fracture of the Ribs Treatment of Fracture of the Ribs 5. Fracture of the Sternum Treatment of Fracture of the Sternum 6. Fracture of the Clavicle Treatment of Fracture of the Clavicle 7. Fracture of the Scapula Treatment of Fracture of the Scapula 8. Fracture of the Arm . Treatment of Fracture of the Arm 9. Fracture of the Fore-arm Treatment of Fracture of the Fore-arm 10. Fracture of the Hand and Fingers Treatment of Fracture of the Hand and Fingers xxii CONTENTS. Sect. 11. Fracture of the Pelvis . Page 270 Treatment of Fracture of the Pelvis . 271 12. Fracture of the Patella 272 Treatment of Fracture of the Patella . 273 13. Fracture of the Thigh 275 Treatment of Fracture of the Thigh 278 14. Fracture of the Leg and Foot 302 Treatment of Fracture of the Leg arW Foot 303 15. Compound Fracture .... 306 Treatment of Compound Fracture 307 16. Pseudo-Arthrosis, or Unnatural Joint 309 Treatment of Unnatural Joint . 309 CHAPTER VIII. LUXATIONS...... 313 Treatment of Luxations 314 Sect. 1. Luxation of the Lower Jaw 317 Treatment of Luxation of the Lower Jaw 318 2. Luxation of the Clavicle, Ribs and Vertebrae . 319 Treatment of Luxation of the Clavicle, Ribs, and Vertebrae 320 3. Luxation of the Arm .... 321 Treatment of Luxation of the Arm 323 4. Luxation of the Fore-Arm 354 Treatment of Luxation of the Fore-Arm 356 5. Luxation of the Hand .... 357 Treatment of Luxation of the Hand 358 6. Luxation of the Thigh and Pelvis 360 Treatment of Luxation of the Thigh and Pelvis 361 7. Luxation of the Knee and Ankle 368 Treatment of Luxation of the Knee and Ankle . 370 CHAPTER IX. DISEASES OF THE BONES AND JOINTS 372 Sect. 1. Caries . ... 372 Treatment of Caries 373 2. Gibbositas, or Caries of the Spine . 375 Treatment of Caries of the Spine 376 3. Necrosis ...... 379 Treatment of Necrosis 380 4. Exostosis ...... 382 Treatment of Exostosis 395 5. Spina Ventosa ..... 405 Treatment of Spina Ventosa 406 6. Osteo-Sarcoma ..... 407 Treatment of Osteo-Sarcoma 411 7. Mollities Ossium ..... 436 Treatment of Mollities Ossium 436 CONTENTS. xxiii Sect. 8. Fragilitas Oesium Treatment of Fragilitas Ossium 9. Rachitis or Rickets Treatment of Rachitis . 10. Coxalgia, or Hip Disease Treatment of Coxalgia . 11. Fungus Articuli, or White Swelling Treatment of White Swelling . 12. Hydarthrus, or Dropsy of a Joint Treatment of Hydarthrus 13. Moveable Cartilage Treatment of Moveable Cartilage 14. Anchylosis Treatment of Anchylosis 15. Deformity of Joints Treatment of 16. Hydro-Rachitis, or Spina Bifida Treatment of Spina Bifida Page 438 438 439 440 441 442 447 449 451 452 453 454 457 458 461 462 464 466 EXPLANATION 05 Plate XVIII. A. A. A. A. The tumour opened to display its structure. B. Extensor communis. C. Tibialis anticus. D. Peroneus longus thrown from its natural situation. E. The tibia. F. The fibula. G. The tendons of the peronei muscles. H. The skin turned back. I. The upper tumour covered by a thick membrane. Plate XIX. Represents the same preparation dried. A. The upper end of the fibula. B. B. B. The bony interstices, and reticulated structure of the tumour. DIRECTIONS TO BINDER, FOR VOLUME FIRST. Plate I. opposite . , . . . Page 56 II.......... 96 III.......... 97 IV..........169 V.......... 171 VI..........198 VII. ,........ 199 VIII..........205 IX. ........ . 244 X. . . ,......254 XI..........255 XII..........294 XIII..........301 XIV..........304 XV.......... 350 XVI..........351 XVII...........406 XVIII..........416 XIX..........417 Explanation of Plate 18th, to accompany the Plate. (See Page xxiv. Vol. I.) >» THE INSTITUTES AND PRACTICE OF SURGERY. CHAPTER I. INFLAMMATION. The words inflammatio, phlegmon, and phlogosis, have been employed indiscriminately to denote that disease, in which there is unusual redness, heat, swelling and pain. By most writers inflammation has been divided into acute, chronic, healthy, and unhealthy; though not, perhaps, with much propriety. Two distinct stages of the disease have also been pointed out. In the first stage there is coldness, languor, nausea, pain in the head, a small quick pulse, and a parched tongue. In the second stage the skin is hot, the pulse full and hard, the thirst considerable, and the part afTected becomes swelled and painful. Every inflammation, however, is not accompanied by constitutional symptoms. There are eight terminations of inflammation—resolution, adhesion, effusion, suppuration, ulceration, granulation, cicatri- zation, and mortification. These terminations constitute a se- ries of stages, extremely interesting to the surgeon. The heal of inflamed parts is apparently very considerable; but it was satisfactorily ascertained by Mr. Hunter, that it ne- ver rises above the natural heat of the animal, or that at the source of circulation. An increase of heat, both in healthy and in inflamed parts, probably depends chiefly upon an increased velocity in the circulation of the blood. The heat generally continues so long as the part remains dry, and is speedily di- minished upon the appearance of perspiration. Vol. I. 3 18 Inflammation. In most inflammations the redness is diffused among the sur- rounding parts, but in inflammation of a specific kind, it often stops with an abrupt edge. The redness, in some instances, has a dark hue, in others a bright scarlet. An increase of redness must always depend upon an inordinate determination of blood to the vessels of the part. The red capillaries are first enlarged, and the blood is thence, oftentimes, transmitted to the serous ves- sels. These changes have been happily illustrated by some very interesting experiments of Mr. Hunter. The swelling is for the most part confined to the cellular tex- ture, and is commonly greatest where the inflammation com- mences. At first it is owing to an inordinate quantity of blood determined to the part; its continuance, however, must depend either upon an effusion of serum, or upon an exudation of coa- gulable lymph into the cellular texture. The pain is acute or otherwise, according to the texture of the part affected. Some organs in their natural state are, com- paratively, insensible, but when inflamed exquisitely painful. In some inflammations, instead of pain, there is a pruritus or itch- ing. In others, the pain is pulsatile. Again, in particular spe- cies of inflammation, a burning sensation is produced. The pain, in every instance, perhaps, depends upon the nerves of the part being compressed by the surrounding swelling. The causes of inflammation may act either chemically or me- chanically. Among the former, cold is supposed to exert a greater power than any other agent. Its first effect is to debi- litate the extreme vessels, and to diminish the sensibility of the part to which it is applied. Cold may operate directly, or in- directly. In the former case, the part may be irrecoverably destroyed, provided the temperature be sufficiently reduced ; in the latter, various degrees of inflammation may arise. How the indirect application of cold is productive of inflammation is a question which has never been satisfactorily solved. Cold, when combined with moisture, more readily excites inflamma- tion than when deprived of it. Heat may also be said to produce inflammation by its chemi- " cal power, and is a frequent cause of the disease. Like cold, it may act directly or indirectly. In the one case, topical inflam- mation is generally the consequence; in the other, various dis- orders of the constitution. Atmospheric air, noxious gases, Inflammation. 19 acids, alkalies, blisters, rubefacients, animal poisons, contagious and specific diseases, may likewise be enumerated among the chemical causes of inflammation. The mechanical causes of inflammation are contusions, lace- rations, punctures, fractures, luxations, long-continued pressure, and innumerable other agents.* Every part of the body, with few exceptions, is liable to in- flammation ; but some parts are more prone to it than others. In general, it may be stated, that the greater the natural sensibility of a part, the more susceptible it is of the inflammatory process. The Serous membranes are particularly subject to inflamma- tion. The danger, in such cases, is often great, and the pain severe. In many instances, adhesions form from the effusion of coagulable lymph, and the functions of particular organs are disturbed or destroyed;—at other times, a salutary purpose is answered, as, without such agglutination, certain diseases could never be cured. The Mucous membranes, also, take on inflammation very readily; but the effects are very different from those of the ad- hesive inflammation. In general, the fluids secreted by mu- cous membranes, are changed in colour and consistence, accord- ing to the degree of inflammation existing in the part. The Cellular membrane, especially the skin, is very suscep- tible of inflammation, which may be either of the adhesive or suppurative kind. Inflammation is not easily induced in the Synovial and Fi- brous membranes; when once established, however, the pain is often excessively severe, and the consequences very serious. The Bones are subject to inflammation, and very tedious dis- eases frequently result; but Cartilage, owing to its supposed want of vascularity, can hardly be said to suffer from inflamma- tory action, The Arteries, Veins, and Absorbents, are all, more or less, ex- posed to inflammation. The former are capable of resisting the process to a great degree, while the latter readily yield, and may give rise to various diseases of an alarming nature. * Those who are anxious to investigate the proximate cause of inflammation, as it has been improperly denominated, may consult Wilson on Febrile Diseases, Hunter on Inflammation,.and Thomson on Inflammation. 20 Inflammation. Treatment of Inflammation. In every inflammation, the first object of the surgeon should be to procure resolution; and this may often be accomplished by removing the exciting causes of the disease. Two classes of remedies may be resorted to—constitutional and local. Among the former, are blood-letting, purgatives, diaphoretics, and low diet. Among the latter, topical blood-letting, blisters, and various ex- ternal applications. General blood-letting need only be employed where the in- flammation is high and attended with disturbance of the system. The quantity to be drawn will depend upon the violence of the disease and the constitution of the patient. Much will depend, also, upon the part in which the disease is seated. Vital parts suffer more readily than others, from depression being induced; but all vital parts are not equally liable to suffer. A good ge- neral rule to observe in all inflammations of the vital organs, is to repeat blood-letting frequently, and to draw only a small portion at a time. In this way depression will be obviated. With respect to the continuance or omission of blood-letting, the pulse will, generally, be found a good guide. If it be full and hard and frequent, and rise after the operation, a repetition may, perhaps, be necessary. There are particular states of the pulse which may lead into error—especially the oppressed pulse.* The existence, or absence, of the huffy-coat will, in many instances, direct us to continue or lay aside blood-letting. Its presence, however, is not always a sure indication of in- flammatory action; and, on the other hand, very severe inflam- mations, occasionally occur, without any appearance of the buf- fy-coat. Perhaps the most certain indication of the presence of inflammation is the continuance of pain; and so long as this remains severe, we can scarcely go wrong in the detraction of blood. Purgatives and diaphoretics, are very useful auxiliaries to the lancet. The best remedies of the kind are such as produce nausea. The warm bath will, in particular cases, be found ex- * See Rush's Works, Inflammation. 21 tremely serviceable. But, in using it, strict attention should be paid to the degree of temperature. In certain cases opium may be advantageously employed, especially after the full effect of evacuations has been obtained. It should be given, however, with caution. As a general remedy, low diet, or strict attention to regimen, is, unquestionably, of great importance, in the treatment of all inflammatory diseases; and we have every reason to believe, that by attention to this remedy alone, many formidable dis- eases have been cured, after resisting all other modes of treat- ment. For the introduction of this practice into the United States, and for a just estimate of its value, the profession is much indebted to the late Dr. Kuhn and to Dr. Physick. Among the local remedies for inflammation, topical blood- letting holds the first rank. It may be performed by Scarifi- cation, Cupping, or Leeches. The first is employed only in certain cases; the second is, generally, applied to parts loose and yielding, and not very sensitive; while the third is adapted to almost every external inflammation, and often proves of im- mense value. The number of leeches must be proportioned to the size of the animals, to the quantity of blood necessary to be drawn, and to the part affected. Unpleasant effects, sometimes, arise from the bite of a leech. Blisters are very efficacious in most inflammatory diseases. They should sometimes be applied directly over the part, and sometimes in its vicinity. When small, and frequently re- newed, they generally produce better effects, than when large, and applied at long intervals. Sinapisms and Issues are both, occasionally, used in the reduction of inflammation, and will frequently be found useful. Cold applications, such as the acetate of lead dissolved in water, cold water itself, ice water, a solution of muriate of am- monia in spirit and vinegar, the water of acetated litharge, and other similar medicines, kept to the inflamed part by linen rags, and changed as often as they become warm, will prove emi- nently beneficial. Cold may often be employed, also, as a con- stitutional remedy, in inflammatory diseases; but great caution should be observed that it be not too suddenly applied, or to an immoderate degree.* Strange as it may appear, in certain con- * See Cume's Medical Reports. 22 Inflammation. slitutions, and in inflammations of particular parts, cold applica- tions do mischief, and the disease is only benefited by fomenta- tions and warm poultices. Whenever such effects are found to follow, the cold should be discontinued instantly, and warmth substituted in its place. Rest and Position are of immense consequence in the treat- ment of inflammation. How often do we see a very trivial ac- cident, for want of attention to these important points, con- verted into a troublesome and dangerous disease. Whilst an inflamed or injured part is kept still, the restorative process goes on without interruption; when the part is in motion, re- production takes place very slowly, owing to irritation, and in many instances is never accomplished. Positio?i, by diverting the blood, and keeping the vessels of the inflamed part compa- ratively empty, may be employed, in almost every situation, and in the extremities especially, (which should, always, under these circumstances, be elevated,) will prove of inestimable value. Consult Hunter on Inflammation, 4to edit. 1794—Burns' Dissertations on In- flammation—Thomson's Lectures on Inflammation—Wilson on Febrile Diseases —Philips1 Experimental Inquiry into the Laws of the Vital Functions—James' Observations on some of the General Principles and on the particular Nature and Treatment of the different Species of Inflammation—Parry's Experimental In- quiry into the Nature of the Jlrterial Pulse—Broussais' Hist, des Phlegmasies ou Inflammations Chroniques—The Principles of Surgery, by John Burns, vol. I. London, 1831. Suppuration. 23 Section I. Suppurative Inflammation. When inflammation does not subside spontaneously, or by the use of the remedies pointed out, other symptoms, in a great- er or less time, take place. The redness assumes a brighter hue, the swelling increases, becomes more pointed and softer, the pain is materially augmented, and the patient distressed by the pulsation or throbbing. Besides these local symptoms, constitutional ones soon make their appearance. Rigor or shivering, is a very common oc- currence, even when the inflammation is slight. It seldom oc- curs at regular periods, and is sometimes, in severe inflamma- tions too, hardly to be observed for many hours or days. Ri- gors often exist for a considerable time previous to the esta- blishment of suppuration. Their presence is almost a sure in- dication that pus is about to be formed. When once it is formed, other changes take place; the pain and redness diminish, the swelling fluctuates, especially at its apex, and a cavity or ab- scess is created, which encloses the matter. Purulent matter, however, is frequently formed on surfaces, and in situations, where it is not confined by an abscess. It was formerly sup- posed that pus could not be created except through the medium of the ulcerative process. But this opinion was proved to be erroneous by Dr. Hunter. Many believe that pus may be formed, in certain cases, without preceding inflammation. For various reasons such an opinion should be discountenanced. Pus, when healthy, is of a light yellow or cream colour. It is made up of small globules, which float in a watery fluid, and has a strong tendency to putrefaction, especially when mixed with extraneous matter. Pus possesses neither alkaline nor acid properties. Unhealthy pus has received different appel- lations, expressive of the particular changes it has undergone. Ichor is a thin and exceedingly acrid discharge. Sanies is a very fetid ichor mixed with the red globules of blood. Sordes is of a leaden colour, very offensive, thick and apparently coa- gulated. Malignant matter is generated in pestilential dis- 24 Suppuration. eases, has a peculiar smell, but does not communicate specific disease. Contagious matter has the power of contaminating parts to which it is applied, and of always producing a disease of the same character. Many attempts have been made to distinguish Pus from Mu- cus, and from other animal matter, without a satisfactory re- sult,—owing to the vague and uncertain operation of chemical agents, when applied to the investigation of disease and of the products of the living body. Disputes have also arisen, re- specting the formation of pus; some supposing it to be the re- sult of a putrefactive process; others that it proceeds from the dissolution of the inflamed part; and others, again, that it is produced by a secretory action. The last opinion, which there is reason to believe was originally suggested by Dr. Simpson of Scotland, seems the most probable. The first detailed ac- count of the doctrine was given by the late Dr. Morgan of this city, in his inaugural thesis, published at Edinburgh, in 1763. Mr. Hunter, also, contends that pus is a secretion, and has fur- nished many strong arguments in support of his opinion. Hectic fever may accompany any inflammation, but is com- monly met with during the suppurative stage. It commences with nausea and a slight chill, which are succeeded by flushes of heat and an increase of pulse. A sweat then breaks out, conti- nues several hours, and is particularly troublesome during the night. After hectic has lasted some time, other symptoms make their appearance, such as a circumscribed red spot on each cheek, and a burning, tingling sensation in the palms of the hands and soles of the feet. The pulse becomes very weak and quick, and the urine high-coloured and full of sediment. To these symptoms succeed flatulence, indigestion and diarrhoea. An opinion formerly prevailed, that hectic always arose from the absorption of purulent matter. Mr. Hunter has put this question to rest, and proved, by a number of well-attested facts, that the fever often exists independently of the suppurative pro- cess, and accompanies many diseases very opposite in their na- ture. Suppuration. 25 Treatment of Suppurative Inflammation. As soon as it is ascertained that inflammation must termi- nate in suppuration, the remedies employed for its reduction should be abandoned at once, and those*substituted which pro- mote the purulent secretion. For this purpose, general means, as well as local, may be employed. The former are seldom ne- cessary, unless the patient has been much enfeebled by evacu- ations. In that case, we substitute a better regimen, and em- ploy tonic medicines, mineral acids and opium. As local applications, fomentations and warm poultices are indispensable. Poultices are more useful than fomentations, as they retain their heat longer, and are more easily applied and renewed. The heat of a poultice should somewhat exceed that of the inflamed part. After the discharge of the matter, the poultice should still be continued for some time. Frequently an unnecessary and profuse discharge is kept up; and in that case mild dressings must supersede the use of the poultice. Hectic cannot, always, be removed radically. When it pro- ceeds from some local disease, curable by an operation or by other means, the fever will speedily terminate after the disease has ceased. When the hectic cause is such as not to admit of removal, the surgeon can do no more than alleviate the urgent symptoms. The proper medicines are bark, wine, opium, di- gitalis, and the acids. Animal food is injurious; but vegetables, if not highly seasoned, prove very useful. Dr. Brocklesby* has commended the free use of Seltzer water, to relieve the symptoms of hectic. See Home on the Properties of Pus, in Observations on Ulcers, p. 13, edit. 2d. 1801—Hunter on Inflammation, p. 371—415, 496—G. Pearson's Observations and Experiments on Pus, in the Philosophical Transactions, 1811—Darwin's Experiments, establishing a Criterion between Mucilaginous and Purulent Mat- ter, 1780—Thomson on Inflammation, p. 308—312—323. * Medical Observations and Inquiries, vol. iv. p. 7. Vol. I, 4 26 [Iteration. Section 11. Ulcerative Inflammation. It has been well remarked by Mr. Hunter, " that whenever any solid part of our bodies undergoes a diminution, or is broken in upon in consequence of any disease, it is the absorb- ing system which does it."* The term ulcerative absorption was, therefore, invented by that great pathologist to express that morbid process by which the continuity of the different textures of the body is destroyed. By the ancients it was denominated erosion. Every texture of the body is, perhaps, liable to ulceration, but the skin and mucous membranes suffer more readily than other parts. This may be exemplified by the extensive erup- tions and blotches, which not unfrequently cover the greater part of the body, and by the sores which follow inflammation of the stomach, intestines, oesophagus, Schneiderian membrane, urethra and vagina. The synovial membranes often suffer from ulceration, but it is seldom that the disease originates in muscles, fasciae, blood vessels, or nerves. The hones very readily take on the ulcerative absorption, and sometimes are rendered by it extensively carious, or else are entirely de- stroyed. More or less pain is always a concomitant of the ul- cerative process. It is, generally, lancinating; though this will depend much upon the texture in which the disease is seated. The worst species of ulcerations result from specific inflamma- tion. Previous inflammation is essential to the existence of the ulcerative process, and this inflammation is generally of the simple kind, or that which Mr. Hunter has called the adhesive. In many instances, however, it follows suppuration and gan- grene. The treatment necessary in the ulcerative inflammation, must depend upon a variety of circumstances—such as the con- stitutional or local origin of the disease, its specific nature, its duration, &c; all of which will be considered under the head of Ulcers. See Hunter on Inflammation, p. 439—Thomson on Inflammation, p. 349. • page 442. Mortification. 27 Section III. Mortification. Gangrene and sphacelus have been employed by some writers to express the same disease—by others, to comprehend different stages of it. Gangrene, as the term is now generally used, is intended to denote that condition of a part which immediately precedes its destruction. By the word sphacelus, the complete death of a part is understood. The general term mortification 1 shall retain, to designate both stages of the complaint. When an inflamed part, instead of terminating by adhesion, suppuration, or by some of the other modes formerly pointed out, loses its sensibility, heat and colour, its vitality is extinguished, and mortification ensues. These changes seldom take place suddenly; but are generally preceded by an increase of pain, of a pungent burning kind. The swelling also is increased, the blood still circulates in the larger vessels, the skin becomes soft and of a dark red or purple colour, and vesicles containing a thin serum, are formed beneath the cuticle. Along with these local symptoms, there is constitutional dis- turbance. The pulse is quick and tremulous, and of the ty- phoid character. The tongue is dry and of a brownish tinge, the skin very hot, and the patient restless and uneasy. Delirium, subsultus tendinum, nausea and hiccup frequently supervene. The part soon becomes cold and insensible, and sphacelus is com- pletely established. If a vital part has suffered, the patient of- ten dies; but sometimes it happens, that the constitutional symp- toms slowly or suddenly yield; a red line is formed at the junc- tion of the living and dead parts, the latter are separated by ulcerative absorption, granulations sprout up, and the patient may recover,—provided the constitution has not been too much weakened by the violence of the disease. Mortification is said to occur sometimes without previous in- flammation—from suspension of the circulation by ligatures, and from ossification of the arterial trunks. There is some reason to believe, however, that, even in these cases, more or less inflammation really takes place, and that, in many other instances, although the common symptoms—pain, redness, and 28 Mortifcation. swelling—be not strongly marked, yet the inflammatory process is present to a certain extent, and contributes to the mischief which ensues. Almost every texture of the body is liable to mortification; but, mucous membrane, the skin, and absorbent vessels are particularly apt to suffer—while the arteries, tendons, ligaments, and fibrous membranes, generally escape. The causes of mortification are innumerable; in general, the disease results from inflammation. Gun-shot wounds, fractures, dislocations, simple punctures, concentrated acids, poisons, sti- mulating applications, infiltration of acrid fluids into the cellu- lar membrane, lightning, burns, long-continued pressure, in- tense cold, must all operate, more or less, through the medium of inflammation, in producing their several effects. There are some specific causes of mortification, which will afterwards be noticed. Treatment of Mortification. The remedies for mortification are either constitutional or local; and those of a very opposite character must be employed under particular circumstances. If, for instance, there be high inflammation which is likely to terminate in gangrene, the an- tiphlogistic system should be enforced: on the contrary, if gan- grene has actually taken place, then a different practice will be- come necessary. We give bark and wine and other tonics, soups and nutritious food of every description. Opium will also be found advantageous, if administered in small doses, and frequently repeated. Formerly, greater reliance was placed upon bark than any other medicine; but of late years, its reputation, in this parti- cular disease, has greatly declined—so much so, that many mo- dern practitioners look upon it as altogether inert. In particu- lar cases I have found it useful, and in others useless if not in- jurious. Musk and volatile alkali, were recommended, many years ago, by Mr. White of Manchester, as extremely useful in cases of mortification attended with spasmodic twitchings. The latter medicine I have frequently employed with advantage. I have, also, prescribed camphor, either alone or combined with opium, and have generally found that the patients were relieved Mortification. 29 by it. The mineral acids are occasionally administered. They act, however, only as common tonics, and as such may be bene- ficial. In some cases great benefit will be derived from small doses of the submuriate of mercury. The same may be said of the internal use of the liquor ammoniae acetatis combined with laudanum. As local remedies, numerous applications were formerly made to mortified parts, under an impression that the progress of the disease might be checked, or the vitality of the texture restored. It is now,, however, well understood, that no such influence can be exerted, and that local remedies are chiefly useful in as- suaging pain and keeping the diseased part clean, moist, and free from foetor. Such applications, indeed, may be useful during the height of the inflammatory stage, and before gan- grene has taken place. The best, under these circumstances, are common poultices of bread and milk, moderately warm, and kept constantly applied. Fomentations are sometimes em- ployed with the same view ; but they are not so useful as poul- tices. In the early stages of gangrene, leeches applied directly to the part or its neighbourhood often prove highly beneficial. When mortification has commenced, and particularly when the cutici^ is elevated in spots by a serous fluid, solutions of sugar of lead, or mild ointments, or a mixture of lime water and oil, will be found very soothing. They should be applied by a camel's hair pencil, or by a feather, and care taken to preserve the cuticle entire. When the skin separates, and the surface discharges an offensive matter, then carrot poultices mixed with yeast, or the fermenting cataplasm, will prove extremely use- ful. In a few cases I have known the patients complain very much after the carrot poultice has been applied, and relief to follow its removal. Most writers recommend powdered carbon, either alone or mixed with a poultice. I have seldom derived much advantage from it; and as it keeps the part to which it is applied black and dirty, so that its real condition cannot always be ascertained, it should, if possible, be dispensed with. A bet- ter application, to correct foetor and to keep the part clean, is the pyroligneous acid. I have several times employed this me- dicine, and particularly in sloughing ulcers and tumours, just be- fore an operation, and have been able, almost instantly, to re- move any offensive odour. 30 Mortification. The older surgeons were in the habit of scarifying all mor- tified parts, under the idea, that such process would speedily promote their separation. Except in cases of extravasation of urine into the cellular texture of the scrotum, and some other analogous diseases, such an operation is never at the present day performed. Neither will any benefit result from the prac- tice, so common in former times, of applying highly stimulating medicines, such as turpentine, spirits, &c. Indeed, in many instances, manifest injury must be the consequence, especially when the progress of the disease had been stopped, and the sound parts are making efforts to cast off the dead. In such cases, very severe pain follows every dressing, and there is rea- son to believe that the disease has, sometimes, been re-established by the continuance of so absurd a practice. Emollient poultices will prove more useful in this stage of the disease, than any other applications. To stop the progress of mortification, Dr. Physick has employed, ever since the year 1803, blisters, large enough to cover the affected part and a considerable portion of the ad joining sound parts, and has in many instances, found the prac- tice extremely beneficial. When patients are confined for a long time in one posture, from fractures, paralysis, typhus fever, and other disfases, mor- tification is very apt to take place in patches on the back and hips. All that can be done, in such cases, is to cover the sores by adhesive plaster, and to place bolsters or cushions under the body, so as to change the position of the patient and restore cir- culation to the injured part. Amputation is now seldom employed to stop the progress of mortification; for experience sufficiently proves that the disease is afterwards liable to fall on the stump. When a red line has formed, at which the dead separate from the living "parts, an operation will become necessary, in order to remove the bone and form a proper stump. But this should seldom be done, un- til the system has, in some degree, recovered its tone. These points, however, will be discussed under the head of Amputation. See Kirkland's Inquiry into the present State of Medical Surgery, vol. 2d. p. 291— Larrey's Memoirs, translatedby Hall, vol. 2d. p. 205—Thomson on Inflam- mation, p. 501. Chronic Mortification. 31 Section IV. Chronic Mortification. By this term I shall designate that particular disease de- scribed by Pott, as attacking " the toes and feet." It differs, in some respects, from common mortification, and is chiefly met with amongst aged persons, although young ones are, by no means, exempt from it. Males, also, are more subject to the disease than females. A small bluish spot is first observed on the inside of one of the toes, from which the cuticle soon sepa- rates. This spot spreads in every direction with greater or less rapidity. Sometimes all the toes are attacked simultaneously; in other cases the disease extends gradually from one toe to the other, and thence to the foot and leg. Its progress, in some subjects, is very rapid, in others protracted. Some patients experience excruciating pain,—others suffer very little. I have known three instances in which the patients were not aware of the existence of the disease, until one or more of the toes were extensively affected. In one of the cases, the disease seemed to have been brought about by the lodgement of a needle beneath the nail of the great toe. The needle had been care- lessly left in a darned stocking, and had penetrated the toe without the patient being sensible of it,—so that its discovery was purely accidental. His constitution had been previously much impaired by intemperance and free living. According to Pott, the majority of patients labouring under this complaint, feel great uneasiness, especially at night, through- out the ankle and foot, before any discoloration lakes place. When once the mortification is fairly established, the patient's constitution sinks rapidly. He is very restless, cannot sleep, is often delirious, and complains of spasmodic twitches. The soft parts gradually separate, or are easily detached, and the bones drop from each other at the joints. The smell of the dead mass is often very offensive, and is sometimes complained of by the patient himself. In almost all the cases I have seen, death has taken place soon after the mortification reached the ankle. 32 Chronic Mortification. The causes of this disease are quite obscure. Cowper first suggested the idea of its being dependant on ossification of the arteries. Dr. Thomson and others, have confirmed the fact— that such condition of the vessels is occasionally met with in chronic mortification: but Mr. Hodgson's* assertion, " that it is a constant attendant," remains yet to be proved. Mr. Pott met with the disease chiefly in gouty subjects. Treatment of Chronic Mortification. Formerly, bark was as much employed in this variety of mortification, as in any other form of the disease. It was con- demned, however, by Mr. Pott, as useless, if not hurtful; and on this account is now seldom employed. Instead of bark, Mr. Pott recommended opium, which he has praised in the highest terms. I have tried this medicine, however, repeated- ly, both in small and very large doses, and although I have found the pain and urgent symptoms sometimes relieved by its use, I cannot say that it has equalled the expectations held out by Mr. Pott in a single instance. A female patient, 35 years of age, in the Alms House, during the summer of 1822, suf- fered for several weeks under this complaint. I commenced with moderate doses of opium, and gradually increased the quantity until she took five hundred drops of laudanum every twelve hours; yet little relief was experienced, and she died some weeks after in a dreadful condition. Bark also was given, both in substance and in the form of extract, without any ad- vantage. Another woman, in the same Institution, whom I attended for the complaint, at the same time, was cured, (with the exception of the loss of the greater part of the foot,) I have reason to believe, by large doses of volatile alkali and by cam- phor, after opium had failed. Dr. Kirkland condemns the use of opium in large doses in this disease, and says that he has often known the mortification removed under the use of ano- dyne tonics, when its internal use was discontinued, because it * On the Diseases of Arteries and Veins, p. 41. Chronic Mortification. 33 brought on delirium and took away the appetite. The same practitioner seems to depend, rather, upon mild nutritious arti- cles of food, than upon medicine, for the cure of this com- plaint.* Various local applications may prove serviceable,—not in stopping the disease, but in relieving pain, and in keeping (he parts moist and free from foetor. Milk alone, or milk and wa- ter, moderately warm, and frequently applied, will be found very grateful to the patient's feelings. A bread and milk poultice I have used in several cases with advantage, where the carrot and turnip poultices gave pain. Dr. Dorseyt states, " that in the only case he ever saw, the application of a blister produced an immediate termination of the mortification." In the worst of the Aims-House cases, mortification followed the day after the blister was applied, and in a part apparently sound before its use;—in the other no benefit appeared to result, al- though the blister was applied repeatedly for several days. Blisters have been known to bring on mortification in other diseases, under particular circumstances, and however useful they may prove in common gangrene, I should not feel inclined, from what I have seen, to recommend them in chronic mortifica- tion. When the complaint occurs in people considerably ad- vanced in age, I believe that all our efforts will prove unavail- ing. Amputation has sometimes been resorted to,—but general- ly without effect. Sir Astley Cooper condemns amputation altogether in this disease. "In these cases," says he, "you must not amputate; whether there be healthy granulations or not, do not amputate; for as surely as you do, mortification of the stump will super- vene, and death quickly ensue." See Pott's Works, Vol. 3, p. 185—Thomson on Inflammation, p. 533—James on Inflammation, p. 296—Kirkland's Medical Surgery, p. 418—Cooper's Lec- tures by Tyrrel, vol. i. p. 239. * Kirkland's Medical Surgery, vol. ii. p. 423. f Elements of Surgery, vol. i. p. 29. Vol. I. 5 34 Dry Mortification. Section V . Dry Mortification. The dry mortification is, in every respect, a very singular affection. Without previous swelling, redness or pain, the toes and feet lose their heat, become shrivelled, discoloured, and final- ly, converted into a hard, dry, insensible mass, of a dark blue or very black colour. In general, no sloughing takes place; on the contrary, each part retains its original form, the skin remains entire and the nails adhere to the toes. To the touch the whole affected part feels cold, as hard as a common smoked tongue, and is perfectly free from foetor. In some patients, the disease begins suddenly with a burning sensation, which continues for several days, and then as suddenly ceases. In others, the pain is violent, the foetor and sloughing con- siderable, and attended by severe constitutional symptoms. For the most part, however, the general health is little disturbed, and the disease continues its course until a line of separation is formed. It seldom proceeds farther than the knee, though in a few in- stances it has reached the hip, or extended to the body, and proved fatal. This variety of mortification often arises without any evident cause. It can be traced, however, in numerous instances to vi- tiated grain, especially rye. During very moist seasons, a sub- stance called ergot, secale cornutum, or cockspur, is sometimes ge- nerated in considerable quantity, forming a disease, in which the grains of rye become of large size, firm consistence and black colour. This being mixed with sound rye, is often eaten by whole families, and for some time without inconvenience. In consequence of large portions being taken, the dry mortification is at length produced in the feet, legs, hands, or other parts of the body; and in some European countries, especially France, has appeared, in certain districts, as an endemial disease. For a considerable time, doubts were entertained as to the real origin of the disease, and many were disposed to believe that its production was totally independent of the ergot. On Dry Mortification. 35 this account, the Royal Society of Medicine, of Paris, requested M. Tessier, one of its members, to visit those districts in which the complaint was very prevalent, and endeavour to settle, by experiment, the point in dispute. For these experiments, a number of the inferior animals were selected, none of which would voluntarily eat the ergot, however disguised by the ad- mixture of other food. All were, therefore, compelled to take it, and its effects upon each corresponded with the quantity ad- ministered—mortification in some being readily induced, in others tardily, and proving fatal to the whole, in the course of a few days or weeks. These experiments of Tessier have since been so frequently repeated by others, as to leave no doubt whatever on the subject, and authorize us to conclude that the dry mortification, in the greater number of instances, proceeds from the above mentioned cause. Were any further illustration necessary to show the power of ergot in the production of dry gangrene, some very inte- resting facts might be detailed in relation to the disease, as it appeared among the horned cattle, many years ago, in Chester county in this slate, and in Orange county, state of New York, in 1819 and 1820. Dr. Mease,* a gentleman well known for his extensive researches, and who has paid particular attention to the diseases of domestic animals, was the first to record the fact—that the dry mortification, affecting the legs of cattle, in the instances referred to, proceeded from the use of the green grass, (poa viridis,) the ends of the seeds of which, to some ex- tent, were affected with the smut or ergot. Lately, a very in- teresting account of the same disease, and a confirmation of Dr. Mease's statement, has been given by Dr. Arnell.t I have met with two or three examples of the genuine dry mortification in this country, neither of which, as far as could be determined, arose from the spurred rye. In one instance, the disease appeared to be the consequence of fracture—the pa- tient, at least, had received a fracture of both thighs, and of the left leg, from which he recovered in four or five months. At the end of that time, a dark spot appeared on one of the toes of the right foot, spread thence to the other toes, and finally in- * Domestic Encyclopedia, vol. ii. p. 52, and vol. iii. p. 196. \ The Plough Boy and Journal of the Board of Agriculture, by S. Southvvick, vol. iii. p. 41. V 36 Dry Mortification. volved the greater part of the leg, which became perfectly cold, insensible, dry, hard, withered, and of a deep purple colour. The skin remained entire, except at the upper part of the leg, where it sloughed, along with a portion of the muscles. In this condition the patient remained several months longer, without .pain or material injury to his general health, when I was re- quested to visit him at York, Pennsylvania, in consultation with Dr. Spangler of that place. It was decided that amputation alone could afford relief. I accordingly performed the opera- tion, (on the 16th January, 1816,) immediately below the knee, and with complete success. Ever since that period the limb has remained in my surgical cabinet, exposed constantly to the air, is now perfectly free from foetor, as it was, indeed, at the time of the operation, and has never since undergone the slight- est change.* There is every reason to believe, in this case, that the mortification was the result of the different fractures, for upon repeated inquiries, no evidence was afforded that the pa- tient had ever lived upon damaged grain of any description: on the contrary, he was a wealthy farmer, and had always used the most wholesome articles of food. A beautiful specimen of dry gangrene was presented to me during the winter of 1827, by Dr. E. Swain of Bristol. It occurred in the practice of Dr. Phillips, an eminent physician of that borough. The patient was seventy-two years of age, and had long been subject to extensive ulceration of the ankle. The disease commenced in the toes, and gradually extended over the foot, which finally separated from the leg. She lived five weeks afterwards, and during the whole course of the dis- ease experienced no pain. The dry is not so fatal a disease as the chronic mortification. Where it has prevailed endemially, however, very few have re- covered. In favourable cases, and in young subjects, amputa- tion has often succeeded, and under any circumstances must be considered the chief remedy. The following case, in which that operation was employed, (by Dr. Carmichael, of Virginia, and by whom the particulars were obligingly communicated to me,) will be read with interest. " Henry Krebbs, Major of the French army, passed through the disastrous retreat from Moscow, without more suffering • latterly it has been worm-eaten. Dry Mortification. 3? lhan fell to the lot of a small part of the retreating force. In the year 1818, he emigrated to this country, and, from that time to the present, has devoted himself to instruction in music: to this occupation he has added great mental labour; being a devoted mathematician in the higher branches, and in botany. His health has, through this period, beep good, his complexion sallow, but his general constitution may be said to equal that of the larger portion of society. These preliminary remarks have been sug- gested with the view of presenting the influence they may have had, in producing the unusual disease with which he was attacked in January last. " Without any indication whatever, this gentleman was seized, during the night, with the most violent pain in both feet, and so great was the suffering that he uttered the most distressing screams; upon examination, the appearance of the parts did not authorize to our eyes the agony he expressed. In the morning, however, we were startled at the more than cadaverous coldness of both feet, and the partially ecchymotic slate of them; a farther examination soon satisfied us of the total absence of arterial cir» culation, and our diagnosis fixed on dry gangrene. " When this fact had been established, a difficulty arose with it. We had been taught, most generally to look for this in the old, and exhausted constitution; here the subject was young, heretofore in good condition, and we farther inferred that the treatment of Pott, however applicable to the former patients, was ill suited to this. As no medium ground could be well occu- pied between Dupuytren and this old but respectable surgeon, I unhesitatingly embraced the pathological doctrine of the Baron. But before putting it into practice, I thought fit, against my usual custom, to read to Mr. Krebbs these new views, with which he was immediately struck, and forthwith bared his arm for the lancet. The first bleeding, to faintness, afforded great relief from the pain, as it did on every trial, which was repeated during the disease not less frequently than eight or ten times. Purgatives, assisted as usual, in the antiphlogistic treatment, and the most agreeable local adjuvant was snow or iced water: whenever any prescription of a raised temperature was applied, the pain was aggravated, and the gangrene extended. " The detailed description in this case, is important only as it exemplifies the successful application of the lancet in a dis 38 Dry Mortification. ease heretofore supposed to be invariably connected with debility, as also its spontaneously arising upon such a constitution as that of this individual: whenever the blood was drawn, which I have stated before to be frequently, the patient was greatly relieved, and on several of these occasions, it was by his earnest solicita- tion. It was always buffed and cupped. Opium was sparingly used, and not on any occasion was it fully given. About the sixth week, I removed one of his legs just below the knee, and upon an inspection of the artery, it was found so filled with gra- nulated, albuminous or fibrous matter, that no ligature was ap- plied, or tourniquet used, nor was there the least hemorrhage, though the circular flap operation was selected, and the healthy parts the seat. Slight delirium followed; this soon subsided un- der the treatment by opium, and on the tenth week the other limb followed the fate of the first; from that hour to the present, he has gradually improved, and is now in a state perfectly con- valescent."* See Thomson on Inflammation, p. 538—Boyer's Treatise on Surgical Diseases, translated by Stevens, vol. 1, p. 77—Gooch's Works, vol. 2, p. 367—Prescott on the National History and Medicinal Effects of the Secale Cornutum, &c. 1813. * He died, however, shortly afterwards, Varieties of Inflammation. 39 CHAPTER II. VARIETIES OF INFLAMMATION. After the account given of common inflammation and its ter- minations, it will be proper to notice certain diseases, which dif- fer in many respects from the original affection, and from each other. These affections, there is reason to believe, are very of- ten dependent upon constitutional peculiarities; but in other in- stances, they result evidently from some particular local irrita- tion. The most common varieties of the disease are erysipelas, boil, carbuncle, chilblain, frost-bite and burns; each of which it will be proper to treat of in separate sections. Section I. Erysipelas. A great diversity of opinion has prevailed among writers re- specting the nature and seat of erysipelas. Some, indeed, con- tend, that the relation between it and inflammation is very re- mote.* This statement is probably without foundation, though it must be confessed that our knowledge of the complaint is very imperfect. Erysipelas commonly attacks some parts of the cutaneous texture, and exhibits the following appearances. The surface of the affected part is elevated and of a bright scarlet co- lour, mixed occasionally with yellow and dusky red, and having an abrupt termination. The redness is accompanied by a burning sensation, or by itching. When pressure is made upon the swelling, the redness disappears, leaving a white spot in its its place. The redness, however, is quickly restored upon * See Pearson's Principles of Surgery, p. 187. 10 Erysipelas. the pressure being removed. In some cases small vesicles con- taining an acrid serum, appear on the diseased surface. Erysipelas is not always attended by constitutional symptoms, but, generally, more or less rigor, fever, nausea, headach and loss of appetite precede the complaint. These symptoms cease about the third day, and the redness and swelling soon after take place. In mild cases the cuticle separates in flakes, and the skin beneath assumes a healthy aspect. When vesicles form, they either dry up and desquamate, or else terminate in ulcera- tion or sphacelus. Erysipelas differs, in many respects, from phlegmon; in certain cases, however, the two affections are com- bined. Authors have enumerated various species of erysipelas, and have designated each by particular names. Some of these spe- cies, it appears to me, are imaginary, and others to be considered as accidental symptoms only of the complaint. Were 1 to fol- low the arrangement of any individual writer, it should be that of Pearson,* by whom the disease,has been divided into three spe- cies—acute, cedematose, and malignant erysipelas. Very often erysipelas arises without evident cause, and spreads rapidly from one part of the body to another. In other instances, the disease can be traced to the operation of some specific agent —such as the application of vegetable, animal, or mineral poi- sons—to wounds, fractures, exposure, intemperance, derangement of the digestive organs, violent passions of the mind, contagious diseases, impure air, &c. Treatment of Erysipelas. In the commencement of the attack, blood-letting, purgatives, diaphoretics and low diet will be found the most appropriate remedies. Leeches, in most instances, should be preferred to general blood-letting. The French have long employed this remedy with great advantage in erysipelas, and the practice is still recommended by their best authorities, especially by Broussais. Dr. Neill, an eminent practitioner of this city, has * Principles of Surgery, p. 197. Erysipelas. 41 detailed several cases in proof of the efficacy of this mode of treatment.* Desault and Boyer extol the use of emetics in that variety of erysipelas denominated bilious. After full benefit has been derived from the antiphlogistic plan, opium, bark and camphor may, perhaps, become necessary; at all events, care must be taken that the evacuations are not carried too far, other- wise, the disease may terminate in mortification. When erysi- pelas occurs in persons debilitated by the immoderate use of ar- dent liquors, it will be found expedient in most cases of the kind to continue such articles, otherwise the patients are almost sure to sink. As local applications, weak solutions of the acetate of lead, cold water, and other similar means, often prove beneficial. Blisters are extremely efficacious, but should not be applied, ac- cording to Pearson, upon the diseased surface, on account of the troublesome sores which sometimes follow. Such effects I have never witnessed, although, in numerous instances, I have covered the inflamed part with a very large blister. Warm so- lutions of opium, frequently applied, I have found very useful in allaying the peculiar burning pain and itching, which so commonly attend the disease. But of all local applications the mercurial ointment is, undoubtedly, among the best. It was first introduced into practice in this complaint, by Drs. Dean and Little, of Chambersburg, in this state. A practice very commonly prevails, in (he preparation of this medicine, of mixing with it turpentine and other stimulating ingredients. It is said that ointment, thus prepared, if used in erysipelatous inflamma- tion, will increase rather than alleviate the disease; but when divested of such materials, speedily relieves every urgent symp- tom, especially in that troublesome form of the complaint which so frequently attacks the face. Within the last few years, I have frequently employed in erysipelas, and with most decided benefit, the preparation known under the name of British oil. It is singularly useful in removing the itching that usually accompanies the disease. In this re- spect, I know of no local application at all equal to it. Di: Coates informs me, that he has often used, with great effect, the tar ointment, in obstinate cases of erysipelas. * North American Medical and Surgical Journal, vol. 1, p. 295. Vui.. 1. 6 42 Erysipetus. Most practitioners recommend, as external applications, va- rious powders, such as starch, flour, chalk, and impure carbonate of zinc. I have seldom found these articles useful; but, on the contrary, often injurious,—by mixing with the fluids discharged from the vesications, and forming crusts or scabs, which irritate the subjacent skin. For the treatment of erysipelas combined with phlegmon, a practice has lately been introduced by Dr. Hutchison, of making numerous longitudinal incisions an inch long, down to the mus- cles, in the early stages of the disease, in order to give free vent to the secretions, which are apt to form and collect in sacs. Dr. Hutchisomstates, that during five years in which the practice was employed at the Deal Hospital, not a case was lost. See Pearson's Principles of Surgery, p. 186—Desault's Works, translated by Smith, vol. 1, p. 502—Boyer's Treatise on Surgical Disease, by Stevens, vol. 1, p. 220 —Bateman's Practical Synopsis of Cutaneous Diseases, p. 125—Hutchi- son's Practical Observations on Surgery—Hutchison, in Medico-Chirurgical Transactions, vol. 5, p. 278—James on Inflammation, p. 234—Cooper's Lectures, by Tyrrel, vol. l,p. 244.—Observations Ton the Nature and Treatment of Erysi- pelas, illustrated by Cases,- by W. Lawrence, Surgeon to St. Bartholomew's Hos- pital, &c. SJc. in London Medico-Chirurgical Transactions, vol. 14. Furunculus. 13 Section II. Furunculus, or Boil. The furuncle is a hard, painful and highly inflamed tumour, of a conical shape, the base of which is below, and the apex slightly elevated above, the level of the skin. The colour of the tumour is of a dusky red, inclining to purple, and its sum- mit is tipped by a whitish pustule or eschar, beneath which is lodged a mass of disorganized cellular membrane, commonly called a core. Although this tumour always terminates in sup- puration, its progress is slow, and the matter never assumes a healthy aspect, but is thick, sanious and ill-conditioned. Boils may occupy the cellular tissue of any part of the body. Sometimes they are very numerous, and though seldom attend- ed with danger, may occasion great inconvenience to the pa- tient. They arise without evident cause, and frequently in healthy constitutions. At other times, they follow eruptive diseases and ty- phus fever. Treatment of Furunculus. It is seldom possible, even in the commencement of this dis- ease, to procure resolution; and when accomplished, the tumour is very apt to return repeatedly, and can only be removed even- tually, by the establishment of suppuration. On this account, it is better in every instance to encourage this process at once, by the continued use of warm poultices or fomentations. As soon as the apex of the swelling becomes soft, an opening should be made into it, sufficiently large to enable us to remove the core; after which poultices may be reapplied, or else the cavity filled with lint, spread with stimulating materials—such as red pre- cipitate mixed with basilicon ointment. A solution of lunar caustic, in the form of injection, I have sometimes used, advan- tageously, for the purpose of stimulating the cavity, and causing, it to fill up. See Imssus, Pathologic Vlnrurgiculr, lam. 1, lop. 15—Pearson's Principles of Surgrri/, ]>■ 70 44 Anthrax. Section 111. Anthrax, or Carbuncle. The carbuncle, in some respects, resembles the furuncle. It is a deep-seated, circumscribed, hard and very painful swelling, of a livid hue, attended with excessive pruriency and burning heat. From furuncle it differs, in having no central core, and in terminating by slough instead of suppuration. Symptoms of common inflammation sometimes attend the commencement of the complaint; but these are soon superseded by vesications, containing an acrid, sanious fluid, which is discharged from numberless pores, occupying every part of the surface of the tumour, and communicating with cellular cavities in a mortified state. Constitutional symptoms not unfrequently attend this disease from its commencement to its termination. In particular there is nausea, loss of appetite, (ever, great prostration of strength, want of sleep, to such an extent as in some instances to destroy the patient. But most persons recover from the attack, after having suffered immensely. When situated on the head, car- buncles are almost sure to prove fatal, by giving rise to effusion and consequent compression of the brain. Treatment of Anthrax. Very opposite modes of treatment must be pursued, in the in- cipient and advanced stage of carbuncle. In the former, all ir- ritating applications prove highly injurious; whilst in the lat- ter, certain stimulating remedies can alone be depended on. An emollient poultice in the commencement affords more relief than any other application, and should be continued until vesi- cations appear on the surface. Sometimes it will be found use- ful to make one or more incisions over the surface of a carbun- cle; and afterwards apply an astringent poultice. To assauge pain and procure sleep, opium must be freely employed; and Anthrax. 45 where the patient is much debilitated, bark, elixir of vitriol, ammonia, and an invigorating diet, are the proper remedies. Blisters* have been highly extolled in the treatment of carbun- cle ; but I have never found them useful, except in abating the pain attendant upon the disease. When openings form and discharge a bloody serum, the poultice should be laid aside, and the surface of the tumour, as far as tne openings extend, covered freely with the caustic ve- getable alkali. The caustic gives some pain, but this soon sub- sides, and the severe burning pain, peculiar to the disease, is from that time entirely removed. Dr. Physick, to whom we are chiefly indebted for our knowledge of the proper application of this remedy, states, that " in all the cases in which he has used the caustic in this manner, the suffering of the patient ceased as soon as the pain from the caustic subsided." It should be recol- lected then, that the caustic will prove hurtful in the commence- ment of carbuncle ; but extremely beneficial in the second stage, or at that period when openings form in the tumour. From inattention to these circumstances, there is reason to believe much mischief has resulted—from deep, ill-timed incisions, from the actual cautery, and from caustics, which have long been em- ployed, at an improper period, especially by the French surgeons. See Bromfields Chirurgical Cases and Observations, vol. 1, p. 118—Boyer's Surgery, vol. 1, p. 241—Physick's Case of Carbuncle, with Remarks on the Use of Caustic in that disease, in the Philadelphia Journal of the Medical and Physical Sciences, vol. 2,p. 172—Larrey's Memoirs, by Hall, vol. l,p.5\. • Dorsey's Elements, vol. i. p. 25. 46 Pernio. Section IV. Pernio, or Chilblain. This inflammatory affection is the result of cold, or of the sudden transition from cold to heat, and is commenly met with in extreme parts of the body, such as the toes, heels, fingers, ears, nose and lips. At first the skin is pale and shrivelled; this state, however, is quickly succeeded by redness, tumefaction, more or less pain, pruritus and oedema. In bad cases the skin assumes a purple cast, the itching or tingling becomes intolera- ble, a serous fluid collects beneath the cuticle, and is soon dis- charged, leaving an ill-conditioned sore, which often penetrates to the bone, and is exceedingly difficult to heal. The mild form of this complaint, or that unattended by ul- ceration, is by no means uncommon, especially in moist and temperate climates, where it often disappears spontaneously during summer, and regularly returns in winter, attacking for the most part patients who have previously suffered. Treatment of Pernio. Very common applications in the simple or mild form of chilblain, are ice water or snow; and there can be little doubt of their general utility, when used with moderation. To cer- tain patients they are not adapted,—especially those inclined to phthisis or subject to the gout; nor are they suitable to delicate females. Spirituous embrocations often prove serviceable. Soap liniment, volatile liniment, spirit of turpentine, and tinc- ture of cantharides are the best remedies of this class. 1 have frequently known the mild chilblain cured in a few days, sim- ply by covering the part with carded cotton. An alum curd is sometimes a very effectual remedy. For the ulcerated chilblain, some of the stimulating ointments, as the unguentum hydrargyri nitrati, or basilicon mixed with red precipitate, are often advantageously employed. Solutions Pernio. 47 of lunar caustic, or of the preparations of lead, or lime water mixed with linseed oil, are likewise useful. At first, these re- medies are scarcely felt by the patient; but in a little time the sore becomes exquisitely sensible, and should then be covered with poultices and mild dressings until completely healed. According to Lisfranc, the chloride of lime is a very useful remedy in the ulcerated chilblain. In one obstinate case of the kind, this surgeon covered the affected part with perforated plasters of simple cerate. Pieces of lint dipped in a solution of the chloride of lime, were then applied and renewed every twen- ty-four hours, and soon effected a perfect cure. See Pearson's Principles, p. 153—Thomson on Inflammation, 646—Bees' Cy- clopedia, vol. 8, part 1—The Art of preserving the Feet, &c. by an experienced Chi- ropodist, p. 149. London, 1818. 48 Frost Bile. Section V. Frost-Bite. Intense cold applied to the body, or to a part, may produce effects very different from those last mentioned. The vital func- tions may be entirely extinguished, or only suspended, or else some particular texture may be destroyed, through the medium of mortification. Although many instances are on record, of persons having died from exposure to severe cold, and of others recovering after the suspension of animation for a considerable time, yet such consequences are rare, compared with the par- tial injuries which result from frost-bite or mortification. Few cold seasons, indeed, pass away, especially on our sea-coast, without numerous instances of frost-bite taking place. The part to which the cold is applied first becomes benumbed, stiff and insensible. These symptoms are succeeded by heat, swelling, and more or less pain; the skin assumes a livid hue, and suppu- ration soon takes place between the sound and injured parts. If the surgeon be called in time, which is seldom the case, the warmth of the part, by proper treatment, may perhaps be re- stored, and mortification prevented. When the cold is long continued, and so intense as to affect the internal organs, the symptoms are drowsiness, shivering, rigidity of the limbs, dimi- nution of the circulation, and finally profound sleep, which often terminates in death. Treatment of Frost-Bile. Premature exposure of frost-bitten parts to heat, has frequent- ly been attended with the worst consequences. Instead, there- fore, of laying a patient in a warm room, or before a fire, cold applications, such as snow, or ice water, should at first be em- ployed, taking care that very little force be exerted upon the frozen part, lest it be broken or otherwise injured by the fric- Frosl-Bile. 49 tion. After the natural temperature has been restored, mode- rately stimulating embrocations, such as camphorated spirit of wine, will perhaps be found useful. But sometimes the inflam- mation is so active as to require cold solutions of the acetate of lead, and other similar applications. In most instances, however, there is a strong tendency to gangrene, and the most powerful stimulants will of course be required to arrest its progress. When mortification has once taken place, the remedies adapted to that particular state must instantly be employed. An oatmeal poul- tice mixed with stale beer, is among the best local applications that can be employed. When the system is affected by cold to such an extent as to ren- der the patient insensible, various means may be used to produce reaction. The chief indications are to excite the muscles of res- piration and to restore the circulation. The former may often be accomplished by sternutatories and volatiles, and the latter by frictions with flannels, covered with stimulating materials, and applied to the whole surface, particularly to the epigastric region. This treatment should be continued, unremittingly, for a consi- derable time; for instances have occurred of recoveries, after the larjse of several days, and under the most unfavourable circum- stances. Some writers recommend the immersion of the whole body in ice water; but the practice cannot prove otherwise than injurious, and should never be pursued. After the patient has been somewhat revived, by the means pointed out, it will be pro- per to administer stimulants internally, such as brandy and water or a little warm wine. Very often it will become necessary to keep up for some time the patient's strength. In such cases the internal use of the sulphate of quinine, or of musk and ammonia combined, will prove exceedingly beneficial. See Kellie's Case of Torpor from Cold, in Edinburgh Medical and Surgical Journal, vol. 1, p. 302—Thomson on Inflammation, p. 613—Larrey's Memoirs by Hall, vol. 2, p. 156. Vol. I. 7 50 Burns Section VI. Burns. Burns are very common accidents, and produce, not unfre- quently, immense injury, and even death. From the time of Hil- danus to the present day, they have, commonly, been divided into three species. The particular arrangement of Pearson— the superficial, ulcerated, and carbunculous burn—appears to me the most satisfactory. In the first, the cuticle is injured, but does not separate from the cutis, until a new one is nearly formed. The pain and swelling are inconsiderable, and there is" no vesication. In the second, the cutis is extensively injured, a serous effusion takes place, the cuticle separates and leaves be- hind a painful and suppurating sore. Constitutional symptoms, such as rigors, a quick small pulse, followed by a hot skin, furred tongue, and difficult respiration, are likewise common attendants. The third species, or the carbunculous or sloughing burn, is that in which the cutis and adjoining parts are disorganized, and con- verted into a hard eschar. The local and constitutional symp- toms are extremely severe, and the shiverings, for several hours after the accident, almost incessant. The pulse is very feeble and quick, and the asthmatic symptoms are so urgent that the patient can scarcely breathe. If he recover from the shock communi- cated to the system, the slough separates in a few days and leaves a very painful ulcer, which is soon covered with fungous granula- tions, and will always be found very difficult to heal. The symp- toms, however, in all the three species of burns must necessarily vary very much, according to the degree of heat applied, the ex- tent of the surface injured, the peculiar constitution of the pa- tient and a variety of other circumstances. Burns. 51 Treatment of Burns. Two very opposite modes of treating burns have been in use from time immemorial—by refrigerants and calefacients; and it is not easy to determine which are the most beneficial. There can be little doubt, however, of the utility of both, pro- vided they are judiciously employed. In superficial burns, rags dipped in cold water, and constant- ly applied to the part, afford great relief. Still better effects result from pounded ice, mixed with hog's lard, or enclosed in bladders. Cold scraped potatoes or turnips are very common- ly applied to a burnt part, and are found very soothing and agreeable. But the best application I have ever tried is raw cotton, thinly spread out or carded, and laid directly over the burn. The value of this remedy was ascertained, accidentally, a few years ago, by a lady living in Hartford county, Mary- land, whose child was scalded by boiling water, nearly over its whole body. The mother was carding cotton in an adjoining room at the time of the accident, and having no medical assis- tance within reach, undressed the child as quickly as possible, and covered the whole burnt surface with masses of the cotton. The effect was wonderful; for the child soon became perfectly quiet, fell asleep, and upon removing the cotton, a few hours af- terwards, no inflammation whatever could be perceived. Dr. Dallam,* to whom we are indebted for an account of this case, has furnished others of a similar character, in which the cotton proved equally efficacious; and my own experience enables me to confirm his statement of its usefulness. It is only, however, in the superficial burn that this remedy can be relied on. A mode of treating burns somewhat analogous to that of Dallam, has been commended by Velpeau of France—by compression. A roller is accurately applied to the injured part as soon as pos- sible after the accident. " By the paper of Velpeau it appears that in a burn of the slightest or first degree, a compressing bandage prevents the development of inflammation; in the se- * See Dallam, on the Use of Cotton in Burns in Potter's Medical Lyceum, p. 22. 52 Burns. cond degree it hinders the occurrence of blisters, or if not em- ployed sufficiently early to do so, re-attaches the epidermis, and occasions the absorption of the effused serum. In the third degree it cannot prevent an eschar, but renders the accident less painful," &c. Vinegar has been highly extolled, of late years, as an application for burns, by Mr. Cleghorn, a celebrated brewer at Edinburgh, whose workmen often suffered severely from such accidents. I have tried it in many cases of burns, but have never known it of service except in the first species. If used during the vesicated or ulcerated stage, the pain is in- tolerable. The ulcerated burn requires a treatment very different from that of the superficial burn. Openings should first be made with a needle through the cuticle, to discharge the serum col- lected beneath; taking care, at the same time, not to tear the cuticle, or expose the raw surface of the cutis to the air, which always has the effect of creating considerable irritation. When ulceration takes place, the patient generally suffers severe pain, and emollient poultices will then be found to afford more relief than any other applications. These should be continued so long as they seem to agree with the sore. Powdered chalk, or lapis calaminaris, sprinkled over the whole surface of the burn, and occasionally renewed, are productive of the best effects. The linamentum ex aqua calcis, spread upon fine old linen, and kept constantly in contact with the ulcerated surface, I have often employed with great advantage. The calefacient, or stimulating plan of treatment, is chiefly adapted to the carbunculous or sloughing species of burn. Re- medies of this class are not only applied to the injured surface, but are often administered internally, on account of the shiver- ings, weak pulse, and other symptoms denoting severe consti- tutional derangement. Great care should be taken, however, lest such medicines be continued too long, or given in too ^reat quantities; for it often happens, after the first effects of the burn subside, tnat violent reaction takes place, and can only be sub- dued by rigid attention to the antiphlogistic system. But in al- most every stage of a burn, where the constitutional disturbance and pain are considerable, opium may be freely and beneficially resorted to. The stimulating articles, usually employed exter- nally, are spirit of wine, or spirit of turpentine, either alone or Burns. 53 mixed with oils or ointments, and applied to the injured parts by a feather, brush, or by linen rags. In some cases they ex- cite violent pain, especially when laid on the sound skin. Baron Larrey has condemned all the common modes of treating burns, and depends, chiefly, upon dressings composed of' saffron oint- ment, spread on old linen, from which he states that he has de- rived the most salutary effects. From carelessness on the part of the surgeon, it often hap- pens, that fingers, toes and other parts grow together, and pro- duce unnatural contractions or extensions. Such accidents may always be prevented, by interposing lint, or plasters, between the burnt parts, and by using splints and bandages. The mode of relieving these deformities is to cut across the adhesions at particular spots, and restore the parts to their for- mer position; taking care to prevent reunion during the pro- gress of the cure. The operation does not always succeed ; al- though it has answered the purpose in all the cases in which I have tried it. On account of its occasional failure, Mr. Henry Earle has proposed to remove the cicatrices altogether, and bring the edges of the sound skin towards each other, in a transverse direction, and there retain them by adhesive strips. See Thomson on Inflammation, p. 585—Pearson's Principles of Surgery p. 171—Earle on the Means of lessening the Effects of Fire on the Human Body__ Kentish on Burns—Larrey's Memoirs, vol. l,p. 43—H. Earle, in Medico-Chi- rurgical Transactions, vol. 5, p. 96—Dickenson on Burns and Scalds__Cases in which the Operation for the Removal of Cicatrices from the Neck consequent on Burns, was successfully performed, with Remarks. By Dr. H James, Surgeon to the Devon and Exeter Hospital, in Medico-Chirurg. Transactions, vol. 13 Part I. 54 Wounds. CHAPTER III. WOUNDS. Wounds may be divided into incised, punctured, penetrating contused, lacerated, poisoned and gun-shot. These admit of subdivision—as wounds of the head, face, neck, chest, belly and extremities. All such injuries will prove more or less danger- ous, according to their extent, the manner in which they are in- flicted, the age and constitution of the patient, the situation and texture of the wounded part, the treatment that may be adopt- ed, and a variety of other circumstances to be considered here- after. In general, it may be stated, that wounds involving large blood vessels, nerves and joints, are more hazardous than others —that a very trivial wound in a bad constitution will sometimes give rise to most violent symptoms, and even death, and that, on the other hand, very extensive wounds often terminate in the most favourable manner. Section I. Incised Wounds. Incised wounds are the most simple, and, independently of he- morrhage, the least dangerous of all. Profuse bleeding, how- ever, is very apt to take place, even from vessels of moderate size,—provided the cutting instrument is exceedingly sharp. A wound produced by a dull instrument, on the contrary, seldom pours out much blood. As soon as any part is divided, there is a recession of its edges, owing either to the size of the instru- ment by which it is produced, or to the elasticity and contrac- tility inherently possessed by most living textures. Incised Hounds. 55 Treatment of Incised Wounds. The chief indications, in the treatment of an incised wound, are to suppress the bleeding, and afterwards to retain the edges in contact, by such means as are best calculated to favour their reunion. The removal of foreign bodies is also, in many in- stances, an object of considerable importance. Hemorrhage may be stopped either by ligature or by com- pression. The first is always the most effectual, and should be resorted to whenever the situation of the wound will admit of it. The tenaculum, needle, and forceps, are the instruments commonly employed for casting a ligature around the divided vessel. When the wound is open, not very deep, and the ves- sels large, the tenaculum will be found the most convenient. The point of the tenaculum should be moderately curved, and not very sharp, otherwise the surgeon will find it difficult to catch the mouth of the artery, and when caught the instrument is liable to cut itself out. After the bleeding vessel is drawn out, it may be tied by an assistant, or if no one be at hand, the surgeon will often succeed by holding the handle of the. tenacu- lum between his teeth, and using his own hands for drawing the ligature. Upon such occasions, a tenaculum with a leaden handle, sufficiently heavy to drag out the vessel when suspend- ed from it, will prove very useful. The artery forceps, which should always be serrated at the extremities and have a movea- ble slide to close the blades, will answer nearly the same pur- pose as a tenaculum. The needle is now seldom used for se- curing bleeding vessels, because it is necessary to include with it more or less of the surrounding soft parts, and in so doing important nerves may be tied, or vessels of considerable size opened, from both of which much mischief will result. For taking up deep-seated arteries, beyond the reach of a tenaculum or common needle, Dr. Physick has employed, ever since the year 1800, a forceps, so constructed as to hold in its extremi- ties a needle armed with a ligature. The handles of the forceps are fastened together, temporarily, by a string or catch, and when the needle is fairly deposited beneath the vessel, it is dis- engaged from the forceps and drawn out, leaving the ligature 56 Incised Wounds. behind, which can be tied without difficulty.*—For a view of these different instruments, see Plate I. Ligatures are commonly madeof thread, silk, or leather. All may occasionally be used with advantage, provided they are of proper shape or size. Round ligatures are superior to the flat or irregularly twisted, inasmuch as they divide the internal and middle coats of the vessel with uniformity. The use of the lea- ther or animal ligature was first suggested by Dr. Physick,f in the year 1806; but no account of it was published until 1816. The best material for animal 4igaTure is French kid leather, cut into strips from a quarter to half an inch in breadth, (the grain or polished surface being previously peeled off,) well soaked in water and then stretched and rounded. Buck-skin and parchment, treated in the same manner, make very good ligatures. Catgut, although recommended by some surgeons for the same purpose, I have never found suitable. The advan- tage possessed by the animal, over ordinary ligatures, is its speedy decomposition and separation from the artery, whereby the patient is saved much unnecessary irritation and pain. For several years past I have practised the plan first recommended by Veitch—of cutting off one end of every ligature and leaving the other hanging from the wound, in order to diminish irrita- tion, and have good reason to be pleased with the result. I have also tried, upon several occasions, the method, (mentioned it is said as early as the year 1786, by Mr. HaireJ of England,) of cutting off both ends of the ligature close to the knot, and then healing the wound over them—but generally without any ma- nifest advantage. The fact that a ligature divides the internal and middle coats of an artery, leaving the external coat entire, was first pointed out by Desault. Compression may be accomplished either by the tourniquet, or by rollers and pledgets. The tourniquet, (see Plate I.) is chiefly adapted to wounds of the extremities. When the regu- lar instrument is not at hand, a very convenient one may in- * Dr. Physick's forceps is a modification of the Acutenaculum or Porl-Aguille, an instrument used by the older surgeons for sewing wounds. Richerand recom- mends a needle mounted upon a handle for taking up deep-seated arteries. See Nosographic Chirurgicale, torn. iv. p. 37, edit. 4th. \ See Eclectic Repertory, vol. vi. p. 389. * See Hennen's Principles of Military Surgery, p. 181, 2d edition. ei-.i. Incised Wounds. 57 sftantly be made, by tying together the ends of a common hand- kerchief, throwing the circle around the limb, and twisting with a stick until the necessary degree of pressure is effected. The roller and compress may often be used with advantage, when the bleeding vessel is superficial and supported by a bone, as in the wrist and temple. Agaric and sponge, formerly much used for arresting hemorrhage, are now seldom employed. Under particular circumstances, however, the sponge will prove very serviceable, especially in hemorrhage from deep cavities. Styp- tics, of which the older surgeons were very fond, are scarcely ever thought of, and the actual cautery, anciently resorted to upon the most trivial occasions, is nearly banished from prac- tice. Pieces of glass, and other foreign bodies, are occasionally lodged in incised wounds. They should always be carefully picked away; for if left behind, great irritation will be excited. Sometimes bits of glass are working out for months or years after the wound has healed, and frequently are never found. The wound should always be kept open, and covered with an emollient poultice, when there is reason to suspect the lodge- ment of such articles. Blood, interposed between the edges of an incised wound, may act as an extraneous substance, and on this account ought to be removed before they are brought to- gether. Adhesive plasters are preferable to all other means for re- taining in contact the lips of a wound. The parts to which they are applied should be perfectly free from moisture, and if co- vered by hair, closely shaved. It is difficult, in many instances, to obtain plaster sufficiently adhesive to prevent the edges of the wound from gaping. The material chiefly resorted to at present, is a mixture of lead plaster and resin, in the proportion of a pound of the former to two ounces of the latter. This com- position should be melted and thinly spread on new linen, which must then be cut into strips of a length and breadth adapted to the extent and situation of the wound. Spaces should be left between the different strips for the escape of matter; otherwise abscesses are liable to form. Adhesive straps may be assisted very much in some cases by bandages, particularly by the uniting bandage, which is merely a double-headed roller, with a slit in its centre, sufficiently large to admit one head of the Vol. I. 8- 56 Incised Wounds. roller to pass through, so as to form a loop well calculated to grasp a limb and afford great support. Previously to the ap- plication of plasters and bandages, it is of great consequence to place the wounded part in a proper position. Sutures are, at the present day, only used when the wound is so extensive, or so situated, as not to admit of the application of adhesive straps. There are only two sutures in common use —the twisted and interrupted. The twisted is made by pass- ing a silver pin about two inches long, armed with a moveable steel point, or a common sewing needle fixed in a temporary handle, through both edges of the wound, and then casting a ligature obliquely from one end of the pin or needle to the other in the form of the figure 8. This suture is well adapted to wounds of the face, lips, &c. To make the interrupted suture, two crooked needles, one at each end of a ligature, are necessary. The needles are entered on the inner sides of the wound and brought outwards, carrying with them the ligature, which is tied directly across the wound. In extensive wounds, a number of these stitches will be required, and should be placed at mo- derate distances from each other. Neither the interrupted nor twisted suture should ever be made in an inflamed part, if possi- ble to avoid it. The object of adhesive straps, bandages, and sutures, is to procure adhesion, or union by the first intention, as it has been denominated. This very important process was well under- stood by some of the older surgeons, particularly by Taliacotius of Bologne, who succeeded, by means of it, in restoring muti- lated parts, and to a surprising extent. Mr. Hunter restricted the term union by the first intention, to that state in which the divided parts are held together, temporarily, by the interposi- tion of blood. By most surgeons, no distinction is drawn be- tween it and the adhesive inflammation. The French surgeons are, for the most part, extremely averse to the practice of closing wounds, after injuries or operations, for the purpose of procuring a speedy adhesion. They believe that secondary hemorrhage and abscesses not unfrequently result, and give rise to very troublesome consequences. Such apprehensions, however, are extremely unfounded in the generality of cases, although it is certain that much mischief has occasionally arisen, especially after amputation, owing to the edges of the wound having com- Incised Wounds. 59 pletely healed, while the deeper parts suppurated. On this ac- count, Dr. Physick has for many years been in the habit, in all amputations, of placing a bit of lint between the divided skin, to prevent immediate reunion. Besides these instances, cases un- doubtedly occur in which it would be improper always to bring about direct adhesion—as in certain morbid or cancerous parts. On the other hand, by pursuing an opposite practice and pro- curing a speedy reunion, immense advantages are gained in the greater number of cases. Not only indeed has the adhesive process been applied to the restoration of parts partially sepa- rated, but several very successful attempts have been made to restore fingers, toes, and other portions of the body, that have been entirely severed. These attempts have been founded upon the well known experiments of Duhamel, Hunter, and others, of transplanting teeth, and of fixing the spur of a cock into the comb of another, so as to establish between them a complete inoscula- tion and identity. An account of some very interesting cases of fingers restored, after being lopped off and remaining separated for some time, will be found in the tenth volume of the Edinburgh Medical and Surgical Journal. These cases are drawn up by Mr. Balfour, a respectable surgeon, and are well attested by other practitioners. The result should, at any rate, have the effect of inducing surgeons always to attempt reunion under simi- lar circumstances, whether the process succeed or not, instead of cutting away, as too frequently happens, parts which are hang- ing by a small portion, under the impression that restoration would be impossible. See Hunter on Inflammation, article Union by the first Intention, p. 189—J. Bell's Discourses on the Nature and Cure of Wounds,- also Principles of Surgery —Thomson on Inflammation, article Adhesion, p. 206—Carpue's Account of two successful Operations, for restoring a lost Nose from the Integuments of the Fore- head—Balfour's Observations on Adhesion, &c.—Jones on Hemorrhage, article Ligature, p. 125 and 166—Lawrence on a New Method of tying Arteries, &c, in Medico-Chirurgical Transactions, vol. 6, p. 156—Veitch's Observations on Se- condary Hemorrhage, and on the Ligature of Arteries after Amputation and other Operations, in the Edinburgh Medical and Surgical Journal, vol. 2, p. 176. 60 Punctured I Founds Section II. Punctured Wounds. Punctured wounds are created by sharp and narrow instru- ments, such as needles, pins, thorns, splinters of wood, nails, &c. When slight, they are seldom attended with inconvenience or danger. Much, however, will depend upon the situation of the part wounded, and the constitution of the patient. An appa- rently trifling puncture among tendons, nerves and fasciae, has sometimes caused tetanus. Again,—large collections of mat- ter have formed under the fasciae, producing great distress, and finally permanent contraction or extension of the limbs, by uniting the muscles or their connecting cellular membrane to- gether. Many years ago I attended a young gentleman from the Eastern shore of Maryland, whose fore-arm was covered with sinuses, from which matter could be pressed in every di- rection. The fingers were crooked and useless. The disease arose from a very trivial wound made by a needle fixed in the end of an arrow. The lymphatics often swell from punctured wounds. A wound of the foot will frequently cause a swelling of the groin, in every respect resembling the venereal bubo. Punctures of the fingers also, accidents very common in the dissecting room, give rise to similar swellings of the arm-pit. Several anatomists and students have from this cause lost their lives. A red line may, generally, be traced over the tract of the lymphatic, from the wound to the enlarged glands. Needles are sometimes buried under the integuments, or deep in the substance of the muscles. They are seldom productive of ill consequences, and in the course of time work out by ap- proaching the surface. However, I once attended an old gen- tleman, who died from a needle which penetrated the great toe immediately under the nail. A case is related by Mr. Carmi- ehael in which amputation near the shoulder joint was necessa- ry, in consequence of several needles being imbedded in the pro- nator quadratus muscle, in the periosteum of the radius and ulna and between these bones.' • Dublin Medical Transactions, vol. ii. p: 37. Punctured Wounds. 61 Treatment of Punctured Wounds. In a common punctured wound it is seldom necessary to do more than apply a soft poultice to the part for a few days, when the wound will heal without difficulty. But when the part swells, and evident indications of the formation of matter exist, an incision should be made to prevent its extension, and the ori- fice kept open by a tent or bougie. If nervous symptoms arise, denoting the approach of tetanus, the wound should be freely dilated, and stimulating substances immediately introduced. Opium also must be exhibited in large and repeated doses. He- morrhage is seldom the consequence of a punctured wound, even if a large artery be pricked—the opening being too small for any quantity of blood to flow. When needles, or similar substances are buried under the integuments, it is almost im- possible to find them. But they should be searched for, imme- diately after they are introduced, and before they change their position. In some cases they may be readily drawn out by a forceps, and in others may be forced through the skin, by fold- ing up the integuments or muscles around, and pressing oppo- site each extremity of the needle. See Wardrop's Case of Nervous Symptoms from a Punctured Wound in vol. 7, of Medico-Chirurgical Transactions, p. 246, also a similar case% in vol 4, by Dr. Denmark. • 62 Penetrating Hounds. Section III. Penetrating Wounds. These wounds are more extensive than punctures, and are ge- nerally produced by the small sword, bayonet, or dirk. They may prove dangerous, by entering large cavities, and injuring impor- tant blood vessels, nerves, or viscera ; or they may give rise to extensive collections of matter, among the cellular membrane and muscles or under aponeurotic expansions. All penetrating wounds partake, more or less, of the nature of contused and la- » cerated wounds—the parts through which they pass being forcibly rent asunder, instead of being separated by a sharp-edged instru- ment. To this circumstance Richerand attributes the nervous agitation and other ill effects which occasionally result from such wounds. Treatment of Penetrating Wounds. The first object, in the treatment of penetrating wounds, is to suppress hemorrhage. This will often be found very diffi- cult, owing to the depth of the wounded vessel, and the narrow- ness of the passage leading to it. Sometimes, also, the source from which the blood flows cannot be ascertained. Again,— the vessel may be situated between bones, under fasciae, or among tendons, and cannot be reached without an extensive and painful dissection. Under such circumstances, we should cut down upon the main artery of a limb, or upon the chief vessel in the neighbourhood of the wound, from which the bleeding derives its source, and secure it by ligature.* In some situations pressure may be found very serviceable—as upon the radial artery, in case of wound of the palmar arch, or upon the tibial arteries in wounds of the foot. The plan recommended by * The operation, however, seldom succeeds. Penetrating Wounds. 63 Dr. Dorsey should be preferred to any other.* When the wounded vessels are so deeply seated, as in the chest or abdo- men, that they cannot be reached, our only resource is to dimi- nish the activity of the circulation by general blood-letting, there- by diverting the stream of blood from the wounded part, and preventing its further effusion. After inflammation has taken place, severe constitutional and local symptoms may arise. These are owing, not to the partial division of nerves and tendons, as the older surgeons supposed, but to the inflamed muscle being confined by a strong and dense fascia, or to inflammation of the fascia itself. These effects are most common after penetrating wounds of the thigh, hip, leg, fore-arm, bend of the arm, fingers, temple and head, where the fascia? are numerous, firm and unyielding. The true practice, in all such cases, is to dilate the wound, expose the fascia, divide it freely in a transverse direction, and the urgent symptoms will cease almost immediately. The wound may then be covered with a warm poultice, and in a few hours the thin ichorous dis- charge which is usually poured out while the nervous symptoms last, will be converted into a thick, yellow, healthy pus. In sim- ple penetrating wounds, unaccompanied by profuse hemorrhage, high inflammation, or constitutional disturbance, there can be no necessity for dilatation. The antiphlogistic regimen, and mild superficial dressings, will answer every purpose. Indeed, in many instances, such wounds heal by the first intention. See Charles Bell's Operative Surgery, founded on the Basis of Anatomy, vol. 1, p. 7. * " I shall mention a plan which I have known successful in stopping the flow of blood from an artery in the foot. The patient was a child in whom several unavailing attempts to tie up the divided vessel had been previously made, and the wound was in a state of great inflammation. A compress was applied over the trunk of the anterior, and another over that of the posterior tibial arteries, about two inches above the ankle: over these a strip of sheet copper was passed round the leg, and a tourniquet was applied over the copper; in this way, when the tourniquet was tightened the tibial arteries were compressed and the bleed- ing ceased, the copper prevented the tourniquet from compressing any other vessel, so that the circulation in the foot was not interrupted. In a few days the wound healed without any recurrence of hemorrhage. Probably in some analo- gous cases similar measures maybe found successful."—Elements of Surgery, Vol. I. p. 57. 64 Contused Wound*. Section IV. Contused Wounds. In every contusion, more or less injury is sustained by the deeper seated parts, even although the skin remain entire. In general, the smaller vessels are ruptured, and blood is poured into the cellular texture or among the muscles, producing an ec- chymosis and discoloration. If considerable vessels be torn, a large circumscribed tumour may form, or else the surrounding parts may be extensively injected with blood, giving rise to gan- grene from pressure, or to suppuration from irritation. • The nerves, also, in contused wounds suffer materially from concus- sion—the effect being similar to that, although in a less degree, which takes place in injuries of the head. Hence, such wounds are at first attended with little pain, but their sensibility after- wards increases in proportion to the extent of the inflammation. A blunt instrument will operate according to the velocity with which it is carried, or to the resistance afforded by the texture upon which it is applied. For a blow to produce its full effect, the action and reaction should be equal. Where the parts yield, the shock is diminished and the injury is less considerable. Of- tentimes it happens that a limb is crushed by machinery, the bones are mashed into small pieces, the joints destroyed, and the vessels bruised or torn, and yet the skin, from its yielding nature, is not divided. An injury of this description is dangerous in the extreme, and gangrene the almost certain consequence. When the skin is cut along with the internal parts, it is generally owing to the surface of the contusing weapon being not very broad. Treatment of Contused Wounds. A simple bruise or contusion, should be treated upon com- mon antiphlogistic principles. Leeches applied to the part will Contused Wounds. 05 be found extremely serviceable in subduing the swelling and pain. Cloth.s dipped in a cold solution of the acetate of lead, and constantly applied, will also prove very useful. Perfect rest and relaxation of the muscles are essential. After the inflammation has subsided, repeated friction with stimulating embrocations, such as the soap and volatile lini- ments, by promoting the absorption of the effused coagulated blood, will soon effect a cure. When the extravasation of blood has been too considerable to be taken up by the absorbents, an opening should be made in order to evacuate it. In slight cases, however, such an operation should always be avoided. A roller applied with moderate firmness will often assist mate- rially in dissipating the swelling, and in preventing oedema, which is always apt to ensue. Although there is seldom much prospect of uniting a con- tused wound by the first intention, it should always be at- tempted, inasmuch as even partial agglutination will serve to kee'p the edges together, and prevent deformity and other ill consequences. But great care must be taken not to approxi- mate the sides of the wound too closely, by rollers, adhesive straps or sutures, lest so much pressure and irritation be pro- duced as to bring on gangrene. Stitches indeed should, in most contused wounds, be prohibited. When along with the contusion there has been loss of substance, and the edges of the wound cannot be brought together, a poultice moderately warm, and occasionally repeated for a few days, will keep the part easy and promote granulation. Afterwards, simple dressings may be employed. As there is always more or less concussion in every extensive contused wound, blood-letting and other gene- ral depleting remedies should be avoided until reaction is com- pletely established. Should symptomatic fever follow with high local inflammation, the patient must be bled freely, take purga- tives, and be kept on a low diet. Vol. I. 9 66 Lacerated Wounds. Section V. Lacerated Wounds. Any obtuse or irregular body, driven with force, may pro- duce a lacerated wound. Machinery in full motion, a cannon ball, splinters of wood, are apt to create very extensive and ragged lacerations. Sometimes a patient falls from a height, and lights amidst sharp and disjointed stones, by which the soft parts are torn and shockingly mangled, and dirt kneaded into them in such a way as to render it almost impossible to wash them clean. In other instances, the scalp is suddenly whirled off by the wheel of a cart or carriage passing over the head. Again—whole limbs are torn from the body by being entangled in machinery. Many such cases are recorded by dif- ferent surgical writers, especially by Chesselden, Carmichael, La Motte and Morand. Lately, an interesting case has been detailed by Dr. Kennedy of India, where a dreadful lacerated wound took place from the bite of a shark. The abdominal muscles were cut asunder and turned back, so as to expose the colon and several convolutions of small intestines; three of the lowest ribs were laid bare, the gluteal muscles torn up, the ten- dons about the trochanter divided, and the vastus externus and rectus muscles completely separated. A more extensive and shocking wound could hardly be produced, and yet the patient in a few weeks recovered. Every lacerated wound is peculiar in this—it bleeds spa- ringly. However large or numerous the vessels torn—how- ever extensive or complicated the injury, it will be found uni- versally that the hemorrhage is comparatively inconsiderable. Some years ago, I was called to visit a patient at Dorsey's iron works in Maryland, whose right arm above the elbow had been torn off in a mill. Seven or eight hours elapsed before I reached him, and although the arm had been dreadfully mutilated, the muscles torn to tatters, and the brachial artery was gaping with open mouth on the surface of the stump, yet not more than a few spoonsful of blood were lost. So extensive, indeed, had been the shock, and so far had its influence extended, that, in Lacerated Wounds. 67 amputating the arm several inches above the torn extremity, hardly any blood was poured out, even when the main artery was cut through in a part apparently sound, and which after- wards healed with great facility. In another instance, a boy in falling from the top of a tree, had the brachial artery, at the bend of the arm, torn completely across by a projecting branch. Scarcely a drop of blood was lost, and in searching for the ves- sel, some hours after it, could hardly be made to bleed, although repeatedly cut with a view of ascertaining the extent of the injury. The indisposition manifested by a lacerated part to bleed, is owing to the injuries sustained by the nerves, not only in the immediate vicinity of the wound, but to a greater extent around than the eye can discover. Hence the arteries are paralyzed and do not contract to propel the blood, which coagulates in their cavities or among the torn muscular fibres. Hence, also, all lacerated wounds are attended with little pain, are liable to gangrene and to secondary hemorrhage, which is then more dangerous than bleeding produced by sharp cutting instru- ments. Treatment of Lacerated Wounds. In every lacerated wound the attention of the surgeon should be directed first towards the removal of extraneous bodies, and the suppression of hemorrhage, if any exist. The edges of the wound should be next loosely drawn together, and retained by adhesive straps. Although we can scarcely calculate upon ad- hesion to any extent, after such injuries, yet great benefit results from keeping the parts as nearly as possible in their natural situa- tion, inasmuch as fewer granulations will afterwards be required to supply any loss of substance, than if the parts were permitted to recede, from each other. Adhesion, however, does in some cases take place to a much.greater extent than we could ima- gine possible, and that, too, after very severe and extensive lace- rations. We, should make it a rule, therefore, never to remove any loose hanging portion, under the idea that it must neces- C8 Treatment of Lacerated Wounds. sarily slough or separate, since this can only be determined by the event of the case. At any rate no harm will result from permitting the wounded parts to remain, even if they be in a gangrenous state, as they must soon separate spontaneously. If much swelling and pain arise after the lips of the wound are approximated, the straps should be removed, and the whole sur- face of the wound covered with a warm poultice, which should be repeated frequently and continued until suppuration is fully established, when the edges may again be drawn together, and generally with decided benefit. After the sloughs have sepa- rated and the surface of the wound becomes clean and granu- lating, simple dressings may be employed. Very severe constitutional symptoms—as fever, restlessness and delirium, sometimes follow lacerated wounds. These must be subdued by blood-letting, saline purgatives and low diet. But care should be taken not to carry depletion too far or to de- tract suddenly a large portion of blood, otherwise gangrene, to which at any rate there is generally a predisposition, may be hurried on. Tetanus, moreover, which is very apt to ensue from lacerated wounds, will more readily be induced, if the system has been much prostrated by evacuants. When there is no prospect of healing a lacerated wound, but on the contrary when gangrene is inevitable, then amputation, if the part admit of it, must be resorted to. The surgeon, however, should possess much judgment, to enable him to determine the precise period when the operation should be performed. In particular, he should carefully avoid, amputation, so long as the extremi- ties are cold, the pulse weak and fluttering, the wound dry, and the powers of life nearly exhausted. From inattention to these circumstances, I have known four patients lose their lives, who, under judicious treatment, might probably have been saved. But there is another extreme into which the surgeon may fall if not strictly on his guard—the removal of the limb after the circulation has been restored, after fever has commenced and the wound become painful and begun to discharge a bloody serum. A medium should then be chosen, and the moment se- lected for operation when the powers of life have returned, when the lips have regained their colour, the features their na- tural appearance, and the extremities a proper warmth. When patients die from a premature operation, it is owing to Treatment of Lacerated Wounds. 69 the shock communicated to the nervous system, before the vital energy has rallied sufficiently to encounter so severe a stimulus. When they die, after the full restoration of the circulating sys- tem and the establishment of febrile action, then life is assaulted through the medium of inflammation and high action, and the operation is almost sure to be followed by gangrene. Each state then, it will be seen, is precarious, and it is only by ob- serving a happy medium that we can expect to succeed. Te- tanus in some instances follows very speedily a lacerated wound. In hopes of arresting its progress, some surgeons have advised immediate amputation. I have known the remedy tried in one instance only, but the patient died before the operation was completed. Immense doses of opium and asafoetida I believe to be the only alternative under such circumstances. See in Pott's Works, vol. 1, p. 9, a note by Sir James Earle—Chesselden's Ana- tomy, Case of James Wood—Carmichael, in Medical Commentaries, vol. 5—Mo- rand, in Academie de Chirurgie, torn. 4, p. 141. La Motte, Traite des Ac- couchemens—Kennedy, in Medieo-Chirurgical Transactions, vol. 9, p. 240. 70 Poisoned Wounds. Section VI. Poisoned Wounds. Poisoned wounds occur frequently, and are dangerous or otherwise, according to their extent, and the agent by which they are produced. Whether these agents be derived from the animal, vegetable, or mineral kingdoms, they are in many in- stances equally deleterious. In this country such injuries gene- rally arise from insects, serpents, rabid animals, or from the introduction of morbific matter into the system. Among the insect class, wounds from the common bee, humble-bee, wasp,* hornet, yellow-jacket, are very frequent, and sometimes productive of high inflammation and pain. In- stances, indeed, are recorded of death, both in human subjects and inferior animals, from the attacks of swarms of these ani- mals. Occasionally death has followed from swallowing a wasp or bee, in consequence of the gullet being wounded by the sting of the animal while passing to the stomach. In this way a young woman in Jersey, a few years ago, lost her life;—a bee having been enclosed in a piece of honey-comb which she swallowed. * Mrs. Day, aged 69, wife of Colonel Day, of Deerfield, Portage county, died in fifteen minutes after receiving the sting of a yellow wasp whilst engaged in drying apples, " As Mr. Martin Lazarus, of Salisbury township, Lehigh county, was em- ployed in hauling manure, in a three horse wagon, a bee happened to light on the leader horse whilst passing the garden fence, and stung him. This started not only the leader, but also frightened the other two horses, and endeavouring to stop them, the wagon got in contact with the garden fence, tore it away and upset a whole row of hives. The enraged bees all fell upon the horses and men, and stung two of the horses to death, and very much injured the other, as well as Mr. Lazarus, his son, and servant." " Mr. Edwards, of Peckham, placed a pony about fifty yards from a bee-hive, and quite out of sight thereof. The bees alighted upon the pony, and stung her so violently, that she died in about fifteen hours after. The pony was bled and washed with stone blue water, and dissected: the kidneys appeared much bruised. It is supposed, from the agony she appeared in, that it was as much from the effects of fright as of pain that she died." Poisoned Wounds. 71 The mischief resulting from the stings of bees, wasps, &c, does not proceed from the mechanical injury, but from the acrid liquor infuaed into the wound by these animals; each of which has a subtle poison contained in a receptacle, situated within the abdomen among the air-vessels, and is furnished with muscles and other apparatus for injecting the wound made by the barbed dart or sting. In the hornet and yellow- jacket this liquor is highly acrimonious, and quickly excites very violent inflammation. Besides insects of the bee kind, there are several others which occasionally inflict severe and dangerous wounds—the common moscheto, some varieties of fly, certain spiders, the scorpion, &c. In peculiar constitutions the moscheto bite will degenerate into a very troublesome sore, and death has even followed. Dr. Dorsey* states, that he once knew gangrene and death to take place from the bite of this insect, in the case of a lady who previously enjoyed very good health. I am in- formed by a distinguished naturalist of this city, that numerous instances have occurred at Egg Harbour and other places of similar situation, of cattle being destroyed by the wounds re- ceived from these animals. The bite of the green-headed fly, common about Cape May and other parts of the Atlantic coast, is extremely severe; but I have never heard of serious injury from it. The spider has long been considered a venomous reptile. There is reason to believe, however, that most of the species are harmless, whilst it is certain that in a few instances, very se- vere symptoms and even death have followed from the bites of particular animals of the class. Dr. Measef mentions an in- stance of a person who lost his life, from an apparently insigni- ficant wound of one of these insects. The bite of the tarantula, a species of spider common about Naples and many other parts of Europe, was formerly supposed to be extremely venomous and often fatal. Modern observations, however, prove that few ill consequences result from wounds inflicted by these ani- mals. It is very surprising that such men as GeoffroyJ, Baglivi,§ * Elements of Surgery, vol. i. p. 68. t Domestic Encyclopedia. t Koyal Academy of Sciences, 1702. § Bnglivi Opera, 72 Poisoned Wounds. and Mead,* should not only give credit to the fanciful and ridi- dulous reports of the supposed operation of the poison of the tarantula, but should even endeavour to account for its specific mode of action, and for the imaginary effects of music in pro- moting its cure.—During the expedition up the Missouri under the command of Major Long, Mr. Say and the other naturalists often met with a spider of monstrous size and very hideous ap- pearance; but no opportunities were offered of ascertaining whether it was venomous. M. Morau de Jonnes has furnished a memoir on an enormous spider common at Martinique and its vicinity, which attacks small birds and reptiles, and infuses into the wounds made by its strong jaws a subtle poison which quickly proves fatal.f The scorpion is a very venomous insect, and often in warm climates inflicts a fatal wound. The largest of the species, {scorpio afer,) inhabit India, Persia, and Africa, and are much dreaded on account of the activity of their poison, which is con- tained in a reservoir situated near the tail of the animal, and ejected from two small holes on each side of the tip of the sting. The American scorpion is not so large as some other species, but is capable of producing by its sting most violent inflamma- tion and sometimes death. From a number of experiments per- formed on dogs and other animals by Maupertius,J it appeared that the sting of the scorpion caused the whole body of the wounded animal to swell, and was productive of violent retch- ing, convulsions and death. In other instances no inconvenience whatever followed from the sting of these insects. " I have fre- quently seen," says Mr. Allan, " the sting of the scorpion fol- lowed by violent inflammation and swelling, similar to those of bees and wasps, only in a more aggravated degree. In the years 1803 and "1804, I had many opportunities of witnessing wounds inflicted by the sting of the scorpion on board of La Dianne frigate. She was one of those French ships which escaped from the battle of the Nile, but was afterwards captured by the British when coming out of Toulon. In August, 1803, she was commissioned at Plymouth, and taken into the service * Mead on Poisons. t For an account of the medical properties and bite of the spider, see Lister, De Araneis Tractatus, also Berner, De'Ardnsc punctura et ejus medela. t Mem. de l'Acadrmie des Sciences, 1731. Poisoned Wounds. 73 of the British Navy. Having been long in the Mediterranean while in the French service, the scorpion had got on board. From the coldness of our climate the insect had lost its vigour, and lay concealed behind the lining, in the seams, betwixt the timbers, and in other parts of the ship; but no sooner had the ship gone to sea, and proceeded to the southward, than it was found she was literally swarming; the heat renewed their acti- vity; they crawled forth from their lurking holes and stung many of the men. The wound was always followed by violent and extensive inflammation, considerable swelling, and great pain, but I never observed any violent constitutional symptoms succeed to the local."- Of the numerous American serpents two species only are known to be venomous—the rattlesnake and copperhead. Eight varieties of the former have long been familiar to naturalists, and two others have been discovered lately by Humboldtf and Bon- pland. All are poisonous, but in particular the crotalus du- rissus, horridus, and miliarius. The copperhead, {boa crota- loides,) sometimes called the bastard rattlesnake, is also exceed- ingly malignant. All these reptiles are furnished with long teeth, or poisonous fangs, the roots of which are surrounded by a bag or reservoir containing an active or virulent poison. This poison is discharged into the wound through a small fis- sure of the tooth situated near its extremity, and in many in- stances very quickly proves fatal both to man and to inferior animals. As regards the effects of the poison, much will depend upon the size of the animal bitten—death being produced more readily in the smaller than in the larger animals. According to the experiments of Vosmaer, sparrows, finches and other small birds died in about four minutes, while a mouse died in a minute and a half. The deleterious operation of the poison will also depend materially upon its quantity, and upon the season of the year at which the wound is inflicted. To ascertain the effect of the bite of the rattlesnake, several experiments were made by Captain Hall of Carolina, upon dogs, cats, chickens and frogs. Three dogs were bitten in succession by a snake four feet long. » Allan's system of Pathological and Operative Surgery, vol. i. p. 370. t These arc the Crotalus Cumanensis and the Crotalus Lttflingii. See Re- cucil d'Obscrvations de Zoologie et Anatomie Compared, 4to. Vol. I. 10 74 Poisoned Wounds. The first died in less than a quarter of a minute, the second in two hours, and the third in three hours. Four days after, two other dop-s were bitten; one of which died in half a minute, the other in four minutes. Several experiments nearly similar, were made by the late Professor Barton on chickens. Of three chickens bitten on three days successively, one died in a few hours, another lived much longer, and the third recovered after having been exceedingly swelled. On the fourth day, several other chickens were bitten, but recovered without a bad symp- tom. The rattlesnake is more lively, and its venom more active, during very warm weather than at any other period: upon the approach of the cold season, it becomes languid, and then strikes reluctantly, and frequently without any ill consequence. The effects produced by the poison either on the human body or on the lower animals, vary according to the parts wounded, the depth to which the fang penetrates, and the quantity and strength of the venom in the reservoir. In many instances death follows in a few seconds or minutes, and in others not until many days or weeks. The interesting case detailed by Sir Everard Home, which I witnessed whilst a student in Lon- don, furnishes striking proof of the speedy operation of the poison of the rattlesnake, and at the same time affords incontes- table evidence that it may remain a long time in the system before death is produced. The patient was teasing a large rattlesnake with the end of a foot rule, but could not in- duce the animal to strike; the rule accidentally dropping from his hand, he opened the door of the cage to take it out; the snake immediately darted at the hand, and inflicted four wounds—two on the back part of the first phalanx of the thumb, and two on the side of the second joint of the forefinger. The hand soon after began to swell, and in the course of ten or eleven hours the whole arm, axilla and shoulder were verv much tumefied, and cold. There was an unusual coldness also throughout the skin of the whole body. At this period the mind of the patient was perfectly collected; but immediately after the accident he talked incoherently, owing probably to strong drink, which it was ascertained he had taken before he was bitten. From the axilla the swelling extended down the side, and blood was extravasated under the skin as far as the Poisoned Wounds. 75 loins, giving the back a mottled appearance. The skin over the whole body became warm, faintings occurred repeatedly, vesications appeared in different parts of the body, a large ab- scess formed on the outside of the elbow and discharged half a pint of reddish matter; mortification took place in the axilla, in the forefinger and some other parts, and finally destroyed the patient after he had laboured for eighteen "days under the most distressing symptoms. Upon dissection the body presented a natural appearance, (with the exception of the arm that had been bitten,) and the wounds made by the fangs of the reptile had healed. Instances have occurred, both among the Indians and among the white people, who inhabit the mountainous and thinly set- tled parts of our country, of almost instantaneous death from the bite of the rattlesnake. On the other hand, it is very certain that many persons wounded by this animal have sustained very trivial injury, if any. In such cases, it is probable that the teeth enter obliquely and do not penetrate the true skin, or that the reservoirs at the roots of the fangs have been empty, or the virus itself, owing to particular circumstances, so modified or changed in its properties or in such small quantity as not to produce fatal effects. Again,—where death has followed al- most immediately or shortly after the wound, the poisonous fangs have probably penetrated directly a considerable artery or vein, and conveyed the noxious matter at once into the cir- culation. According to Catcsby, the Indians very soon ascer- tain when this has happened, and, under an impression that the wound is necessarily fatal, apply no remedy. Upon these prin- ciples it will be easy to account for the supposed good effects of the numerous and diversified remedies, at different times pro- posed for the cure of the bite of the rattlesnake; inasmuch as there is reason to believe that nature, unassisted, is often suffi- cient to accomplish a cure, or that a sufficient quantity of virus has not been inserted to produce death. The poison of the rattlesnake is of a yellow colour tinged with green: during extreme heat, and particularly in the procreating season, it becomes of a much darker hue. The copperhead is equally poisonous with the rattlesnake, but few experiments have been made to ascertain its peculiar characters. In Europe the viper is more dreaded than any other poison- 76 Poisoned Wounds. ous reptile: it would appear, however, to be less deadly than the rattlesnake, and according to Fontana, (who has studied its history more than any other naturalist, and who has instituted a great number of experiments in order to become acquainted with the operation of its \irus,) produces injury or death in pro- portion to the size of the animal bitten, and to the depth of the wound—small animals dying almost immediately, and wounds penetrating beyond the skin being equally fatal. The natives of India often suffer from the bites of the nume- rous species of Coluber, particularly from the cobra de capello, (Coluber naja,) which is extremely venomous. In many parts of the Eastern continent, the three Arabias and Africa, the ce- rastes or horned viper is extremely numerous, and often by its bite proves fatal. According to Bruce, however, the black peo- ple in the kingdom of Sennaar are perfectly armed against its bite. " The Arabs," says he, " have this secret naturally, but from their birth they acquire an exemption from the mortal consequences attending the bite of these animals, by chewing a certain root and washing themselves with an infusion of certain plants in water. One day when I was sitting with the brother of Shekh Adelan, prime minister of Sennaar, a slave of his brought in a cerastes, which he had just taken out of a hole, and was using with every sort of familiarity; I told him my suspi- cion that the teeth had been drawn, but he assured me they were not, as did his master Kitton, who took it from him, wound it round his arm, and at my desire ordered the servant to carry it home with me. I took a chicken by the neck and made it flutter before him; his seeming indifference left himi and he bit with signs of anger; the chicken died almost imme- diately;—I say indifference, for I constantly observed, that, however lively the viper was before, yet upon being seized by any of these barbarians, he seemed as if taken with sickness and feebleness, frequently shut his eyes and never turned his mouth towards the arm of the person who held him. I will not hesitate to aver that I have seen at Cairo, (and this may be seen daily without trouble or expense,) a man who came from above the Catacombs, where the pits of the mummy birds are kept, who has taken a cerastes with his naked hand from a num- ber of others lying at the bottom of the tub, has put it upon his bare head, covered it with the common red cap he wears, then Poisoned Wounds. 77 taken it out, put it in his breast, and tied it about his neck like a necklace; after which it has been applied to a hen and bit it, which has died in a few minutes; and to complete the experi- ment, the man has taken it by the neck, and beginning at the tail, has ate it as one would do a carrot or stock of celery, with- out any seeming repugnance."* Wounds from the bites of rabid animals are not always fol- lowed by rabies canina, or hydrophobia; indeed it has been well ascertained, that out of numerous persons bitten by dogs undoubtedly mad, very few have sustained material injury. This is owing, probably, to the human system being less sus- ceptible of impression from the virus than that of the lower ani- mals, and to the circumstance of the greater part of the body being covered by clothes, by which the infectious matter is wiped from the teeth, and thereby prevented from entering the wound in sufficient quantity to produce its full effects—to the teeth of the rabid animal not penetrating deep, or not striking a vascular part—to the saliva or venom being in smaller quan- tity in the animal's mouth at one time than another—and to an erythismus in the lymphatics of the wounded part sufficient to prevent the absorbent action. Dr. Hunter relates an instance of twenty persons bitten by the same mad dog, and out of that number only one took the disease. According to an estimate made by Dr. Hamilton, founded upon numerous facts, about one in every sixteen of the human species bitten by mad dogs, take the infection and suffer from the consequent disease. Great doubts still exist respecting the peculiar nature or mode of action of the virus, in giving rise to rabies canina. Mr. Cline instituted a number of experiments to ascertain whether the saliva of a hydrophobic man, in the last stage of the disease, could, by inoculation or other means, infect the inferior ani- mals, so as to propagate the complaint; but none of the animals into whom fresh saliva was inserted, were in the slightest de- gree affected, even at the end of three months. It would ap- pear, also, from some experiments by Sir Astley Cooper, that the saliva of a mad dog, inserted by a lancet into the inside of the thigh of a dog, a pig, a rabbit and fowl, produced no dele- Bruce's Travels, octavo edition, vol. vii. p. 302. 78 Poisoned Wounds. terious effect whatever; notwithstanding some of the animals were kept from nine weeks to twelve months. Between the infection and the appearance of the constitutional disease, the interval is often very various and uncertain. In general, the attack does not commence until after the lapse of thirty or forty days, in some instances no signs of the disease have appeared for twelve or eighteen months, and in one case recorded by Dr. Bardsley, the patient remained perfectly well for twelve years and then died from the disease. These facts would seem to prove that the system is affected through the medium of absorption, and not from any influence exerted by the virus upon the extremities of the nerves of the part,—an opinion formerly entertained. The wound made by the teeth of a rabid animal heals with as much facility as any other wound, and often is entirely obliterated, long before the constitutional symp- toms have appeared. It has been observed, however, that when any constitutional disturbance takes place, before the closure of the wound, then instead of continuing to granulate and dis- charge a healthy pus, the sore puts on a sloughy character and the matter becomes thin and ill conditioned. The symptoms of rabies canina vary very much according to the constitution of the patient; in general, some uneasiness, soreness or itching is first felt at the wounded part; the spirits of the patient are depressed, and he oftentimes suffers from in- describable anxiety. Occasionally a chill or rigor is the first symptom manifested. At night, the patient's sleep is disturbed by frightful dreams and by spasmodic startings; the pulse is quick and fluttering: the appetite fails; but the thirst is increased. At this period it is generally observed, that when the patient attempts to drink, he is immediately seized witfi a sudden and spasmodic catch in the breathing, which is increased upon re- petition, and finally is attended with indescribable horror and universal agitation. The very idea or thought of liquids is af- terwards sufficient to excite the same painful and distressing symptoms, and should the patient have resolution enough to at- tempt to swallow, or to struggle against the spasmodic and agonizing contractions of the muscles of the throat, the whole system becomes so convulsed, that he finds it impossible to ac- complish his purpose. This fear of water or hydrophobia, is Poisoned Wounds. 79 not, however, a universal concomitant of the disease; in many instances, it is altogether absent; it is, moreover, an attendant upon other diseases, not in the slightest degree allied to canine madness. But in the worst forms of the complaint it is for the most part present, and of all the individual symptoms by far the most horrible and appalling. A symptom, less constant than those mentioned, but some- times very distressing, is a collection of thick, viscid, ropy phlegm, which adheres to the fauces and throat so closely, that the patient finds it extremely difficult and often impossible to throw it out; although the most vehement efforts are employed for the purpose. In a patient attended by Dr. Marcet,* the quan- tity of this tenacious lymph was so considerable, and ejected with such extreme torture, that he exclaimed, " Oh! do some- thing for me; I would suffer myself to be cut to pieces ! I cannot raise the phlegm, it sticks to me like birdlime." In the latter stages of hydrophobia the pulse becomes ex- ceedingly agitated and hurried, and the breathing very quick and laborious; the countenance is expressive of great anxiety and fear, the eyeballs glare and seem ready to start from their sockets, and the muscles of the face and neck are horribly con- torted. Sometimes the patient becomes altogether furious and unmanageable, and attempts to tear and bite himself and every one near him ; but in general he is perfectly inoffensive, and answers questions with great precision and in the most rational manner. He seldom lives beyond the fourth or sixth day, and is either carried oft'suddenly by a violent convulsion, or expires quietly—his bodily vigour being completely exhausted by inor- dinate exertions and continued suffering. The introduction of morbific matter into the system, is some- times apparently productive of the worst consequences. Per- sons much engaged in the dissection or examination of putrid bodies, or in macerating or making preparations, have occasion- ally suffered from wounds of the scalpel or dissecting hook, or from punctures made by spicula of bone, &c. In such cases vio- lent inflammation has followed, extending up the arm as high as the axilla or neck, rendering the whole limb exceedingly tense and painful, and finally producing extensive abscesses, some- times gangrene, and sometimes death. Examples of this kind * Medico-Chirurgical Transactions, vol. i. 80 Poisoned Wounds. have been recorded by different writers. Mr. Fyfe, the cele- brated anatomist at Edinburgh, informed me that he nearly lost the use of one arm for several years, owing to a wound of the finger by a dissecting knife. Dr. Chambon of Paris, in attempt- ing to separate a sphenoid bone, which had long remained in maceration, from the other bones of the head, received so severe a wound in one of the fingers as to keep him on the brink of the grave for upwards of three years.* Corvisart,f also, in examining a dead body, pricked a finger, in consequence of which the whole arm swelled enormously, and was only re- lieved by very extensive incisions performed by Desault. Percy relates the case of a student who died, in three days, from dis- secting a body which had been kept for several weeks. Mor- tification took place in the wounded finger, and extendly rapid- ly throughout the arm. Professor La Clerc is said to have lost his life from touching, with a sore finger, the pulse of a patient in a profuse perspiration, who laboured under a malignant fever. Dr. Rush mentions an instance of a young man who died from a wound he received in skinning an ox.J But none of these examples furnish direct evidence of the absorption of morbific virus; since many others might be adduced to show that the same symptoms have followed from apparently trifling injuries, and under circumstances where no virus could possibly have been absorbed. Dr. Physick informs me, that he once attended a patient who died from gangrene of the whole arm, simply from a slight scratch of the shell in the act of opening an oys- ter; and I have known a puncture from a needle in one of the fingers produce nearly throughout the arm most violent inflam- mation and suppuration. In all probability, then, a simple puncture, in certain constitutions, is capable of producing ef- * Dictionnaire des Sciences Medicales, torn. ix. p. 649, t Ibid. t Within the last few years several interesting cases have been detailed in which surgeons and medical students have lost their lives, or been reduced to the lowest extremity by slight wounds, received in the dissection or examina- tion of dead bodies. Among these may be mentioned the names of Professor Dease, of Dublin, Dr. Pett and Mr. Newby, of London, Mr. Gerard, professor of the veterinary school of Alfort, Messrs. Etcock, Shekelton, Graves, Archer, and Hutchinson, students of medicine, all of whom perished in a few days, after having suffered beyond description. Other cases are recorded, too, and these by no means few in number, in which the patients thus wounded, have, though with great difficulty, recovered after a lapse of weeks or months. Poisoned Wounds. 81 feels which might easily be attributed to the operation of some specific virus. This conclusion is rendered more probable from what we know to happen in tetanus, which is sometimes pro- duced by the most insignificant scratch, and at other times can- not be excited by the most extensive laceration.'' Treatment of Poisoned Wounds. It seldom happens that the stings of bees and wasps are so se- vere as to require active remedies for their cure. In general lo- cal applications afford speedy relief. A solution of common salt, 'applied to the part, will produce almost instantaneous ease. This remedy was first introduced, it is said, by Dioscorides, and has since been found serviceable even in wounds of the oesophagus. An English gentleman saved the life of his friend, who had swallowed. unperccived, a wasp in a glass of beer, by causing him to drink plentifully of salt and water.! The aqua ammonise, applied to a part stung by bees, I have often known to act like a charm. Cold water, rose water, a solution of the acetate of lead or of opi- um, constantly applied, will, in many instances, soon cause the pain and inflammation to subside. Bleeding and purging, with strict antiphlogistic regimen, will probably become necessary when the patient has suffered from a swarm of bees. The same remedies will be found equally useful for the bites of spiders, flies, moschetoes and other insects. In Morocco, where the scorpion is very common, most fami- lies keep a bottle of olive oil, in which the bodies of several of these reptiles have been infused, and when bitten apply it to the wound, and with reputed success. A ligature, moreover, is • For various illustrations and numerous interesting cases and observations re- specting the effects of poisoned wounds, see Thavirs on " Constitutional Irri- tation." f Dictionnaire des Sciences Medicales, torn. i. p. 40. Vol. I. 11 82 Poisoned Wounds. generally placed above the wounded part, to interrupt the pro- gress of the poison, and the wound is afterwards scarified and cauterized. " In Tunis, when any person is stung by a scor- pion," says Mr. Jackson,* " or bit by any other venomous rep- tile, they immediately scarify the part with a knife and rub in olive oil as quick as possible, which arrests the progress of the venom. If oil is not applied in a few minutes death is inevitable, particularly from the sting of a scorpion. Those in the kingdom of Tunis are the most venomous in the world." According to the same author, the eooiies or porters, who work in the oil stores, have their bodies constantly saturated with oil, and on this account not only never suffer in the slightest degree from the bites of scor- pions and other reptiles which creep over them at night as they sleep on the ground, in great numbers; but there is not a single instance known of one of these people ever having taken the plague, although the disease frequently rages at Tunis in the most frightful manner. The use of olive oil has been highly extolled by many wri- ters as ,a remedy for the bites of poisonous serpents. Dr. Mil- lert of South Carolina relates the case of a man who was bitten in the sole of the foot by a very large rattlesnake. Although very little time elapsed before he reached the patient, his head and face were prodigiously swelled, and the latter black. " His tongue was enlarged and out of his mouth; his eyes as if start- ing from their sockets; his senses gone, and every appearance of immediate suffocation." Two table-spoonsful of olive oil were immediately got down, but with great difficulty. The effect was almost instantaneous; in thirty minutes it operated freely by the mouth and bowels, and in two hours the patient could articulate, and soon after recovered. The quantity of oil taken internally, and applied to the wound did not exceed eight spoonsful. In the course of twelve years, Dr. Miller has met with several similar cases, in which the oil has proved equally successful. Mr. Oliver}; has detailed a number of experiments in proof of the efficacy of warm oil, when applied to the wound * Jackson's Reflections on the Commerce of the Mediterranean. London, 1804. f New York Medical Repository, vol. ii. p. 242. - t Philosophical Transactions, vol. xxxix. p. 310. Poisoned Wounds. 83 made by the bite of a viper; but Linnaeus* found it quite ineffi- cient. The volatile alkali was, for a long time, in very general use as an antidote against the poison of different serpents; but trie experiments of Fontana are calculated to show, that so far from being useful, the symptoms produced by the bite of the viper were increased either by the internal exhibition of the medicine or by its external application. On the other hand, the late Dr. Ramseyt of South Carolina, one of the most distinguished phy- sicians our country can boast of, has declared " that the volatile alkali properly administered, will, in a short time, cure the bite of any snake, or the sting of a spider, or any other venomous in- sect, is a medical fact as well established as that the Peruvian bark will cure an intermittent fever." Dr. Ramsey's declaration is founded upon the result of several cases, wherein patients have suffered from the bites of rattlesnakes, and have been cured, ap- parently, by the volatile alkali. We are strongly inclined to the opinion, however, that the injuries received were not, indepen- dently of the action of the remedies employed, sufficient to cause the patient's death, or, in other words, that spontaneous cures, which we know to be very common, took place. The same re- marks may, perhaps, apply to the cases detailed by Dr. Ander- sonj of Madras, respecting the cure of the bite of the cobra de capello, and by Dr. Brichell§ of Savannah, of the rattlesnake and mochison, by means of alkalies. In the latter case, the patient probably would not have died, as it is well known to naturalists that the mochison is not a venomous serpent. As an internal medicine, arsenic has been lately found more decidedly beneficial than any other. Mr. Ireland|| has recorded five cases, in all which the most violent symptoms produced by the bite of the coluber carinatus, a poisonous serpent very com- mon at the island of St. Lucia, were, by the use of this medi- cine, speedily arrested. The supposed efficacy of the Tanjore pill, a medicine very commonly employed in India against the • Amoenitales Academicac, vol. xi. p. 407. j- London Medical and Physical Journal, vol. xi. p. 332. i Medical Repository, vol. ix. p. 109. § Ibid. vol. viii. p. 451. p \l;di( n-Ohirurgical Transactions, vol. ii. p. 394. 84 Poisoned Wounds. bites of serpents, the chief ingredient of which is arsenic, first led Mr. Ireland to employ Fowler's mineral solution. He gave it to the extent of two drachms every half hour, and repeated for four hours, with the best effects. Severe vomiting and purging fol- lowed the administering of the medicine, and the patients were soon after relieved. When a person has been bitten in the extremities by a ser- pent supposed to be poisonous, a ligature should immediately be thrown around the limb above the wound, and drawn exceed- ingly tight in order to interrupt the progress of the venom through the absorbents: after this a portion of flesh, for some distance beyond the wound, should be quickly removed by the knife; then the kali purum, the lunar caustic, or the actual cau- tery, must be applied until an eschar is produced. The wound should afterwards be dressed with some simple ointment. With regard to internal medicines, no objection can arise to the exhibi- tion of oil, volatile alkali, or Fowler's mineral solution; for if use- less, they cannot at any rate prove injurious, and upon this prin- ciple should be tried. As hydrophobia may still be considered an incurable disease, the great object of the surgeon must always be to secure the pa- tient against its attack. Fortunately this can be accomplished, in many instances, by removing the bitten portion of flesh as speedily as possible after the accident, and in some cases even after weeks have elapsed and the wound has healed. When- ever, therefore, we are called to a patient, who has been bitten by a dog or any other animal supposed to be mad, such inci- sions should instantly be made as will include a portion of flesh greater than the depth to which the teeth of the animal have extended. This operation should be performed, were it only by way of precaution, or in cases where no absolute certainty has existed of the animal being mad. If the surgeon is timid and cuts sparingly, there will be much reason to apprehend that the operation will not prove successful. In general, owing to several teeth penetrating at the same time and at different parts, it will be necessary to remove several distinct portions of flesh. Should the teeth perforate between the bones of the hand or foot, as often happens, so as to leave insufficient room to remove all the injured soft parts, our only resource will be to amputate Poisoned Wounds. 85 without delay. By way of security, after the incisions have been practised and the bleeding suppressed, it will be advisable to apply to the wounds the lunar caustic, the kali purum, or what is still better, equal parts of white arsenic and sulphur, a remedy introduced by Mr. Cline, and extolled by Sir Everard Home as extremely valuable in cancer, and which experience has proved to be the most powerful caustic employed in surge- ry. By adopting these measures, we shall often have the satis- faction to find the fears of our patient allayed, or the disease consequent to the bite of rabid animals entirely prevented. The same operations should be resorted to, after months have elapsed without any thing having been done for the patient, pro- vided the cicatrix becomes sore or painful and indicates the approach of the disease. When any doubt exists of the animal being mad, instead of having it killed as soon as possible, as is generally done, it should be confined until the symptoms be- come so clear as to remove or confirm all suspicion on the sub- ject. When our operation fails and rabies canina is established, then various remedies may be tried. Of these opium, mercury, cantharides, volatile alkali, belladonna, musk, arsenic, camphor, lunar caustic, the cold bath, and blood-letting, have been con- sidered the most powerful. Blood-letting, carried ad deliquum animi, has lately been extolled in the highest terms by Mr. Schoolbred of Calcutta, and some facts have been adduced by Mr. Tymon, assistant surgeon of the 22d English light dragoons, which go to prove, that taking away, at once, an immense quantity of blood, so that scarcely a pulsation can be felt in ei- ther arm, has been attended with the most favourable result.* According to Professor Brugnatellist several cases of hydropho- bia have been cured in the hospitals of Lombardy, by the ex- ternal and internal use of hydrochloric acid. Dr. rhysick,J some years ago proposed, under the idea that many patients la- bouring under hydrophobia, died from suffocation caused by spasm of the muscles of the glottis, to open the trachea in order to sustain the breathing, until the effects of different remedies • See Cooper's Surgical Dictionary, edit. 4th, p. 611. | Eclectic Repertory, vol. viii. p. 256. t Medical Repository, vol. v. p. 1. 86 Poisoned Wounds. could be fully tried. I do not know of any instance in which the experiment has actually been performed ; but am strongly inclined to believe, from the termination of numerous interest- ing cases, recorded by different writers, in which the chief symp- tom was a difficulty of breathing and swallowing, to such a de- gree as apparently to destroy the patient, that decided benefit would result from the practice. Under this impression, should a case present, I would perform the operation of tracheotomy, or else introduce a gum elastic catheter into the glottis and tra- chea. It is well known that such an instrument may be carried into the larynx, and there suffered to remain for any length of of time, without exciting any unpleasant symptom, except a violent and convulsive cough at the moment of its passage through the glottis. As respects the treatment of wounds received in dissection, much diversity of opinion prevails even amongst the most dis- tinguished members of the profession. Some are inclined to trust mainly to the antiphlogistic system, to saline medicines, calomel, antimony, opium, and the local application of lunar caustic. Such is the plan recommended by Sir Jlstley Cooper. Mr. Travers objects to the caustic unless applied immediately after the receipt of the injury, and seems inclined in most cases to prefer the stimulating to the depressing plan of treatment. But he is an advocate for soothing applications and for poultices af- ter the parts have been freely divided in the course of the wound by a sharp lancet. According to Mr. Shaw, the most effectual mode of reducing the inflammation of the lymphatics is to "apply lint soaked in the sugar of lead lotion and tincture of opium to the arm, and to take calomel purges, and large doses of opium with plenty of wine and porter." The same gentle- man recommends that the finger be wrapped in lint dipped in equal parts of Goulard's lotion and laudanum, and advises to lay open the injured part to the bone when there is reason to believe that the matter has formed. Fortunately for the profession in this country, injuries from dissection are extremely rare. This may probably be owing in part to the abundant supply of fresh subjects every where to be obtained in the large towns, owing to which students are Poisoned Wounds. 87 seldom under the necessity of using such as are decayed or in a diseased state. On this account, too, our knowledge of the treatment of such injuries must be comparatively limited. But much, we are inclined to believe, may be done in all such cases by way of prevention. Professor Chaussier, of Paris, has long been in the habit of advising that each student should carry a vial of butter of antimony in his pocket, and apply a portion of it to the wound immediately after its receipt. Others, with the same view, commend the nitric or muriatic acid. Others, again, by way of prevention, direct the hand to be covered with oils, po- matum, &c, or with gloves. Would not suction by the mouth, or the cupping-glass, answer in most cases, if employed immediately after the injury? Within the last few years, some very interesting and satisfac- tory experiments have been performed in relation to the patholo- gy and treatment of poisoned wounds. From the result of these, it appears, beyond all doubt, that the old remedy, the cupping- glass, recommended by Hippocrates, Celsus, Galen, and others, may be employed to a certainty in the removal of poisons from wounded surfaces or cavities, provided it be resorted to in time, and continued sufficiently long. For the knowledge of these facts the profession is greatly indebted to Dr. Barry.* The following extract will exhibit satisfactorily the whole treatment pursued by this eminent practitioner. 1st. " In all cases of superficial poisoning, when the delete- rious matter is simply deposited in the wound, the application of the cupping-glass over the point of contact will save the in- dividual, provided it be made with the precautions to be noticed hereafter, and before a dose sufficient to cause death shall have been absorbed. 2d. In cases where the poison has been inject- ed, as, for instance, by the hollow fang of a viper or rattlesnake, though the cupping-glass may have been applied, yet as the lo- cal action of the venom goes on in vacuo, the parts acted upon should be cut out after the venom has been concentrated and • Experimental Researches on the Influence exercised by Atmospheric Pres- sure upon the Progression of the Blood in the Veins, upon that Function called Absorption, and upon the Prevention and Cure of the Symptoms caused by the Bites of Rabid or Venomous Animals, &c, by David Bany, M. D. Lon- don, 1826, 8vo. 88 Poisoned Wounds. partly extracted by the cupping-glass, which should be imme- diately reapplied over the wound made by the knife, for the pur- pose of extracting the contents of the newly divided vessels from a greater distance than could be done before the operation. After this the actual cautery may be administered, if thought necessa- ry ; but never under any circumstances before the second appli- cation of the cupping-glass, for this reason—that when the mouths of the vessels are hermetically sealed by the hot iron, they can give out nothing to the vacuum. 3d. The poisoning that results from the bite of a mad dog, so far as regards the simple deposi- tion of the deleterious matter in the wound, and the total absence of local action upon the wounded tissues, comes strictly under the first or least complicated class of cases. But the tardiness with which the poison is absorbed, or if absorbed, with which it produces its peculiar effects, entitles it to be considered as a spe- cies sui generis. Fortunately this anomaly does not alter the preventive indications. These are purely physical, and as such must be ever unvaried. The first thing, then, to be done in treat- ing the recent bite of a rabid dog, is to apply a powerful cup- ping-glass over the wound. This measure supersedes at once the ligature, ablution, excision, &c, during the period of its applica- tion, and for a certain time after its removal. After the cupping- glass has been applied for an hour at least, the whole of the parts wounded or abraded by the bite, should be freely dissected out. The cupping-glass should then be reapplied immediately for the reasons already stated. The wound should next be hermetically sealed by the actual cautery. The part should be as little ex- posed to the contact of the air after the slough comes away, and as soon healed up as possible." On wounds from Insects, consult Dictionnaire des Sciences Medicates, torn. l,p. 40, article Abeille,- also torn. 25, p. 315—RicherancTs Nosographie Chirurgicale, torn. l,p. 104. On the bites of Serpents, Fontana on Poisons—Barton on the Rattlesnake, in American Philosophical Transactions, vol. 3—Home, in Philosophical Transac- tions, part 1st, 1810. On Hydrophobia, see Hunter, in Transactions of a Society for the Improve- ment of Medical and Chirurgical Knowledge, vol. 1—Hamilton on Hydrophobia, Poisoned Wounds. 89 vot. 1—Cline, in Medical Records and Researches—Bardsley, in Memoirs of the Literary and Philosophical Society of Manchester, vol. 4—Rush's Inquiries—Fer- riar's Medical Histories and Reflections—Fothergill, in Medical Observations and Inquiries, vol. 5— Vaughan's Cases and Observations on Hydrophobia—Laud's System of Surgery, vol. 3—Mease on the Bite of a Mad Dog—Physick, in New York Medical Repository, vol. 5. On Wounds from Dissection, consult Travers on Irritation—Sir Astley Cooper's Lectures by Tyrrel—Colles' Fatal Consequences resulting from Slight Wounds received in Dissection in Dublin Hospital Reports, vol. 3—Shaw's Manual of Ana- tomy—Shaw on Dissection Wounds, in the London Medical and Physical Jour- nal—Thomson on Dissection Wounds, in London Medical Repository—Duncan, Cases of Diffuse Cellular Inflammation, in Transactions of Medico-Chirurgical Society of Edinburgh, vol. 1—Case of Air. Adrian A. Kissam, student of medi- cine, who perished in a few days after receiving a flight wound in dissecting. Re- ported by John D. Godman, M. D., Professor of Anatomy and Physiology, in Rutgers Medical College, N. Y, in American Journal of Medical Sciences, No. 2, Feb. 1828. Vol. I. 12 00 Gun-shot Wounds. Section VIf. Gun-shot Wounds. Under the head of gun-shot wounds are comprehended all injuries from fire arms, from explosion of shells, rockets, &.c Wounds of this description are oftentimes extremely formida- ble—destroying the patient immediately or remotely, pro- ducing extensive mutilation, or giving rise to abscesses, sinuses, and diseased bones, which last for months or years, or perhaps during the patient's life. The kind and extent of injury must depend, however, upon the form and size of the instrument in- flicting the wound, upon the velocity with which it is carried, and a variety of other circumstances. A ball moving with great rapidity and striking the body, enters readily and pursues its course generally in a straight line, either passing through the part or lodging at a greater or less depth. On the contrary, a ball which moves slowly enters with difficulty, and, instead of following a direct line, is diverted by the slightest obstacle— always taking an angular course. Owing to this circumstance, it often happens, that a bullet strikes some part of the body, and apparently passes through; but upon examination it will be found, that it has taken a circuitous route—having followed the course of a rib, or traversed the head between the bone and scalp, or passed entirely around the abdomen or neck. In other instances the ball strikes an extremity, runs beneath the skin, or among the muscles, and is lod»ed many inches, or even two or three feet beyond the point which it entered. The opening, made by a ball where it passes out, is always larger and more ragged than that by which it entered—because it passes from the body, which is a dense medium, into the air, which is a rare one. On the other hand, the contusion is greater at the place the ball enters, than at that from which it emerges -.—owing to the velocity of the ball being more considerable when it first strikes, than it is afterwards; hence the first open- ing is small, round, comparatively in^en^ible and discoloured, not unfrequently casts off a slough, and seldom heals except through the medium of granulation ; while the last, approaching Gun-shot Wounds. 01 to the natuie of an incised wound, is inflamed and painful, and often heals by the first intention. Two openings, however, are not invariably found; for in many instances the ball does not pass through, but lodges in the substance of a muscle, or in a bone, or immediately under the skin. In other instances it car- ries before it the clothing, which, according to its texture, is ei- ther torn or remains entire. In the latter case, upon withdraw- ing the cloth, the ball is generally discharged with it. Other extraneous matters besides cloth, may be carried before a bul- let, and deeply lodged—such as splinters of wood, buttons, pieces of coin, keys, &c. These always excite more or less irritation. The bullet itself will create as little injury as any other foreign body, provided it remain smooth and round ; but if it is flattened or angular, or incrusted with spicula of bone, or in any other manner rendered rough or pointed, great pain and profuse sup- puration will generally follow. Balls are frequently buried and never found. Sometimes they remain stationary, being either enclosed in a cyst or surrounded by bone, and the patient feels no inconvenience from them. At other times they change their position, and travel to a con- siderable distance, exciting, during their passage, pain and sup- puration, and occasionally violent spasms. Not unfrequently they approach the skin and are discharged spontaneously. Balls are sometimes divided by striking the edge of a sharp bone, in which case each portion usually makes a passage for itself. I have met with several examples of the kind. The veteran M'Culloch, who signalized himself at the battle of North Point, had his thigh broken by a bullet, which was divided by the bone as completely as if effected by a knife or chisel. A ball moving with great velocity and encountering a bone, passes through it in an instant, making a round and compara- tively smooth opening. If the ball move slowly, however, or be nearly spent, it will be apt to produce extensive fracture or fissure. In some cases of the kind the cylindrical bones have been splintered more than two-thirds of their length. Gun-shot wounds, like all other contused wounds, seldom bleed profusely—the vessels, being torn with violence, retract and bury themselves among the cellular membrane. Even very lan*e arteries may be torn across, without shedding more than a few drops of blood ;* but a vessel partially torn will throw out more blood than one which has been completely separated. Al- 92 Gun-shot Wounds. though the vessels bleed sparingly when first wounded, yet in a few days secondary hemorrhage is very apt to ensue, from the de- tachment of the slough with which almost every tract made by a ball is lined; and from this cause many patients have sudden- ly lost their lives. A regular slough or dead tube completely formed, is not so invariable a consequence as many surgeons imagine. I have met with several cases where no vestige what- ever could be discovered of a slough from the commencement to the termination of a wound. When a slough does form, it is lia- ble to be detached at some period between the fifth and twelfth day, and during this period the patient should be closely watched. It happens frequently that an artery is merely brushed by a ball, and yet its coats are so much injured that in a few days an es- char separates from it, and gives rise to profuse hemorrhage. In other cases large arteries are pushed entirely to one side by the passage of balls, without sustaining the slightest injury. This happened, there is reason to believe, to Captain VVorth,t a gal- lant young officer, at the Battle of Bridgewater, who received a shocking wound in the thigh by grape-shot, several ounces in weight, which penetrated a little below the groin over the course of the femoral artery, and tore up the muscles in a frightful man- ner, without injuring the vessel. The nerves suffer immensely in some gun-shot-wounds, especially those of the extremities. Even after the wound has healed, painful and very distressing sensations are often felt, particularly during an easterly wind; and when the atmosphere is charged with electricity. Many surgeons believe that very serious accidents and even death may result from the wind of a ball; but there is no foun- dation for such an opinion. The truth is, that a musket and even a cannon ball will now and then strike a part so obliquely, as not to enter or produce the slightest external wound, and yet the bones are crushed and the muscles dreadfully bruised. If it were possible for the toind of a ball to produce the mischief attributed to it, this ought always to follow whenever the ball passes very near the body. So far from this being the case, nu- merous examples are afforded of portions of clothes, hats, &c. being shot away, without the person wearing them sustaining ♦It must be understood, however, that when arteries such as the carotid or fe- moral, are cut by a bullet, the patient dies almost instantly. f Now Major Worth, a distinguished officer at West Point. Gun-shot Wounds. 93 any injury. There is, however, a real and oftentimes very se- rious injury, which some have supposed imaginary, resulting from a gun-shot wound,—a perturbation and extraordinary con- stitutional agitation, which the bravest men cannot resist. This is not an invariable symptom; for some patients are desperately wounded and do not exhibit any alarm whatever; whilst others are immediately seized with trembling, vomiting, and indescriba- ble anxiety, even from the slightest scratch. Where such con- stitutional disorder, however, continues any length of time, it is to be considered generally very fair evidence of the severity and danger of the wound. Treatment of Gun-shot IVounds. It is very important, in all gun-shot wounds to suppress he- morrhage and extract the foreign body as soon as possible. If an artery be torn across, and continues to pour out blood copi- ously, we shall have good reason to conclude that its size is considerable, (for the smaller vessels seldom shed more than a few drops, and the sooner we attempt to secure it the better. In many instances the part must be laid open freely, until we reach the mouth of the vessel, and secure it by ligature. Fre- quently, however, the vessel from its depth or situation, cannot be tied; in such a case, a compress thrust to the bottom of the wound and supported by a roller, may perhaps succeed. But the surgeon must not, in every case, think of dilatation, even although the hemorrhage be profuse; otherwise he will incur great risk of wounding important organs, or of opening arteries larger than those divided by the ball. As soon as the flow of blood has- diminished or ceased, the wound should be carefully examined, either by the finger or by some other instrument. If the finger be too large, or not suffi- ciently long to reach the bottom of the wound, recourse must be had to the long gun-shot probe or to a wax bougie, or flexi- ble gum catheter, or to the urethra sound of Bell; all of which are very superior to the small probe contained in the common pocket case. Previous to the introduction of an instrument, the wounded part should be placed, as nearly as possible, in the situa- tion it was in at the time the wound was received. Without this 94 Gun-shot Wounds. precaution, the surgeon will often experience great difficulty in reaching the spot where the foreign body is lodged, and will give the patient unnecessary pain. There are very few cases in which an examination cannot be made immediately after the receipt of the wound; for if the patient be overcome by the shock or ner- vous agitation, which is so commonly felt, this may speedily be removed, in most instances, by a little wine or spirits, or by a glass of cool water. Severe pain should never be an obstacle to examination, which should always be conducted with gentleness and care. If the wound be not examined immediately after its receipt, the lips soon close, and the whole tract becomes so much swelled, and so painful, that it is almost impossible afterwards to ascertain the course the ball has taken, or the spot at which it is lodged. On the contrary, when the probe is carried along the passage recently made, it glides with facility, and at the bottom frequently encounters the ball or some other foreign matter, which must either be drawn out immediately by the forceps, or through a counter opening made directly over it. Provided the exact po- sition of the ball be accurately marked at the time of examina- tion, there will be no necessity, in all cases, for removing it at once; it may be left, sometimes, until the wound is healed. Mr. Hunter disapproves of making a counter opening at all, except the skin covering the ball should be deadened by the contusion and likely to slough. The experience of modern surgeons, how- ever, proves that a counter opening may, generally, be re- sorted to with safety and advantage, unless the ball should lodge more than one or two inches from the surface. Forceps of various shapes have been contrived for the remo- val of balls. In general, they are too clumsy, and so large as to fill up nearly the whole passage—leaving very little room for the expansion of the blades. The forceps of Chevalier and those of Percy have this fault, in common with the rest, but are superior to any instruments of the kind. Very narrow forceps, longer and more slender than those contained in the common pocket case, with small and very sharp teeth, I contrived several years ago, and have found them much superior to any others I have tried, particularly in those cases where the ball has not been lodged beyond three or four inches in depth; and where it has been deeper seated, advantage has seldom been gained from at- tempts to remove it by other means. A ball may sometimes be Gun-shot Wounds. 05 extracted very readily by the scoop, or by a single blade of Percy's forceps. The scoop of Thomassin* is said to be the best instrument of the kind ever invented. An instrument admirably calculated to remove a bullet deeply situated, and at the bottom of a narrow passage, was made under my direction a few months ago by Mr. Schively of this city. It is the " curette articutee" of Leroy D'Etiolle, invented by him for the purpose of extract- ing fragments of stone from the urethra, after the operation of Lithotripsy. To adapt it to the removal of a bullet, it was ne- cessary to enlarge the original instrument considerably. In other respects it is unaltered. For a discription and drawing of the urethra instrument, see vol. 2d. Section Lithotripsy. It has been proposed, for the removal of a bullet lodged in a bone to employ the trephine, or else an instrument formed at its end like a gimlet. The former can seldom be necessary, and * " M. Thomassin has constructed a scoop which is more easy of application, and more effectual than the ordinary instrument. It is one of the best instruments which could be devised for the extraction of balls. It is formed of two branches, which slide upon each other by means of a groove. That which, properly speaking, is the body of the instrument, is eight inches long: at one of its ends is a kind of spoon, which is deep enough and sufficiently curved to contain and hold the ball; the other end has two rings, one on each side to receive the fingers; it is hollowed at its anterior and concave part; the other branch is exactly of the same length of the first, with the exception of the ring at its ex- tremity; it is fitted to the groove of the other: its point is cut into an edge, so as to correspond to the edge of a scoop, which is received into a groove near its edge. This groove prevents the branch from going farther from the scoop. The biseau is intended to enter into a ball, so as to retain it in a spoon. A screw passes through this branch a little below the rings, the ends of which pressing against the branch of the biseau, serve to fix it when necessary. This branch is graduated on the convex part of the other ring, so that the operator is able to judge of the size of the ball when it is in the spoon of the instrument. The two branches being united, are introduced to the bottom of the wound and held like a pen. When the ball is touched by the end of the scoop it is clenched, and the biseau is raised about an inch. The biseau is fixed at this height by half a turn of the screw. The scoop is then opened to receive the ball, and is easily passed along its side. When the ball is felt in the scoop, the instrument is to be used so as to dislodge the ball from the parts around it: half a turn of the screw then sets the biseau at liberty, and it is to be pushed upon the ball, by placing the thumb of the left hand in the ring, while the middle and index finger act upon the scoop. We may pass its point into the ball, by a strong pressure or a turn of the screw. We are now sure of our object; however, we must not draw out the ball with violence, but, on the contrary, extract it very carefully. We consider this the best instrument which has been devised for the extraction of balls."—Boyer's Surgery, Vol. I p. 187. 96 Gun-shot Wounds. the latter could not be used in most cases without giving the pa- tient great pain. See Plates II. atid III. After the ball has been extracted or searched for in vain, our attention must be turned to the dressings best adapted to the wound. Some surgeons, particularly Kern, Assalini, Percy, and Guthrie, highly extol the use of cold water, or even of ice water when it can be procured, and direct that the part be con- stantly wet by pledgets. Since the late war my opportunities of treating gun-shot wounds have been comparatively limited, and at that period I was not aware of the reputation of the remedy, although it would seem that its efficacy was well known to the older surgeons, as BloWus published an essay on its virtues as early as the year 1542. I am inclined to think, however, that after the first few hours, during which the tension, heat, and pain are considerable, that the remedy will be found, if not injurious, at least less useful than an ehiollient poultice. At any rate, I have derived very great benefit from such applications from the very commencement of the wound, and have seldom seen injury result from their use, even when unnecessarily continued. The poultice should be applied until the swelling subsides and a free discharge of matter takes place from the wound, which may then be dressed with some mild ointment. Adhesive straps and rollers should be avoided in the commencement of all gun- shot wounds, but it will often prove useful during the suppurative stage. The older surgeons were fond of cramming the orifices of the wound with lint, of making ample dilatations, and of con- veying setons throughout the whole tract made by the ball. These practices are now nearly exploded, and in their place the mild- est and most simple means substituted. The symptomatic fever which commonly follows severe gun-shot injuries must be com- bated by blood-letting, purging and low diet. After the fever subsides and the wound suppurates abundantly, it may become necessary to support the patient, by a generous diet, and by the use of bark and mineral acids. Oftentimes the wound re- mains fistulous and will not heal, owing to the presence of some extraneous matter, which should always be searched for. The severe wound of the shoulder received by General Scott, at the battle of Bridgewater, continued fistulous for many months; but closed permanently in a few days, upon my extracting from it a PL ClMts r.„i, -rftot Ji-ohr. < '/iri'afrers J^orrtps long Gun -shot Probe . (ijai. -shot JToTocps. ') yV/yv.v bullet Forceps. PI..I Blades separable at t/ie .Tovit. 12 Inches loner P", to be itserf as <>/'. Screw oH Incites lona. /r. Gun-shot Wounds. 97 small piece of cloth. Where matter burrows under fasciee and travels among muscles and tendons, ample incisions and free counter openings only will put a stop to its progress. The propriety or impropriety of moving a limb injured by a gun-shot, will be considered under the head of Amputation, See Hunter on Inflammation and Chin-shot Wounds—Chevalier on Gun-shot Wounds—Larrey's Memoirs—Guthrie on Gun-shot Wounds of the Extremities •—Thomson's Report of Observations made in the Military Hospitals in Belgium, 1816—Hennen's Principles of Military Surgery, 2d edition,- the most valuable work perhaps ever published on the subject—Charles Bell's Dissertations an Gun- shot Wounds-^-Mann's Medical Sketches of the Campaigns of 1812, 1813,1814 —C. Bell's Surgical Observations, p. 319 & seq. Vol. I. 13 98 Wounds of the Head atid Face. Section VIII. Wounds of the Head and Face. The scalp being very vascular and abundantly supplied with nerves, is apt to suffer severely from wounds and contusions. An instrument pushed between the integument and bone, and creating a punctured or penetrating wound, will often give rise to an erysipelatous inflammation, which extends over the whole head and face, producing great pain and distress. At other times a slight blow on the head will cause an effusion of blood between the scalp and bone. This blood may remain stationary for months, forming a considerable tumour, and at last by pres- sure render the bone carious. Sometimes it has been mistaken by the surgeon for fracture of the skull. Such tumours are now and then met with on the heads of new-born infants, and are owing to pressure during the passage of the child through the pelvis. Extraordinary nervous symptoms, such as great pain, spasmodic twitchings of the muscles of the face, paralysis of the limbs and even convulsions, resembling epilepsy, occasionally arise from contused wounds of the scalp; and what is remarkable, these symptoms do not appear, in many instances, until months or years after the injury. Pouteau was among the first to notice these singular affections, and to point out the proper remedy. Incised and lacerated wounds of the scalp are by no means uncommon. The first generally proceed from sabre cuts in bat- tle, and often it happens, under these circumstances, that consi- derable portions of the bone, and even of the brain and its mem- branes are sliced off with the scalp, without producing the pa- tient's death. Several such cases are related by military sur- geons, and many years ago I myself attended a patient,? whose * A servant of Richard Caton, Esq. of Maryland. Wounds of the Head and Face. 99 left parietal bone had been forcibly struck by a hand-saw, the teeth of which penetrated the bone, dura mater and brain, and produced a fissure in the bone three inches long, without giving rise to a single bad symptom. It has been remarked by Dr. Hennen, that sabre cuts on the top of the head are not by any means so dangerous as those on its side. Lacerated wounds of the scalp generally proceed from rough bodies forcibly driven against the head, or from the passage of cart or carriage wheels over it, while the patient lies on the ground. These wounds, from being covered with dirt and blood, frequently present a very frightful appearance; but in truth are not so dangerous as some other injuries, provided they are properly treated. Gun-shot wounds are more formidable than any other wounds of the head, and few patients recover from them, where the skull has been fractured and the brain injured. It is true there are examples to the contrary—where the skull has been exten- sively shattered, the ball lodged in the substance of the brain and afterwards successfully extracted. One instance, indeed, is recorded by Hennen, of a French soldier, wounded at the battle of Waterloo, by a bullet, which passed through the squa- mous portion of the temporal bone and lodged in the substance of the brain. The wound was freely dilated, and the ball found embedded in the posterior lobe of the right hemisphere of the brain, where it rests on the tentorium. It was extracted, along with some portions of brain that adhered to it, and the patient in a short time recovered. The same writer states, that he has known five cases, where a ball has lodged in the substance of the cerebrum, without immediately producing a fatal event. These are all to be looked upon, however, as anomalies—curi- ous rather than useful. A bullet docs not always enter the brain, even although it should fracture the skull. Sometimes both tables are fractured and depressed, and the ball rests immediately under the scalp. Sometimes it passes between the scalp and bone, many inches beyond the spot at which it entered, and without injuring the bone in the slightest degree. Sometimes the ball is divided into two pieces, each of which takes a separate route, and frequently the ball is so flattened or changed in shape, by impinging against the bone, that it is hardly possible to recognise it. In all cases where the ball has (ravelled any distance under the scalp, its 100 Wounds of the Head and Face. course may be known in a few hours, by the red stripe or in- flamed line, which traverses the surface of the skin covering it. The same may be observed in all other parts of the body. Frequently a bullet fractures the superciliary arch and lodges in the frontal sinus. In other instances it is buried beneath the aponeurosis, or belly of the temporal muscle, and great tension, swelling and distress are the result. In short, it is- hardly pos- sible to calculate the course a ball may take when it strikes the head, or the effect it will produce; for the most trivial injury frequently terminates in death, contrary to our expectation, and, on the other hand, injuries apparently the most desperate, some- times result in the happiest manner. Bertrandi,* an eminent French surgeon, was among the first to notice the fact, that abscesses of the liver frequently follow wounds and other injuries of the head. His observations were soon after confirmed by Andouill£,t and the experience of mo- dern surgeons has demonstrated the frequency of the occurrence. The same connexion, according to Klein, exists, and to a greater degree, between the liver and the shoulder joint. Many theories have been framed in explanation of these circumstances, but none of them appear satisfactory. According to Hennen, Larrey, and others, wounds on trie back of the head, are sometimes followed by atrophy of the geni- tal organs and loss of the procreative powers. Wounds of the face may involve the eye, nose, lips, salivary ducts, &c. The eye may be burst by a blow, or the humours evacuated by an incised or punctured wound, or one or both eyes may be torn out by the passage of a ball. It happens now and then that a ball passes into the orbit and lodges between it and the bone, without destroying the patient's sight. Some- times the destruction of one eye will cause a paralysis of the crther. Wounds of the supra-orbital nerve almost invariably give rise to amaurosis, and there is probably no instance on re- cord in which the patient has perfectly recovered his sight after such a wound. Painful and very troublesome fungi often sprout from a wounded eye, and sometimes the whole globe becomes enormously enlarged, and protrudes from the socket. • De hepatis abscessibus qui vulneribus capitis superveniunt. In Memoires de l'Academie Royale de Chirurgie, torn. ix. p. 130—edit, octavo, t Idem, p. 168. Wounds of the Head and Face. 101 Diplopia or double vision, may follow an injury of the eye, or of the parts in its immediate vicinity. Wounds which open the cheek, and divide the parotid duct, frequently give rise to a very troublesome disease—salivary fistula. This fistula forms almost immediately, if the wound is not treated in a proper manner, and indeed, it is sometimes im- possible to prevent it, even under the best management. From the fistulous orifice there is a constant and copious discharge of saliva, especially during mastication. This passing over the cheek excoriates it, and, together with the fungus, which almost always sprouts from the opening, renders the patient's situation very uncomfortable. The ear is sometimes completely severed from the head by a sword or ball. It might be supposed, in this case, that the sense of hearing would be diminished or destroyed; but this is not found to happen. The nose and lips may be wounded in a similar manner, and instances are recorded of the greater part of the face, including bones as well as soft parts, being divided by a sabre in the most shocking way; and yet the patients have recovered, without much deformity. The tongttf being protected by the mouth is seldom injured, except by a bullet or by the teeth. In battle it frequently hap- pens that a ball enters the mouth, carrying before it a number of the teeth; these are forcibly driven into the tongue, palate or adjoining parts, and produce a lacerated and dangerous wound. At other times the ball enters one side of the lower jaw, frac- tures it, and passing through the tongue emerges at the opposite side of the face. I met with several cases of the kind after the battle of North Point, and found them extremely difficult to manage. The tongue when thus wounded, is very apt to be- come paralyzed and crooked, and secondary hemorrhage after such accidents is by no means uncommon. During epileptic fits, and other convulsions, the tongue is sometimes almost se- parated by the teeth; indeed, in some instances,it has been com- pletely bitten oft! 102, Wounds of the Head and Fact. Treatment of Wounds of the Head and Face. The first step to be taken in all wounds of the head, is to shave the part accurately. From inattention to this prelimina- ry measure, important injuries have escaped observation, and caused the patient's death. The surgeon should, therefore, not be satisfied with the removal of a few locks, from the imme- diate vicinity of the wound, but should shave to the distance of several inches, and, if necessary, clear the whole head of every particle of hair. This being done, the most careful examination must be made, in order to ascertain whether the bone is in- jured, or whether the scalp alone has suffered. In the former case it may become necessary to use the trephine, provided the symptoms justify it—in the latter, local applications, calculated to prevent or subdue inflammation, such as cold water, leeches and blisters. When the wound is incised or lacerated, and the scalp separated from the bone and turned down, it should be washed, if covered with dirt or blood, carefully replaced, and stitched with the interrupted suture, unless adhesive straps and bandages are sufficient to keep it in its natural situation. The older sur- geons invariably cut away the injured scalp, by which the bone was left bare and made to exfoliate. The moderns always at- tempt reunion, even if the scalp be ever so much torn, and for a very good reason—the part cannot be rendered worse by the attempt, and may be completely restored. Bloody tumours of the scalp resulting from contused wounds, should never be opened, unless they become very large, remain for a long time, or proceed from the wound of some large vessel which pours out blood copiously, and requires the ligature. Or- dinarily these tumours are absorbed in a few days. When the scalp remains tender and painful for months or years, and spasms are excited by pressure on the affected part. the most certain way of removing the complaint is to make a free and decided incision to the bone. Pouteau practised this operation with great success; and the celebrated case of Mag- dalen Mondct, recorded in his " Melanges de Chirurgie," proves the efficacv of the remedy. Dr. Physick has for many Wounds of the Head and Face. 103 ytars pursued the same plan, though not always with the de- sired effect. When the incision has failed, however, he has sometimes succeeded by repeated doses of emetics; indeed, emetics alone will occasionally effect a cure; in other instances, they prove of no service, and the disease remains incurable. Fn two or three cases I have prescribed the extract of stramo- nium with great relief. For the removal of the erysipelatous affection which so commonly follows a punctured or penetrating wound of the scalp, there is nothing so useful as nauseating antimonials, the blue pill, mild purging, and abstinence. For this practice we are chiefly indebted to Desault Gun-shot wounds of the head must be treated upon the prin- ciples formerly pointed out; but especial care should be taken not to search too diligently for a ball that has passed through both tables of the skull, lest more injury result to the brain and its membranes, from the officiousness of the surgeon, than from the presence of the extraneous body. With the exception of salivary fistula, the treatment of wounds of the face is commonly very simple. When the nose, lips, eyelids, and ears, are incised or lacerated, we bring the edges together by a few tacks of the interrupted or twisted su- tures, and support them by adhesive or court-plasters, and by bandages, taking care to secure, in the first place, the angles or hanging portions of the flesh; in order to obviate the deformity, which otherwise is apt to follow, from one edge overlapping the other. The common roller has superseded all the particular bandages formerly contrived for the head. There are three modes of treating a wounded or fistulous pa- rotid duct—by compression, seton, atid caustic. The first is ge- nerally employed immediately after the duct is wounded, and with a view to procure direct reunion. Owing to the difficulty, however, of approximating the two ends of the duct, and of hold- ing them in exact contact, permanent benefit seldom follows any attempt of the kind. On this account, the wound, in almost every instance, becomes fistulous and requires a regular opera- lion, or the caustic. Monro, the father, was very partial to the seton, and Desault, with particular modifications, preferred it to any other mode. His plan was to introduce Uvo fingers 104 Wounds of the Head and Face. into the paiient's mouth, opposite to the fistula, to keep the cheek tense, while from behind, he passed forward a small tro- car and cannula through the cheek, immediately before the pos- terior end of the duct. The trocar was then withdrawn, leaving the cannula, through which a thread was conveyed into the mouth. This thread was attached to a seton, then carried from within outwards, but not sufficiently far to fill up the external orifice, in which the thread alone rested. The wound was dressed daily for six weeks with lint, the patient kept on a low diet, and the jaw as still as possible. The seton and thread were then with- drawn, and the external orifice touched with lunar caustic until it healed. Simple as this operation may appear, it will be found by no means free from difficulty, and although successful in the hands of the dexterous Desault, can hardly fail to embarrass the inexperienced surgeon. I have strong doubts, however, of the propriety of resorting to the operation, under any circum- stances, without the previous trial of other remedies, especially the caustic, which has proved successful in almost all the cases in which I have used it. When the eye has been so severely wounded as to be irreco- verably lost, the surgeon will save the patient much pain and dis- tress by an incision, sufficiently free to evacuate suddenly all the humours. The mildest dressing should then be employed, and if troublesome fungi afterwards sprout, repeated applications of the argentum nitratum will be found sufficient to repress them. The antiphlogistic system, to the fullest extent, is commonly de- manded in such cases. It is often extremely difficult to manage a wounded tongue, especially as the accident most frequently occurs amongst ma- niacs, or persons subject to convulsions. The best plan, in all cases, is to pass the interrupted suture through the substance of the tongue, and connect the wounded edges to each other—af- terwards taking care to prevent the teeth from irritating the parts, by interposing some contrivance calculated to keep them asunder. The machine of Pibrac, described in the 9th volume of the " Memoirs of the Academy of Surgery* of Paris," and which consists of a piece of wire, having attached to it a bag, sufficient to contain and support the tongue, is perhaps as well calculated to answer the purpose as any other. Wounds of the Head and Face. 105 When the ear is wounded, and nearly separated, it should be stitched like any other dependent part, and afterwards firmly supported against the head, by compresses and bandages. See Desault'a Works, vol. 1—Pott's Works, by Earle, vol. 1—Pouteau's Pos- thumous Works—Hennen's Principles of Military Surgery, p. 277—Thomson's Report of Observations made in the Military Hospitals in Belgium, p. 49 and 63—Discourses on the Nature and Cure of Wounds, by J. Bell,- also his Princi- ples of Surgery, vol. 2, part 2. Vol. I. 14 106 Wounds of the Keck. Section IX. Wounds of the Neck. Extensive incised or deep penetrating wounds of the neck are very apt to prove fatal,—owing to the large and numerous blood vessels and important nerves with which it is supplied. If the carotid or vertebral arteries be cut across by a sharp in- strument, or by a ball, the patient dies instantly. It is true a few cases have been recorded of recoveries after such accidents; but these are so extremely rare, and the circumstances attend- ing them so peculiar, as not to affect the general position—that such accidents are mortal. The most common wounds of the neck are incised, and these are generally made by the attempts of suicides. These attempts, however, frequently fail, owing to an impression, which almost universally prevails—that wounds of ftie windpipe are necessarily fatal. Under this idea most suicides aim at the division of the larynx or trachea simply, and carry the cut- ting instrument as high up on the neck as possible. On this ac- count the carotids, which retire deeply in proportion as they as- cend the neck, escape—when even a superficial wound, low in the neck, would open them. A patient may die, however, from hemorrhage, without the carotids being touched—from the divi- sion of the thyroid or lingual arteries. Frequently it happens, that these vessels are divided and bleed furiously, and the patient faints. The surgeon being called during this interval, draws out the arteries and secures them. When the thyroid gland is wound- ed deeply, the hemorrhage is very copious and often fatal. A mere division of the larynx or trachea is, comparatively, unattended with danger. Some surgeons have doubted the pos- sibility of wounding the oesophagus, without dividing at the same time the large blood vessels and nerves, but several examples to the contrary are recorded. When the neck is wounded above the os hyoides, numerous muscles, the root of the tongue, the lingual artery, and perhaps the salivary ducts, the ninth pair of nerves and the pharynx, may be divided. An opinion has long Wounds of the Keck. 107 been entertained that a division of the eighth pair of nerves^is necessarily fatal. Klein, a celebrated German surgeon, not only questions the statement, but denies positively that it is found- ed in fact. The experiments of Haighton, however, prove that the nerve on one side of the neck may be wounded without pro- ducing the death of the animal, but that the division of both nerves is inevitably fatal. Treatment of Wounds of the Neck. In many instances the patient dies of hemorrhage before the surgeon can reach him, having completely severed the carotids, thyroids or jugulars: at other times he is found weltering in blood and almost lifeless. The surgeon takes advantage of his reduced state, sponges away the clotted blood and seeks the divided vessels. These being secured by ligature, the edges of the wound are brought together by adhesive plaster or sutures. In extensive and deep wounds sutures are indispensable; they should only pass, however, through the integuments and mus- cles, and not involve either the larynx or trachea, otherwise a troublesome cough and incessant irritation will be kept up. It has been too much the practice to use sutures upon all these oc- casions, whether the wound be extensive or not. In superficial wounds adhesive straps answer every purpose, and should be preferred to sutures, inasmuch as they obviate deformity, and prevent considerable pain. Over the straps or sutures it will be sufficient to place a light pledget or bandage. Maniacs, who have attempted suicide, should be confined by the straight waistcoat, to prevent them from tearing open the wound to which they are exceedingly prone. In all cases the position of the patient's head is of great consequence as respects the healing of the wound. Writers usually recommend the head to be brought forward, and supported on the breast. The practice I am sure is objectionable, inasmuch as the parts over- lap, and uniting irregularly and in an unnatural position, create deformity by leaving an ugly gap. To prevent such conse- quences 1 have, for many years, employed a common leather 108 Wounds of the Neck. stock, similar to that worn by military men, which being slight- ly confined to the neck, has supported the chin and kept the head in a natural position. An oval hole cut in front of the stock has enabled me to dress the wound without disturbing the patient, or changing the position of the wounded parts. No bandage, however contrived, can retain the patient's head im- moveably fixed. On this account, assistants should constantly sit by him and keep it steady with their hands. The elastic catheter, although recommended both in wounds of the trachea and oesophagus, with a view to prevent motion of the larynx and to nourish the patient, will be found, I con- ceive, seldom necessary, and in some cases cannot be employed without exciting great irritation. When the neck is laid open above the os hyoides, so as to leave the pharynx gaping, and fluids run out of the wound as soon as they are introduced into the mouth, then the catheter becomes extremely useful, and in- deed indispensable; but to introduce it upon every common occa- sion, whether the pharynx or oesophagus be touched or not, mere- ly for the purpose of preventing the motion of the windpipe, is manifestly improper, inasmuch as it cannot remain in the oeso- phagus for any length of time, while the surrounding parts are highly inflamed, without great inconvenience to the pa- tient; and to introduce it every time he requires drink, and ge- nerally the thirst is incessant, would be productive of more irri- tation than any efforts to swallow in the natural way could pos- sibly occasion. See J. BelPs Discourses—C. BelPs Operative Surgery, vol. 2, p. 22—Allen'* Surgery, vol. 1, p. 425—Thomson's Report, p. 71. Wounds of the Chest. 109 Section X. Wounds of the Chest. Any one acquainted with the structure of the "organs con- tained within the chest, would naturally conclude that it was hardly possible for a sword or bullet to pass through the lungs or large vessels, without inflicting a mortal wound. Recoveries, however, are so common after severe and apparently desperate wounds of this description, that few surgeons of the present day look for an unfavourable result, even in the worst of cases. This calculation would seem well grounded, when we recollect the statement of Dr. Gregory—" that of twenty-six wounds 'of the thorax received at the battle of Quebec, two only were fatal."* On the other hand, it should not be concealed that many patients die instantaneously from wounds of the chest, or linger months or years in the greatest distress, and finally sink from profuse dis- charges of matter and hectic fever. Dr. Hennen calculates strongly upon recovery in almost every case, provided the pa- tient survive beyond the first 48 hours. " I have seen so many wounds of the thorax," says he, " both from pike and sabre thrusts, and from gun-shot do well ultimately, that I cannot but hold out great hopes where the third day has been safely got over."f The great danger of all wounds within the cavity of the chest consists in the hemorrhage. This may proceed from a wound of the lungs, or of the intercostal artery, or from both at the same time. When the lungs are wounded, the patient is instantly seized with difficult respiration, accompanied by great anxiety and a flow of blood from the mouth, which, as it is poured out from the wound, enters the air cells of the lungs and occasions a distressing sense of suffocation. These symptoms • • Hennen's Principles of Military Surgery, p. 387. t Ibid. 110 Wounds of the Chest. are sufficient to assure the surgeon of the nature of the case: it is possible for the lungs to be wounded, however, without the patient's coughing up blood, especially if the wound is so situated as to permit the blood to escape into the cavity of the chest, as often happens. A wound in the intercostal artery may proceed from a shattered rib or from the instrument inflicting the wound; in either case the blood may flow into the chest, or out of the external wound. Hemorrhage from this source is neither so pro- fuse nor so dangerous as has commonly been imagined. Another consequence of wounds of the chest, although not a frequent or dangerous one, is emphysema or a collection of air in the cellular membrane adjacent to the wound, and spreading thence in some instances throughout the whole cellular tissue of the body, creating an immense windy tumour, inconvenient to the patient-from pressure rather than pain. This collection of air may rise from a wounded lung, or from a simple opening in the cavity of the chest; in either case the air is forced into the cel- lular membrane, in consequence of the wound being partially closed by coagulated blood, by a change in the position of the mus- cles and other parts adjacent to the wound, or by extraneous sub- stances blocking up the track made by the instrument inflicting the wound. Emphysema from a wounded lung may become very general and extensive, while that from a simple opening into the chest must necessarily be very limited. An opinion commonly prevails that a wounded lung will al- ways collapse. This is by no means the case; for although it really happens in most instances, and is the great safeguard of the patient, by allowing the wound fair opportunity to heal during the quiescent state of the lung, while retired to the bot- tom of the chest and ceasing to perform its function, yet many examples are recorded of an opposite state—a protrusion of more or less of the lung from the external wound, which has occasionally given rise to very troublesome and even fatal con- sequences. Supposing the patient to have escaped the immediate dangers of his wound—hemorrhage, emphysema, &c. he may yet be doomed to suffer immensely, and perhaps die, from the effects of inflammation. Suppuration is soon established within the cavity of the chest, which is denoted by rigors, a flushed cheek, Wounds of the Chest. Ill difficulty of breathing, pain and swelling in the injured side, and not unfrequently by a sense of fluctuation. Sometimes matter is coughed up from the lungs, but generally it accumulates in the chest until the quantity is so large and its presence so intolera- ble that the patient is suffocated unless relieved by the operation of empyema. At other times the wound becomes fistulous, and quantities of matter are constantly discharging from the open- ing, or are drawn off at stated periods. The extraneous bodies, such as broken and exfoliating ribs, pieces of cloth or bullets, often contribute in no small degree to its secretion, by falling into the chest and lodging on the diaphragm, where they keep up perpetual irritation. Many patients survive for years under these circumstances, while others perish in a few weeks from debility, or confirmed phthisis pulmonalis. Upon dissection, the injured lung is generally found contracted and indurated, its cells consolidated, and the whole volume so diminished as to occupy a very inconsiderable portion of the chest—leaving it, in fact, almost empty. Many wonderful cases have been recorded by the older sur- geons and by modern writers, of wounds of the heart and large vessels in its' neighbourhood, without being followed by instant death—the patients surviving for days or weeks. Pare, Bone- tus, and Morgagni give detailed accounts of such accidents, and within a few years Babington, Chastenet, Featherton, and Fuge have furnished very interesting particulars of similar cases. Superficial wounds of the chest are seldom productive of much injury, inasmuch as there is little danger of hemorrhage — the vessels being small and few in number. An exception to this occurs, however, in the case a of wounded infra or su- pra scapular artery. The former vessel in particular is liable to be cut across, and pours out blood so insidiously, that the surgeon is scarcely aware of the hemorrhage, until the patient is nearly exhausted. After death the whole cellular tissue, and even the interstices of the muscles from the shoulder to the loins, are found loaded with blood*. I have met with two cases of this description, both of which proved fatal in a few hours, A ball striking the chest obliquely, is very apt to take an an- gular or circuitous route—by following the course of a rib: in some instances it has run entirely around the chest, and emerged 112 Treatment of Wounds of the Chest. near the spot at which it entered. Many owe their lives to this accidental deviation of a bullet. Treatment of Wounds of the Chest. The moment the surgeon casts his eye upon a person wound- ed in the chest by a sword, lance, or bullet, and sees the blood streaming from the wound or issuing from the mouth, he may calculate immediately upon the nature of the case, and should lose no time in affording relief. He must draw blood copiously from the arm, which will have the effect of diverting it from the lungs, and thereby save the patient perhaps from suffocation. From thir- ty to forty ounces may be drawn with perfect safety. The blood- letting must be repeated according to urgency of the case, and indeed can hardly be carried too far; for if the patient be not relieved by this measure, no other can possibly save him. After the hemorrhage from the mouth and wound has di- minished or ceased, the attention of the surgeon should be di- rected towards the removal of extraneous bodies and dressing of the wounds. As little probing as possible is desirable. If there be loose and shattered ribs, these must be picked away careful- ly, or, if not easily gotten at, the wound may be moderately en- larged. It is very seldom that a bullet which has entered the chest can be found—at least until the establishment of the suppurative inflammation. The best practice, I conceive, is in every in- stance to close the wound as soon as possible after the removal of foreign matters; even although a considerable quantity of blood be deposited in the chest. Adhesive straps should first be applied, and over these lint and a light compress secured by a roller carried over the greater part of the chest, with sufficient tightness to oblige the patient to breathe by the diaphragm and abdominal muscles. During the cure, frequent repetition of the blood-letting may become necessary; and, together with this, purgatives, digitalis, low diet, and occasional doses of opium, to relieve the cough will be found extremely useful. Emphysema is a very rare occurrence after wounds of the chest, and may always be prevented, there is reason to believe, Wounds of the Chest. 113 by an accurate closure of the wound. When it does occur, a few decided incisions or punctures as near the seat of injury as possible, followed up by bandaging, will speedily effect a cure. The so much dreaded hemorrhage from a wounded intercos- tal artery, may generally be stopped by a compress judiciously applied. Gerard proposed to secure the vessel by a ligature, to which was attached a dossil of lint passed around the rib by a curved needle. This plan was tried successfully by Plenck, but a similar operation in the hands of Theden, caused the patient's death. Hennen a most experienced military surgeon, never found it necessary to employ even the tenaculum. When a wounded lung protrudes beyond the walls of the chest, it should be carefully returned by the fingers; when it forms ad- hesions with the surrounding parts, as sometimes happens, and becomes strangulated, it should be left to slough away. The li- gature, recommended and practised by some surgeons, ought never to be used. The treatment of the secondary or suppurative stage of a wound of the chest will often prove as tedious and difficult as that of the primary symptoms. As soon as it is ascertained that matter has collected within the chest, in such quantity as to cre- ate urgent symptoms or endanger the patient's life, the operation of empyema must be performed for its removal,—provided the wound in the chest has entirely closed. Between the sixth and seventh rib is the proper place to make the opening, which should not extend beyond an inch and a half. The muscles being cut through, the pleura is exposed and opened cautiously with a bistoury or lancet. Many patients are immensely relieved upon the discharge of the matter, but others become suddenly debilitated and very soon die. If a fistulous orifice remain, an opening into the chest may not become necessary, unless as a counter opening,—which may serve to drain off the pus more completely than could be done through the fistulous ori- fice, owing perhaps to its high situation. To empty the chest completely through the fistula, the surgeon will find it most convenient to lay the patient on his side, so as to make the po- sition and outlet as dependent as possible. In four or five cases I have succeeded in floating out with the matter, pieces of cloth and bits of exfoliated bone, by throwing an injection of tepid Vol. I. 15 114 Wounds of the Chest. milk and water. These substances kept up considerable irrita- tion and promoted the secretion of matter, which soon after their removal nearly ceased. During the whole course of the suppu- rative stage the patient should enjoy a good diet and fresh air. Tents, if possible, ought to be dispensed with, as they prevent the wound from healing, and, if worn long and habitually, cannot be removed without detriment to the patient's health. See J. BelPs Discourses—Hennen's Military Surgery, p. 367—Larrey's Me* moirs—Halliday on Emphysema. On the subject of Empyema, consult Hey's Practical Observations in Sur- gery, p. 494, edit. 3d, 1814—Sharp's Critical Inquiry, p. 231. Wounds of the *flbdomen. 115 Section XI. Wounds of the Abdomen-. Wounds of the abdominal viscera have generally been con- sidered not less perilous than those of the chest and some other parts. The danger must obviously depend, however, upon the particular organs wounded, and upon the extent and kind of wound inflicted. The peritoneum, being endued with exqui- site sensibility and extremely prone to inflammation, sometimes suffers immensely even from the most trivial accident, and is the chief source of mischief in all abdominal injuries. Inas- much, therefore, as this membrane envelops most of the viscera of the belly, and is more or less concerned with those of the pelvis, it can hardly escape any instrument which may pass be- yond the muscular or tendinous parietes. Many cases have oc- curred nevertheless, in which balls and swords have passed com- pletely through the abdomen; transfixing the peritoneum and several convolutions of intestines, not only without producing the patient's death, but without giving rise to a single bad symptom. Such favourable terminations are readily explained, when we recollect the remarkable property possessed by all serous membranes of taking on speedily the adhesive process, which serve to prevent effusions and to obliterate in a wonder- fully short time all traces of the wound. This adhesion is brought about by the universal pressure of the abdominal mus- cles and diaphragm upon the viscera of the abdomen, by which they are kept in close contact with each other and a vacuity completely prevented, and by the serous effusion poured out almost immediately from the abdominal and intestinal perito- neum, which agglutinates the surrounding parts and closes the wound. The older surgeons were in constant dread of fecal ef- fusions between the intestines and walls of the abdomen, and re- sorted to many useless and dangerous expedients to counteract the supposed tendency. The experiments of the celebrated 110 Wounds of the Abdomen. Petit put to flight all idle fears on this point, and proved that ef- fusion from penetrating wounds must necessarily be of rare oc- currence. When effusion does take place, however, whether of bile, blood, or the contents of the stomach or intestines, as occa- sionally happens from extensive wounds' or from violent blows, rupturing the intestines and giving rise to ulceration, the patient hardly ever recovers, but dies in a few days in great torture— from universal peritoneal inflammation. Superficial wounds of the abdominal muscles or their integu- ments seldom prove of much consequence, and are to be treated upon common principles. To ascertain whether an intestine or some other internal viscus be wounded, is often by no means an easy matter. Frequently it happens, that a ball enters the abdo- men and passes out at the opposite side, leaving two openings, having penetrated apparently all the intermediate viscera, when in reality its course has been diverted by the resistance of the tendinous or muscular walls of the belly, and it has ranged between these and the intestines—brushing their coats without opening their cavities. In this way many patients have es- caped when the surgeon has supposed the bowels extensively wounded. But a wound of this description is often not less dangerous than one which penetrates the intestines at once; for in a few days a slough separates from the bruised viscera, and opens a direct communication between them and the ex- ternal wound. The most certain sign of a wounded intestine is the discharge of blood from the anus, or of fasces, bile or food from the wound. The absence of such signs, however, is no proof that the viscera remain entire. In general we may cal- culate upon some large vessel being opened, or some important organ being injured, when we find the patient's countenance sunk and covered with a cold sweat, his extremities cold, his breathing difficult, and the nervous energy very much ex- hausted. Wounds of the small intestines, especially the duodenum, are much more dangerous than those of the large, inasmuch as there will be greater difficulty of nourishing the patient, and more risk of effusion. An intestine sometimes protrudes a con- siderable distance beyond the external wound, although it has sustained no injury; in other cases it is extensively wounded, and along with the omentum projects beyond the parieles of the Wounds of the Abdomen. J 17 abdomen. Instances are recorded of the protrusion of the whole of the intestines except the duodenum. Wounds of the stomach are extremely hazardous, and in nine cases out of ten mortal. Dr. Thomson saw but two patients re- covering from such wounds, after the battle of Waterloo. Dr. Hennen never had an opportunity of treating a wounded sto- mach; and hence, perhaps, it may be concluded, that most pa- tients die immediately upon the receipt of such injuries. Many wonderful examples are to be found, especially among the older writers, of perfect recoveries after wounds of the stomach, even under the most desperate exigencies. Wounds of the substance of the liver, where large vessels are opened, are almost certainly fatal; but patients frequently reco- ver after slight injuries of this viscus. A very interesting case, of a most desperate wound of the liver, followed by perfect reco- very, is related by Hennen." Wounds of the kidney generally prove fatal, immediately or re- motely—either from effusion of blood or urine; but the urinary bladder is often pierced by balls and other instruments, without producing the patient's death. " We saw no fewer than four- teen cases," says Dr. Thomson, " recovering, in which the blad- der had been penetrated by musket balls."t During the late war 1 had two patients who received bullet wounds in the bladder, between which and the rectum communications afterwards formed—causing an admixture of the urine and faeces. A mus- ket ball lodged in the bladder has served as a nucleus for a stone, to get rid of which the patient has sometimes undergone the ope- ration of lithotomy. Wounds of the genital organs are not very common, but very distressing when they do occur. Sometimes the whole scrotum sloughs away and leaves the testicles bare; at other times, fun- gous excrescences sprout from the testicles themselves, and are very difficult to manage. In other instances, the testicles are ir- recoverably destroyed, from the diseased action induced by the injury. • Page 430. f Report, p. 108". 118 Wounds of the Abdomen. Treatment of Wounds of the Abdomen. The surgeon should make it a rule, when called to a wound of the abdomen, to spare the probe and finger as much as possi- ble. Such examinations, too often thoughtlessly made, can do no good, and have been the cause of great mischief. When there is reason to believe that an extraneous body, a bullet or piece of glass, has merely passed through the muscular parietes, and lodged on the surface of the peritoneum, the finger should be in- troduced, and if felt, an attempt made by the forceps to extract it; but when the foreign body has entered deeply among the vis- cera or has taken a circuitous course, it will be quite useless to attempt to follow it. Sometimes a bullet has been discharged by stool, after the surgeon has made repeated and vain efforts to reach it by theprobe. When a portion of intestine protrudes from the external wound, distended with flatus, and not reducible by mere pressure with the fingers, many of the older and some of the modern surgeons advise puncturing it with a needle or fine trocar. This practice I consider dangerous and unnecessary, inasmuch as a slight dila- tation of the wound will relieve the stricture and restore the gut. Besides, experience has proved that a puncture does not al- ways answer the purpose; for the opening is immediately closed by mucus, or as Mr. Travers contends, by the villous or mucous coat of the gut. Should the external wound be large, it may be found difficult to retain the protruded gut after it has been re- stored, unless a suture be employed. In this case it should be used ; but the adhesive strap ought first to be tried. If the omen- tum should adhere to the edges of the wound from being long protruded, it may with safety be cut off and the individual vessels tied. To arrest internal hemorrhage and combat inflammation, ve- nesection, low diet, and rest, in the supine posture, are the pro- per remedies. Purging is out of the question; but mild enemata may be used with advantage in particular cases. As respects the management of a wounded intestine, much con- troversy has prevailed, and to a certain extent still exists. I believe it may be slated, however, that the most experienced surgeons concur in reprobating the interference of the surgeon Wounds of the Abdomen. 119 in the generality of cases—under the impression that nature, unassisted, will do more for the patient than art can ever ac- complish by the most ingenious contrivances. Cases, however, undoubtedly occur, though very rarely, in which it may be- come necessary to stitch a wounded bowel. For this purpose two operations only, as far as I am acquainted, are ever resort- ed to at the present day—those by the interrupted and conti- nued sutures. The former is strenuously advised by Mr. John Bell, the latter by Mr. Travers. Although I have had frequent occasion to treat wounds of the intestines, I have never yet been under the necessity of employing a suture in a single case, having trusted always to the general means pointed out, and to simple dressings. Dr. Hennen declares, that "in the course of a very extensive practice, (and perhaps no military surgeon ever had more,) two cases only have come under his notice where stitching was required to a wounded intestine,,, Should a case present itself which, from the extent of the wound and other circumstances, seemed to require a suture, I should be inclined to follow the plan of Mr. Bell, and simply employ one or more tacks of the interrupted suture, merely for the purpose of connecting the wound in the gut slightly to the ex- ternal wound. Sir Astley Cooper tied up an opening in a gut, by passing a ligature around it in the manner we encircle the mouth of a bag, and cut off the ends of the ligature close to the knot; the patient recovered without a bad symptom. Many years ago I performed a similar operation in a case of hernia, and with equal success. From experiments made by Dr. Thomson and others upon inferior animals, it has been ascer- tained that the ligature, when thus placed upon a wound of the intestine, finds its way through the coats of the gut and is dis- charged by stool. Although sutures are so seldom necessary for the wounded intestine itself, they are often extremely ser- viceable, and indeed indispensable, for holding together the edges of an extensive external wound—for, without such support, it would frequently be impossible to prevent the whole contents of the abdomen from escaping. They should always in these cases be well supported by adhesive straps. It has been proposed in the event of blood largely effused within the abdomen, to make an opening and evacuate it; and instances are recorded where the operation has been successful- 120 Wounds of the Abdomen. ly practised. The experience of the best modern surgeons is against the operation—upon the ground that peritoneal inflam- mation of a fatal character always precedes the symptoms that would seem to justify the measure. An artificial anus not unfrequently follows a gun-shot wound of the intestines. In all the examples of this description I have seen, spontaneous cures have taken place, after the contents of the bowels have been discharged for several weeks through the fistulous opening—which has healed up very soon after the faeces have resumed their natural route. The treatment of the com- plaint, when it proves obstinate, will be considered under the head of Hernia. The treatment of wounds of the stomach must be very decisive. We draw blood copiously from the system and keep the pa- tient as low as possible, both to subdue inflammation and to prevent any food introduced by the mouth from finding its way into the cavity of the abdomen, where it would be liable to ex- cite great irritation. Stitching will, in most cases, be unneces- sary, and indeed perilous. When resorted to, however, the interrupted suture should be passed in such a way as to con- nect the edges of the stomach with those of the surrounding muscles and integuments—instead of sewing up the stomach alone. The patient must be nourished for some time by glys- ters, and this will be found the most difficult part of the treat- ment.* * "Mr. Travers, in the Edin. Journ. of the Med. Science, for Jan. 1826, re- lates, that a female, aged 53, and the mother of nineteen children, inflicted on herself a wound in the abdomen, three inches in length, and in a transverse di- rection. When admitted into St. Thomas' Hospital, at the expiration of six hours, the greater part of the large curvature of the stomach, the arch of the colon, and the entire large omentum, were protruded and strangulated in the wound. The omentum was partially detached from the stomach, which organ was wounded in two places; one, half an inch long through the peritoneal coat; the other a per- foration of all the coats, admitting the head of a large probe, and giving issue to a considerable quantity of mucus. Patient faint; pain slight; pulse 102, and ir- regular; some hiccup. A silk ligature was placed round the small puncture in the stomach, and the displaced viscera returned, after enlarging the external wound. This last was closed by the quill suture. Warm fomentations and ab- stinence from food and drink enjoined. 2nd day, some reaction; had been sick in the night from some drink given; is free from pain; pulse 120; pain on pres- sure; an enema ordered. Evening, a dose of castor oil, and twenty leeches to the abdomen. 3d, much fever: V. S. ^xviij., and 20 leechea to the abdomen^ Wounds of the Abdomen. 181 For wounds of the liver, spleen, pancreas, and kidney, but one plan can be pursued—the lancet and whole antiphlogistic sys- tem. When the urinary bladder is injured in such a way as to give rise to urinal infiltration, the elastic catheter will prove immensely serviceable, and indeed is our only resource, inde- pendently of the depleting plan, which must not be neglected. Escharotics will rarely prove powerful enough to subdue the fungus which sprouts from a wounded testicle. Nothing less than the knife will answer, by which all the diseased parts must be sliced away, in order to make room for sound granulations and the healing process. bowels not opened. 4th day, two stools^ pulse 98; tension ef the abdomen^ three more stools during the day. 5th, sutures removed; wound united, except at its right extremity, where a serous fluid is discharged in considerable quanti- ties. On the 6th day, was allowed food, and on the 23d of Dec, about two months after the accident, was discharged cured."—North Amer. Med. and Surg. Journ.No.lU.p. 199. See Hunter on Inflammation and Gun-shot Wounds—J. BelPs Discourses— Trovers' Inquiry into the Process of Nature in repairing Injuries of the Intestines —Hennen's Military Surgery, p. 401—Allen's Surgery, voL 1, p. 444—Scarpa on Hernia, Memoir 4th, p. 288—Smith's Inaugural Essay on Wounds of the In- testines, published at Philadelphia, in 1805—Larrey's Essay on Wounds of the ZXrinary Bladder. Vol. I. 16 122 Wounds of the Joints- Section XII. Wounds of the Joints* I might next consider wounds of the extremities; but these, when simple, or not complicated with fractures, are to be treat- ed upon the principles already laid down. Gun-shot and other extensive injuries, involving shattered bones, will be discussed under the heads of Fractures and Amputation. In this place a few peculiarities attending the condition and treatment of wounded joints may be pointed out. Wounds of the larger joints are among the most dangerous accidents in surgery; and although numerous cases are met with in writers, of perfect recoveries after such injuries, these do not affect the general position, but must be referred to pecu- liarities of constitution and to causes not easily explained. The same may be said of those wounds of the smaller articulations, trivial in the eyes of the surgeon, but in defiance of all calcula- tion sometimes followed by tremendous symptoms and even death. So far then as cases go, both sides of the question, as respects the harmless or perilous nature of wounded joints, might be equally well supported; and in proof of this I may mention, that I have known a bullet pass directly through the knee joint of a dragoon, between the heads of the bones and among the ligaments, without being followed by any serious symptoms—in another case, the knee joint torn open and com- pletely exposed by the machinery of a steam engine—in a third, a complete dislocation of the knee, in which the leg was turned outwards and placed at right angles with the thigh, pro- duced by the limb being entangled in the spokes of a carriage wheel, and yet the patients all recovered in a very short time.* • These cases all occurred several years ago in Maryland. The dragoon be- longed to Captain Littlejohn's troop, and was wounded at the battle of North Point; the second case occurred on board the steam-boat Enterprise, and the third in the family of Mr. Pechin. The last was a boy sixteen years of age and attended by Dr. Taylor and myself. Wounds of the Joints. 123 On the other hand, I may state, that I once saw a patient, appa- rently in good health, die from amputation of the finger in the Edinburgh Infirmary, and in another instance, most violent symptoms ensue from a trivial wound of a joint of the great toe. When any of the large joints are opened by an incised, la- cerated, or gun-shot wound, there is an immediate discharge of synovia, and this will be a sufficient indication of the nature of the case. It is possible, however, for the surgeon to mistake the fluid contained within the bursae mucosae, or within the sheath of a tendon, for the synovial fluid. Sometimes a punc- tured or penetrating wound extends obliquely into a joint, and the synovia does not escape, owing to the narrowness and length of the passage. The constitution suffers exceedingly in most cases from a wounded joint. A coldness or rigor, with sick stomach, is speedily induced, and this is followed by high fever and delirium, sometimes by twitchings or convulsions, with ex- cessive pain and inflammation! in the joint. The synovia is soon increased in quantity and rendered thinner than natural, and in a very short time coagulable lymph is thrown out on the sur- face of the synovial membrane and ligaments. Suppuration is soon after established, and the matter discharged in great quanti- ty from the wound or from fistulous openings around the joint. Finally, the bones become carious, and the patient is either worn out with hectic and irritation, or saved only by amputation. Occasionally the symptoms slowly subside, anchylosis takes place, and an imperfect cure is brought about. At other times the patient is carried off by tetanus after the wound has nearly healed. " In referring to my notes," says Dr. Thomson,* " 1 find that we have taken notice of the principal symptoms that had oc- curred in more than sixty examples of wounds of the knee joint. Most of these wounds had been inflicted by musket balls; but we saw a few which had been made by canister and grape-shot, and also some made by the lance. In a great proportion of the wounds of the knee joint, the local and constitutional symp- toms were peculiarly severe. Several ha I died of these wounds, and others were in imminent danger of doing so, before the symptomatic fever should undergo such an abatement as to * Report after the Baltic of Waterloo, p. 136. 124 Wounds of the Joints. warrant the amputation of the limb. Great pain, tension and swelling of the joint itself, was usually accompanied with oedema of the foot and leg, and not unfrequently with an erythematous swelling of the whole limb. This erythematous swelling often extended up to the trunk of the body, and rendered it impossi- ble to perform amputation in cases in which the removal of the limb seemed to be the only means by which the life of the pa- tient could be secured. It terminated, in some instances, in ex- tensive abscesses round the knee and in the cavity of the ham, which took the direction sometimes of the thigh and sometimes of the leg. In other instances, this inflammation terminated in erysipelas; and in others again,.in gangrene and actual mortifica- tion of the foot and leg. In a few instances, it is true, balls had passed through, and in others they appeared to be lodged in the joint, or in the ends of the bones which compose it, without the patients appearing to have suffered much from constitutional fever or from local inflammation. These instances, however, were rare in comparison with the number of those whose lives were in danger, from the injuries which their knee joints had sustained. In the dissection of several of the knee joints after amputation, I found that the balls in passing through the joints had fractured the ends of the bones, and had occasioned in the synovial membrane and cartilages appearances very similar to those which occur in scrofulous affections of the joints. The cartilages were loosened, in some instances, from the bones; in others, they were partially absorbed; and in the divisions of the cartilages produced by fracture, the edges were rounded off by absorption ; the synovial membrane was much thickened in sub- stance, and covered by soft, velvet-like, spongy granulations." Dr. Thomson met with numerous instances of gun-shot wounds of the ankle-joint after the battle of Waterloo, and from the severe symptoms attending them and from their result, is in- duced to consider such accidents almost as dangerous as those of ihe knee. Treatment of Wounds of the Joints. It has been well remarked by the judicious Hey, that it is easier to prevent inflammation in the joints after a wound, than Wounds of the Joints. 125 to arrest its progress when once begun. This maxim cannot be too strongly impressed upon the mind of the surgeon, and guided by it he will instantly adopt the most vigorous measures for the patient's relief. He will draw blood copiously from the system, and by leeches from the vicinity of the wound. Im- mediately afterwards, a very large blister should be applied over the injured part—barely leaving room for dressing the wound, if daily dressing should be required, which is seldom the case for the first few days. If necessary, the blister may be renewed, or a perpetual blister kept up for some time. The patient should be freely purged, and the most rigid abstinence enjoined. Under this treatment, if carried sufficiently far, even the most desperate injury will be placed in a little time under circum- stances most favourable to recovery. The treatment proper for the wound itself, must depend upon its nature and extent. A simple incised wound which has laid open the joint, may safely be brought together and retained by adhesive straps. If possible, sutures should be dispensed with; but if absolutely necessary, too much caution cannot be observed in avoiding the capsule of the joint, and in confining the stitches to the integuments alone. Under ibis management, the wound may, perhaps, heal by the first intention, and thereby save both patient and surgeon a vast deal of trouble. A gun-shot wound of a joint will require a different kind of dressing; for a wound of this description must necessarily sup- purate, and will be weeks or months in healing. The surgeon's first object in such a case, is to search after the extraneous body; for, however harmless a ball may prove, while lodged in a mus- eular part or among cellular membrane, in the cavity of a joint its presence cannot fail to excite the most violent symptoms; therefore, the probe or finger ought to be introduced in the most eautious manner, and the ball immediately withdrawn if practi- cable. Jf it cannot be felt, or if imbedded in the head of a bone so firmly as not to be moved without great violence, it must be left until suppuration takes place, in hopes that it may then be loosened and brought away. In the mean time the orifice of the wound is covered with an emollient poullice, while the mea- sures for preventing or subduing inflammation are pursued with the utmost vigour. After suppuration is fully established and the fever and inflammation have abated or entirely gone, the pa- 126 Wounds of the Joints. tient's system will feel the effect of the antiphlogistic plan and rapidly sink. The surgeon should watch this change, and in- stantly adopt an opposite course—administering a good diet, the mineral acids, to check hectic, and perhaps bark and wine. Throughout every stage of the wound itself, the poultice will be found the most agreeable and useful application. All stuffing with tents must be forbidden. But besides the treatment pointed out, there is one auxiliary, not yet mentioned, of immense value, especially in the early stage of all inflamed joints—position. If the knee is wounded, for example, the limb should be extended, and at the same time considerably elevated, in order to drain the blood from it as much as possible, and thereby lessen the inflammation. For this purpose, pillows, or an inclined plane well covered with quilts, are placed beneath it; or what generally answers a better end, the foot of the bedstead is raised by blocks to the necessa- ry height. Nothing can be more effectual than this simple plan in all injured or diseased joints, and for a knowledge of it the profession is chiefly indebted to Dr. Physick. The limb is kept extended, in order that it may prove more useful to the patient, in case anchylosis should ensue. A contrary position ought, however, to be assumed in wounds of the elbow joint, and for obvious reasons. When the joints are extensively shattered by grape-shot, or bullets, or by machinery, and the external wound ex- tensive, or the principal vessels of the limb torn, there can be, generall}T, no question as to the propriety of amputation; and the sooner the operation is performed the better. Cases occur, however, every now and then, which seem cal- culated to demolish the best established maxims of the surgeon. In the month of June, 1832, I was requested by the Count Sur- veilliers to visit, along with Drs. Chapman and Dubarry, at Bor- dentown, a young Italian in the service of one of the sons of Lucien Bonaparte. The young man had gone out on the Dela- ware to fish, and had placed a loaded musket in the bottom of his boat, with its muzzle directed towards him. In the act of throwing out his line the hook became entangled with the trig- ger, the gun was discharged, and a large ball passed directly through the left ankle, entering the fibula, perforating the as- tragalus and tibia, and emerging at a large and frightful open- Wounds of the Joints. 127 ing on the inner side of the ankle. I saw the patient twelve or fourteen hours after the accident; the homorrhage, which had been rather profuse, was in a great measure suppressed, the joint less swollen and painful than could have been imagined, the constitutional irritation inconsiderable, and the patient compara- tively cheerful and unapprehensive of danger. The serious na- ture of the injury, and the little prospect of recovery, except through immediate amputation, were, after full consultation, ex- plained to the patient and his friends. He resisted, however, every proposal of the kind, said that his constitution was an ex- cellent one, and that he would rather die than wear a wooden leg. It was, therefore, determined, (notwithstanding the axiom —" that gun-shot fractures of the ankle, involving the three bones, are almost necessarily fatal unless amputation be performed")* —to attempt to save the limb. The foot was elevated, accord- ingly upon an inclined plane, the wounded part supported by small bolsters, and covered with emollient poultices; and by keep- ing up the antiphlogistic system for some time, and afterwards supporting the constitution, whilst under the wasting influence of the suppurative process, the wound granulated, and at the end of three or four months the patient recovered perfectly—with the exception of an anchylosed joint. Wounded joints seem to have escaped the notice of most sur- gical writers, but the following works may be consulted with ad- vantage. Hey's Practical Observations in Surgery, edit. 3d, p. 354—Thomson's Report, pp. 123,136,143,146,156, &c.—Dorsey's Elements of Surgery, vol. l,p. 101, edit. 2d.—Boyer's Surgery, by Stevens, vol. 2, p. 325—Hunter's Commentaries, part 1, p. 69—Hennen s Military Surgery. For a most interesting and romantic account of a wound of the knee joint, re- ceived by General Drisen of the Russian service, at the battle of Borodino, from which the patient suffered the most excruciating torture during four years, part- ly from bad surgical treatment, especially from the use of large quantities of quicksilver introduced into the wound to amalgamate the ball, see Surgical Ob- servations by Charles Bell, vol. I,j3.431. • Guthrie. 128 Abscesses. CHAPTER IV. ABSCESSES. After the general observations on suppurative inflammation and its treatment in a preceding part of the volume, it-will be proper to speak of abscesses in particular situations. In so do- ing, no attention will be paid to the distinctions pointed out by some of the French writers, whose terms—cold abscesses and ab- scesses by congestion—if not nugatory, have at least no very definite meaning, and are calculated to create false impressions, inasmuch as they are founded upon the belief that such collec- tions are independent of the inflammatory process—which, we have every reason to think, has a most important concern in the production and propagation of every abscess. Section 1, Abscess of the Antrum Maxillare. This is not a very common disease, but is always painful and difficult to cure. It is met with chiefly among middle-aged persons, and arises generally from decayed teeth, which by ir- ritating the lining membrane of the antrum, produce extensive inflammation and large quantities of very fetid matter. Some- times the roots of the teeth excite ulceration in the lining mem- brane, and project into the cavity of the antrum. The disease may also proceed from severe colds, affecting either the Schnei- derian membrane of the nose or that of the antrum itself. The fetor of the matter is so extremely offensive in many instances, that it is hardly possible to remain in the room with the pa- tient, who is also very much annoyed by the circumstance, and Abscess of Antrum Maxillare. 129 Complains of its flowing into the mouth and throat, especially at night when lying in bed. The disease may exist for many months, or even years, without the surgeon or patient being aware of its nature. A deep-sealed, severe pain is felt in the face, which no application to the part will assuage. The teeth also, in the neighbourhood of the disease, become painful—so much so, that the patient often has them pulled, under the idea of their causing all his distress. Upon these occasions it is not uncommon for more or less matter to flow along the sockets into the mouth—and then the true nature of the affection is discovered. In many instances, however, the face swells gra- dually, becomes deformed, and the walls of the antrum are dis- tended by the matter which eventually is discharged through the cheek. The frontal sinuses are subject to purulent collections within their cavities, though the disease is rare, compared with that of the antrum. Within the last fifteen years I have only met with six cases of the kind. In one of these the matter found its way outwardly, and was discharged at the inner angle of the eye—leaving the fistulous orifice which proved very difficult to heal. All Ihe patients complained of a troublesome, fetid, discharge from the nostril, and of a diminution of the sense of smell ing. Treatment of Abscess of ihe Antrum. The most simple and perhaps the most effectual operation for the removal of the matter collected in the antrum, has been prac- tised ever since the nature of the disease was understood. This operation consists in the removal of one or more teeth corre- sponding with the floor of Ihe antrum. The third molaris is generally selected, inasmuch as it is situated near the most de- pending part of the cavity. Immediately after the tooth is drawn, the matter is often discharged into the mouth. In other instances, it becomes necessary to pass a stilet or small trocar into the cavity whence the tooth has been pulled, and push it gradually into the antrum. After the contents have been completely evacuated, astringent injections of oak bark. Vol. 1. 1* 130 Abscess of Antrum Maxillare. tincture of myrrh, &c. may be introduced into the antrum by a small syringe, with a pipe somewhat curved and about two inches in length. The injections should be used four or five times a day, and to prevent the opening from closing too soon, a bit of bougie must be worn—taking care that it be not so small and short as to slip into the antrum. I have known this to happen, and cause the patient great distress before it could be gotten out. When the quantity of matter has so far dimi- nished as scarcely to be perceptible, and the inflammation has subsided, the bougie may be withdrawn and the opening suf- fered to close. Sometimes it happens that collections of matter form in the antrum, and yet the teeth remain perfectly sound. To obviate the necessity of pulling such teeth, La Morier of Montpellier proposed to perforate the antrum above the alveolar processes immediately over the third grinder. The disease, however, so seldom occurs, without being accompanied or caused by carious teeth, that such an operation although practicable, can scarcely ever be rendered necessary. A third plan for evacuating the purulent contents of the an- trum, was proposed many years ago in France by Jourdain and Allouel—to wash out the cavity by means of a syringe carried up the nostril and into the natural opening between it and the antrum. From numerous experiments made to ascertain the feasibility of this proposal, it appeared that ihe operation was practicable, but so difficult as to be beyond the skill of common practitioners, and besides not so serviceable, even when well executed, as might have been expected. For these reasons it is now seldom attempted, and the old operation of pulling a tooth and perforating the antrum is on every account preferred. An abscess of the frontal sinuses is always very difficult to remove, on account of the remote situation of these cavities. Injections through the nostrils can scarcely be made to reach them, and I have derived benefit from no other source than fu- migation with athiops mineral. On abscess of the Antrum, see Hunter on the Teeth, Edit. 3d, p. 174—Pox on the Teeth—Jourdain, in Memoirs de PAcademie de Chirurgie, torn. 4, p. 357— Boyer's Trait* des Maladies Chirurgicales, torn. 6, p. 149—Bordenave, sur let Maladies du Sinus Maxillaire, in torn, 12, ofMemoires de PAcademie, p. 1. Mammary Abscess. 131 Section II. Mammary Abscess. This disease is not peculiar to lying-in women, although more commonly met with among them than others. Males are also subject to a similar affection. When suppuration forms soon after delivery, it proceeds from cold or a large accumulation of milk, which by distending the breast irritates and gives rise to inflammation. It is seldom, however, that an abscess forms until five or six weeks or even two or three months have elapsed. A swelling of the breast, accompanied by throbbing an dpain, and soon followed by coldness or a severe chill, are the first symp- toms. To these succeed restlessness, thirst and fever. Soon after the breast enlarges in every direction, becomes very tense and so exceedingly painful that the patient can scarcely bear the pressure of her own clothes. The secretion of milk is inter- rupted altogether, or its appearance and properties very much altered. Suppuration is generally established in eight or ten days; but sometimes the process goes on for several weeks, during which intolerable suffering and distress are experienced. The matter is not always collected in one cavity, but may be lodged in separate cysts. One of the most common causes of mammary abscess in this country, so far as my observation ex- tends, is the practice', very common among nurses, of feeding women immediately after delivery upon nutritious articles of food seasoned with wine and other stimulating ingredients—instead of observing a strict regimen and taking such precautions as are indispensable to obviate inflammation. A variety of mammary abscess, particularly noticed by Hey, of which I have seen several examples, is now and then met with. It begins like a common mammary abscess, but verges with less rapidity towards suppuration. The matter is often discharged from several openings, and these openings become fistulous and lead to narrow sinuses, which wind in every direction among 132 Mammary Abscess. the cellular membrane and glands of the breast. These sinuses, when opened are found nearly filled with a soft purple fungus. The disease may last for a very long time, and indeed there is reason to believe will never get well spontaneously, but gradual- ly continue to grow worse until the patient's constitution is worn out by hectic. Treatment of Mammary Abscess. It is very important, particularly among puerperal women, to prevent the formation of matter in inflammation of the breast, or in the common language of surgery to procure resolution. This may frequently be done by judicious treatment. The most effectual remedies are repeated applications of warm vinegar, topical blood-letting by leeches, and gentle suction of the breast by the mouth or nipple glass. General blood-letting is fre- quently inadmissible amongst lying-in patients, but may be em- ployed, nevertheless, provided much fever be present. Purga- tives, in all cases, will be found highly useful, and abstinence indispensable. By these means, together with various local ap-. plications, I have frequently succeeded in preventing suppuration. When we find, in spite of all our exertions, that suppuration must take place, we immediately discontinue resolvents, and endeavour to bring the matter to the surface as quickly as possible. For this purpose warm poultices are must useful. When the matter is deeply seated, and approaches the surface very slowly, and the patient is much reduced by severe pain and sleepless nights, an opening with a lancet or bistoury may become necessary, and should be made in a depending part of the breast. The poultice must be continued until the discharge nearly ceases, and then superficial dressings will complete the cure. If sinuses remain, pressure by a roller well applied will soon obliterate them. In the variety of mammary abscess described by Hey, it is re- commended to lay open each sinus completely; without which, it is stated, a cure cannot be accomplished. If I may judge from the result of two very extensive and obstinate cases of the dis- Mammary Abscess. 133 ease, which fell under my care a few years since, this severe proceeding may be dispensed with, and a seton substituted in its stead. Both patients recovered under this treatment in a very short time. A separate seton was placed in each sinus. In slight cases of the disease I have sometimes succeeded by covering the tract of the sinus by a firm compress, and support- ing it well with a roller around the chest. See Pearson's Principles of Surgery, p. 77—Underwood's Surgical Tracts, p. 252—Jameson Inflammation,p. 171—Hey's Practical Observations, edit. 3d,p. 522. 134 Hepatic Abscess. Section III. Hepatic Abscess. In warm climates, particularly the East and West Indies, where acute and chronic hepatitis are very common complaints, abscess of the liver is often met with, but, in this country, is comparatively rare. The liver may suppurate, however, from other causes than common hepatitis—as from blows or injuries of the head,* from biliary concretions, and from the presence of worms in the biliary ducts. A remarkable instance is recorded by Kirkland, of an abscess formed on the left side about the lowest false rib, from which was discharged a large red worm. " The tumour had broke," says he, " and discharged a considerable quantity of matter before I saw the man, and the ulcer had de- generated into a fistula; but by the quantity of bile that daily came away along with matter, the source of the disease was evident. 1 dilated the orifice a little, to give a free exit to the discharge, and in three or four days afterwards a living worm showed itself, which was taken away, and the sore healed in a moderate time. The man could give no account of his feelings, except that he had a deep dull pain and uneasiness in his left side, below the chest, some time before the gathering appeared; I therefore could not help suspecting, that the worm had entered in at the duct in the duodenum, and crawled to the opposite side through one of the branches of the hepatic duct."f The late' Dr. Thomas Bond,J of this city, has detailed a very interesting and extraordinary case (of a Mrs. Holt, who died, after suffer- ing above eighteen months,) of a disease of the liver, occasioned by a worm, twenty inches long and one inch in diameter. Upon dissection, a cavity was found in the external part of the liver, containing nearly two quarts of a fluid mixed with coagulated blood. A very beautiful preparation, made by the late Dr. * Bertrandi de Hepatis Abscessibus. \ See Kirkland's Inquiry into the present State of Medical Surgery, vol. ii. p. 186. \ See London Medical Observations and Inquiries, vol. i. p. 68. Hepatic Abscess. 135 Wiesenhall of Maryland, of a liver, the substance and ducts of which are filled and preforated in every direction, by numerous and very large lumbrici, which destroyed the child by irritation and suppuration, is contained in my surgical cabinet deposited in the University. Fontanelles* has lately recorded the case of a boy, thirteen years of age, in which death took place after an illness often or fifteen days, from the lodgement of a lumbricus, six inches long in the ducts of the liver. " The worm was found to have pe- netrated the ductus communis choledochus, reaching as high as the ductus cysticus and ductus hepaticus. The ductus communis was rent by the worm, the head of which came out through a hole in the ductus hepaticus. From whatever cause abscess of the liver proceeds, it is cha- racterized by deep-seated pain and swelling in the right side, and in the advanced stage of the disease sometimes by fluctua- tion which may be felt externally. As in hepatitis, the patient cannot lie, without an increase of pain, upon the left side, and there is always more or less pain in the right shoulder. Rigors precede and accompany the suppurative process, and in a little time the patient's strength is much reduced by irritation, hec- tic, and not unfrequently by large quantities of purulent matter from the intestines. There is reason to believe, indeed, that in most instances a communication is formed between the intestines and liver, or between the abscess and biliary ducts, through which the matter is poured into the intestines and passes off by stool. In other cases an ulcerated opening is established be- tween the liver and diaphragm, and the pus is discharged into the chest or coughed up from the lungs. By whatever route the matter escapes, whether through the abdominal muscles or by the internal passages mentioned, it generally happens that through the medium of the adhesive process it is enclosed in a cyst, and so separated from the adjoining parts as to prevent all danger of effusion. Sometimes, however, effusion actually takes place from rupture, ulceration, or the want of adhesion; and then the patient dies in a very short time. After the pus has been discharged externally, whether spontaneously or by art, it soon changes its colour and consistence, and becomes sanious, fetid and ill-conditioned. Many years ago I attended a patient, in • Johnson's Medico-Chirurgical Review, vol. 8, p. 287. 136 Hepatic Abscess. consultation with Dr. Coulter of Maryland, from whose right side, between two of the ribs, a large quantity of healthy puru- lent matter was discharged, which in a few days became so changed in colour as to resemble coffee-grounds, and so con- tinued for several months, when the patient died—worn out by hectic and debility. Upon dissection, the fistulous orifice in the side was traced into the liver, or rather into its remains; for the substance of the liver had disappeared, and nothing of its struc- ture could be found except a shell or cyst, somewhat larger than an egg and filled with the same kind of brownish matter. Similar appearances have been reported by authors. Treatment of Hepatic Abscess* Few patients recover after matter has been discharged into the chest, or passed off by the bowels; and all that can be done, under such circumstances, is to protract the life of the sufferer by appropriate nourishment and medicine. When the matter collects in the external part of the liver and makes its way to- wards the surface of the body, the event is more likely to prove favourable and many have recovered after large quantities have been discharged through the abdominal muscles. Surgeons were much in the habit formerly of waiting for the spontaneous opening of the abscess ; but experience proves, that the patient's chance of getting well, is proportionably increased by an early evacuation of the matter. On this account it is now a practice almost universal among surgeons in India, to make an incision through the intercostal or abdominal muscles as soon as the slightest swelling can be perceived, or indeed without any swelling being evident, provided the nature of the disease in other. respects be well ascertained. The operation may be performed with a common lancet, bistoury, or trocar, and re- quires very little skill. After the discharge of the matter, the patient's strength should be supported by tonics and a good diet—taking care at the same time, not to permit too liberal a supply of food, as the appetite of convalescents from this dis- ease is often voracious, and from being unrestrained has, in too Hepatic Abcsess. 137 many instances, brought about a relapse and fatal termination- The external wound should be healed as soon as the discharge has so far diminished, as to render its reproduction improbable; otherwise a fistula is apt to form. See Lassus' Pathologie Chirurgicale, tom. I. p. 144—Kirkland's Medical Sur- gery, vol. 2, p. 185—Bertrandi, de Hepatis Abscessibus qui vulneribus Capitis su- perveniunt, in Memoires de PAcademie de Chirurgie, tom. 9, p. 130—Curtis on the Diseases of India—Barry's Case of an Ulcer in the Lungs piercing through the Diaphragm into the Liver, in Edinburgh Medical Essays, vol- 1, p. 273— Similar Cases by Kite and Farquharson, in the Land. Med. Communications and Lend. Med. Memoirs. Vol. I. is 138 Lumbar Abscess. Section IV. Lumbar Abscess. Psoas or lumbar abscess, although common in Europe, is rarely met with in the United States. That this assertion is correct, will perhaps be admitted, when I state that I have seen only ten cases of the disease during the last twenty years, although pro- fessionally connected with extensive hospitals and alms-houses during the greater part of the time.* In Great Britian the com- plaint is so frequent, that it is hardly possible to pass through the wards of any common infirmary, without meeting with several cases. The symptoms are pain in the lumbar region, extending from the kidney down the outside of the thigh—the testicle of the af- fected side is drawn up, and there is more or less uneasiness and pain throughout the course of the spermatic cord. The patient is fatigued upon taking the slightest exercise, and whilst in bed re- laxes the muscles of the thigh and leg in order to relieve partial- ly the uneasiness which is constantly felt. These symptoms of- ten continue for several months nearly stationary, and then a change is observed, which is indicated by rigors, loss of appetite, and other symptoms of hectic, denoting the formation of matter. In the peighbourhood of the psoas muscle there is abundance of adipose substance; this is filled and" surrounded by matter in such a way as to separate many parts from their connexions and to form a cyst, extending in many instances considerably below the groin. Sometimes the matter drops flown near the rectum, or passes through the ischiatic notch, or above, or below, Pou- part's ligament. In a case, lately presented to me, at the Blockley Hospital, the abscess formed a communication with the urinary bladder and the urine and pus were intermingled. In whatever situation the tumour presents, it may be felt soft and fluctuating—projecting in the erect, and receding in the recum- bent posture. * Dr. Physick informs me that he never met with a case of psoas abscess in America unconnected with disease of the spine. Lumbar Abscess. 139 The consistence and colour of the matter, in some instances, do not differ from common pus; but generally the fluid is thin and gleety, and mixed with small flocculi, or with lumps resembling curds or cheese. After a time ulceration takes place in some part of the swelling, and the matter is suddenly discharged in large quantity, weakening the patient so much that he cannot survive more than a few days; or else the contents of the cysts are poured off gradually through a narrow aperture, and in this way the patient's life may be protracted, or a sponta- neous cure brought about. The causes of this complaint are very obscure. It occurs chiefly among the lower orders of people, such as are scantily fed and clothed, and exposed to the vicissitudes of weather and great hardships. In Britain it is said to be more common among scrofulous persons than others, and that adults are more subject to the disease than children. Sometimes the vertebrae become carious, but whether antecedently or subsequently to the forma- tion of matter, is not easily determined. Treatment of Lumbar Abscess. Very few patients recover from this disease under any circum- stances, and those that escape remain puny and debilitated. In the early stages it may relieve the patient, and perhaps check the progress of the disease, to employ purgatives, blood-letting and low diet; but as soon as the formation of matter is indicated, these remedies should be laid aside, and an opposite mode of treatment adopted. Formerly surgeons were in the habit of making a large open- ing in the abscess; but the ill consequences which almost in- variably followed, caused the practice to be abandoned. Kirk- land was among the first to state, that the patient had the best chance of getting well when the abscess opened spontaneously, and the matter drained gently off'through a very small aperture: and it was probably a suggestion of this kind which led Mr. Abcrnethy to propose a small and valvular opening—a prac- tice which experience proves to be generally more success- 140 Lumbar Abscess. ful than any other. It is slated by Mr. Pearson, however,, that in comparing the result of the different modes of treatment in his own practice, a greater number of patients have recovered where the matter has been suffered to escape of ils own ac- cord. Crowther has recorded four or five cases, which, without discharging the matter, he succeeded in curing, by means of large blisters over the swelling, kept open for a considerable time by the savin cerate. A similar plan should always be tried, and, if ineffectual, the operation recommended by Mr. Abernethy ought, I conceive, to be preferred to any other. This consists in making an opening at the most pointed part of the tumour with a common lancet, barely sufficient to permit the escape of flocculi or lumps of coagulated blood, which are apt to collect wilhin the cyst, drawing off a small quantity of matter, and then healing the orifice by the first intention. In a week or two, or when the matter collects again in sufficient quantity, the operation must be repeated, and performed after- wards as often as the case may require, always taking especial care to close the opening after each puncture with sticking plaster. By draining off the matter in this gradual way, the sides of the upper part of the cyst coalesce, in proportion as the contents settle towards the bottom, until the cavity is entirely obliterated and a cure effected. See Kirkland's Medical Surgery, vol. 2, p. 199—Pearson's Principles of Sur- gery, p. 102—Abernethy's Surgical Works, 1819, vol. 2, p. 132—Crowlher't Practical Observations on the Diseases of the Joints, p. 204. Femoral Abscess. 141 Section V. Femoral Abscess. I have met with several cases of deep-sealed, purulent col- lections under the fascia lata of (he thigh, where the disease has assumed a regular form, attended with uniform symptoms. Similar cases are mentioned occasionally, but the disease is not treated of by systematic writers. Children from six to twelve years of age, so far as my observation extends, are more sub- ject to this complaint than others. There is always pain ex- tending from the top of the thigh down to the knee, and gene- rally in the course of the rectus muscle, so much resembling rheumatism that it is commonly mistaken for that disease. To relieve the pain, the patient bends the thigh on the pelvis and the leg on the thigh, and in this position the limb is constantly kept. More or less swelling is soon perceived. This is ex- tremely hard and unyielding, and for the most part is situated a little above the middle of the thigh. The pain increases with the swelling, and in the advanced stages of the disease is so ex- tremely severe, that the patient finds it impossible to sleep even under very large doses of opium. The constitutional symp- toms also run very high, and in a little time a complete hectic is formed. The thigh continues to swell, and eventually the tumour often extends beyond the knee. A very large quantity of matter may accumulate beneath the fascia, without any per- ceptible fluctuation being evident, owing to the dense and un- yielding structure of that membrane, which does not take on ulceration, but opposes the progress of the abscess towards the surface so effectually, that in one case to which I was called, after the disease had existed for three months, the matter had travelled along the leg and been discharged near the ankle— leaving the muscles of the whole limb completely dissected, and the patient so reduced as scarcely to be alive. Care must be taken not to confound this disease with psoas abscess. 142 Femoral Abscess* Treatment of Femoral Abscess. In the commencement of this disease I have usually resorted to blisters, frequently repeated or kept open for a week or ten days by savin cerate. Sometimes 1 have established a large issue in the most prominent part of the tumour ; and under these modes of treatment the matter has not formed, or has been dis- persed in a short time. But, in most instances, before the sur- geon is called, the thigh is so completely filled with pus, that nothing less than an operation will answer. Kirkland, who has slightly noticed this affection, seems to recommend an incision on the outside of the thigh, throughout its whole length; while Sir Charles Bell condemns a large opening as likely to produce most violent symptoms, and even death. In all the cases which have fallen under my care requiring an operation, I have pushed a common sized lancet into the thigh through the fascia, when the matter has immediately followed to the great relief of the patient. After this I have introduced a tent into the opening, and bandaged the" whole limb as firmly as could be borne. Not- withstanding this treatment, large quantities of matter have con- tinued to be secreted for some time, and in a few instances a fistula has remained, and could only be cured by strong injec- tions and a tight roller. See Kirkland's Medical Surgery, vol. 2, p. 268—Charles BelPs Operative Sur- gery, vol. l,p. 2. Paronychia 143 Section VI. Paronychia or Whitlow. This is a very common and frequently a most severe affection, commencing in the extremities of the fingers, in the form of a small abscess, and sometimes extending gradually upwards so as to involve the hand and fore-arm. The toes also are not en- tirely exempt from the disease. Authors have enumerated several species of whitlow, though it appears to me without much propriety. There are certainly varieties of the complaint, but most of them originating perhaps from the same cause, and differing only in situation. Most writers describe four species, the first of which is said to be seated under the cuticle, near the root or side of the nail,—the second, in the cellular mem- brane, under the cutis,—the third, in the theca, or sheath of the flexor tendons, about the fingers, hand, or fore-arm—and the fourth, in the periosteum, or between the periosteum and bone. Even these distinctions, however, are in a great measure arbi- trary ; for it is not always in the power of any surgeon to declare, from examination of the part, what particular texture is affected. So far as I have observed, indeed, the symptoms are nearly the same in all cases; more severe in some than others; especially when the pus travels along the sheath of the tendons up the fore-arm. In ordinary cases a pungent, deep-seated pain is felt in the end of the finger, which is sodh succeeded by considerable swell- ing. The pain increases with great rapidity, and in a little time becomes so intolerable that the patient is kept awake in some instances for whole days and nights together. Indeed, in- stances are recorded of delirium and even death from this ap- parently trivial complaint. Although the inflammation is rapid in its progress, and attains an enormous height, yet the suppura- tive process goes on tardily, so much so that weeks not unfre- quently elapse before fluctuation can be perceived; and even af- ter the pus has accumulated, it is so confined by fasciae and 144 Paronychia. tendinous sheaths, as to render its escape almost impossible and its diffusion internally inevitable. On this account we very often find the bones bathed in matter and rendered carious, and the tendons and muscles separated from each other and com- pletely undermined. Sometimes the ravages of the disease do not extend beyond a single phalanx; at other times the whole finger is destroyed, and several of the contiguous joints in suc- cession. Paronychia may be traced generally to some local injury,— such as pricking the finger with a needle, or splinter. Persons engaged in such occupations as require frequent immersion of the hands in warm water and other fluids, are very subject to it. Often its cause is perfectly unintelligible. Mr. Pearson has described what he calls the venereal pa- ronychia, and Mr. Wardrop has given a detailed account of a particular disease under the title of onychia maligna. How far these differ in reality from ordinary whitlow remains to be proved. Treatment of Paronychia. Venesection, both general and topical, may be required in the early stages of whitlow; leeches especially prove very servicea- ble in all cases, by abating pain and reducing the inflammation. These remedies, however, are seldom sufficient to procure reso- lution; but this has often been accomplished by the early and repeated application of a blister. On the other hand it must be stated, that many patients derive*io advantage whatever from the blister; though the same applications, I have observed, prc? duce very opposite effects on different patients; thus I have known common linseed oil, spread over a whitlow, afford in- stantaneous relief in some cases—and in others, so far from proving beneficial, aggravate all the symptoms. Soft soap or common brown soap, warmed and applied to the affected part, occasionally acts in a wonderful manner—assuaging the pain and subduing the swelling in a very short time. Poultices ome times give relief, and are useful always in softening the kin and removing tension, but when the swelling is very great, Paronychia. 145 the pain intense, and matter evidently formed, the most ef- fectual mode of easing the patient is to lay open the part freely with the knife. From the wound a large and painful fungus is apt afterwards to arise, and the same happens after a spontane- ous opening of the abscess. In either case its growth must be repressed by lunar caustic and other escharotics. Opium given in repeated doses is essential during the height of the pain. After the matter has ceased to flow copiously, and the inflam- mation has subsided, the sores may be dressed with lint and mild ointments. Any portion of carious bone may be picked away cautiously. Amputation is seldom necessary in this complaint, inasmuch as the phalanges of the fingers separate spontaneously at the joints, which, when the disease is arrested, heal up and form an appropriate stump. When matter collects in the hand and fore-arm, several different openings will be required. For the removal of the onychia maligna Mr. Wardrop re- commends the evulsion of the nail, and subsequent application of caustic. When these fail, amputation becomes necessary. The venereal paronychia is treated by Mr. Pearson, in the in- cipient stage, by no external applications,—the part being merely covered with a fine linen rag. After the matter is discharged spontaneously, equal parts of balsam of copaiba and thebaic tinc- ture prove serviceable. See Pearson's Principles of Surgery, p. 87—Wardrop on Onychia Maligna, in Medico-Chirurgical Transactions, vol. 5, p. 135—Dorsey's Surgery, vol. 2, p. 292. Vol. I. 19 146 f Icen CHAPTER V. ULCERS. Theke is no class of surgical diseases in which the student should feel a more lively interest than that of ulcers—both in a pathological and practical point of view. In the one case, he has fair opportunity to speculate upon the important processes of animal decay and reparation; in the other, to exert his utmost ingenuity to overcome difficulties which the best surgeons in every age have felt and acknowledged—the obstinate, and often- times intractable nature of the complaint. Strange as it may appear, however, so little attention is paid by most students to this department of surgery, that it is hardly possible for the pre- scribing surgeons, or clinical lecturers, in the Philadelphia Hos- pital at Blockley (one of the finest establishments perhaps in the world, as regards the number of patients and the variety of dis- eases,) to interest a class by any observations they may make on the subject, or by any cases they can exhibit. But this feeling, amounting almost to prejudice and disgust, is not peculiar to the members of the profession in this country; it h noticed and complained of every where, and arises doubtless from the loath- some condition in which ulcers are generally found—such dis- eases being most common among the lower orders of people, especially (he intemperate and filthy. There is another reason too, I am convinced, which has had great influence in prevent- ing that attention to ulcers they deserve—the unsatisfactory, complicated and adverse distinctions made by almost every writer. This is so conspicuously the case, that the student can hardly take up any common treatise on the subject without find- ing himself immediately involved in a labyrinth of perplexities; and if he proceed so far as to understand, as he supposes, the views of the writer, and attempts to apply them to practice, all his conceptions vanish in a moment, and he only knows that Ulcers. 147 there is an ulcer before him without being able to say to what class or species it belongs. This confusion, it appears to me, has arisen from the numerous appellations given by authors to ulcers of the same character, and from very trifling and often- times accidental varieties being dignified with the name of species. Thus the simple purulent ulcer, and the simple vi- tiated ulcer of Mr. Benjamin Bel!, are the heal/hi/ and irrita- ble ulcers of Sir Everard Home. Again—what Sir Everard Home describes as an " ulcer in parts too weak to carry on the actions necessary for its recovery," is called by Mr. Burns the overacting ulcer, and by common writers the fungous ulcer. The name of inflamed ulcer has sometimes been substituted for irritable ul- cer, and callous ulcer for that of indolent ulcer. These contra- rieties, however, are pardonable and unimportant compared with others which have been adopted almost universally—such as the sinuous ulcer, the carious ulcer, the fungous ulcer, the slough- ing ulcer. These, it must be evident to any practitioner much accustomed to the treatment of ulcers, are accidental symptoms merely, or, at farthest, variations which are not peculiar to any particular species, but may accompany or follow all. After these remarks, it will be proper to attempt a classifica- tion of ulcers calculated to obviate the objections that have been urged. This may perhaps be accomplished by an arrangement approaching to that of Home, but differing from it chiefly in being more simple and intelligible. With this view, I shall ar- range all ulcers under three classes—healthy, unhealthy, and specific ulcers. The first class comprehends but one species; this I shall call the simple ulcer. The second contains two species—the irritable and indolent ulcer. Under the third class may be arranged several species, the. principal of which are ulcers from scrofula, cancer, fungus, hoGmatodcs, and syphi- lis. To these might be added perhaps with propriety, the sy- philoid, scorbutic, herpetic, and contagious* ulcer. The ulce- ration that attends lupus, or that particular disease called noli me langerc, may also rank as a species of specific ulcer. * Usually denominated Hospital Gangrene. 148 Simple Ulcer. Section I. Simple Ulcer. The simple ulcer is the result of some injury done to a sound part, by a wound, contusion, abscess or burn. It is generally met with in young and healthy subjects, and may occupy any part of the body. The surface of this ulcer exhibits a florid ap- pearance, owing to the small, pointed and numerous bright red granulations, which cover it in every direction. In a little time small white patches may be observed, on the top of these granu- lations, first near the edge of the old skin, and afterwards in the middle and other parts of the sore. These lay the foundation of a new cuticle. From the sore there is always discharged a white, thick, inodorous pus, small in quantity and easily wiped away. Provided the constitution remains sound, and no additional inju- ry is sustained by the ulcer, it will generally heal in a very short time; but it is possible for such an ulcer to become diseased, and then, according to circumstances, it may take on the irritable or indolent character. Treatment of the Simple Ulcer. As the natural tendency of this ulcer is salutary, the only re- medies required are such as will defend it from external injury and prevent evaporation of the pus. Keeping the patient in a horizontal position, if it be an ulcer of the leg or foot, elevating the limb upon a pillow or moderately inclined plane to facili- tate the return of blood, and barely covering the sore with some mild and fresh ointment spread on lint or on a fine linen rag, will often effect a cure in a few days. The simple ointment and Turner's cerate I have found the most useful. Dry lint is an excellent application in most ulcers of this description. It should not cover the whole sore, but chiefly its centre—the edges being protected by small slips of linen spread with ce- Simple Ulcer. 149 rate. Some patients complain of dry lint, as too stimulating and adhering so closely to the granulations as not to be removed without giving pain. In such cases, I have usually found a cold bread and milk poultice a very soothing and useful application. Sir Everard Home condemns the employment of poultices alto- gether in this species of ulcer. Few ulcers of the simple species will bear pressure either from a roller or adhesive straps. In some particular constitutions, applications which keep the sur- face of the sore moist do mischief; in these cases, the ulcer will often heal by exposing it to the air and permitting it to form a scab. 150 Irritable- Ulcer. Section II. Irritable Ulcer. The irritable ulcer is the first species of the class of unhealthy ulcers, and is generally characterized by the following appear- ances and symptoms. The edges of the sore are ragged, under- mined, and sometimes almost serrated. The parts for some dis- tance beyond the ulcer are red and inflamed, and often cedema- tous. Irregular hollows occupy the bottom of the ulcer and con- tain a thin, greenish or reddish matter, which is so extremely acrid as to excoriate the adjoining skin. In place of granula- tions may be found a white or dark red spongy mass, extremely painful and shedding blood upon the slightest touch. Although the irritable ulcer generally proceeds from local causes, it is influenced, in most instances, materially, by the state of the constitution and habits of the patient. The digestive or- gans in particular, as I have often witnessed, are very apt to be disordered in persons afflicted with the irritable ulcer, whe- ther primarily or secondarily cannot always be ascertained. Commonly also this ulcer is met with in persons of nervous or irritable temperament. Hence the disease is by no means un- frequent in the higher classes of society, particularly amongst epicures, huge feeders and debauchees. When seated in the leg, as usually happens, the patients suffer immensely from pain, which is most severe at night, and sometimes attended with spasms of the limb. Irritable ulcers are generally situated on the fibula, immediately above the ankle, where, without pene- trating" far, they soon expose the bone, and quickly render it carious if not arrested by appropriate remedies. Irritable Ulcer. 151 Treatment of Irritable Ulcer. When we have reason to believe that an irritable ulcer pro- ceeds from, or is kept up by, some derangement of the digestive organs, immediate recourse must be had to steady purging and nauseating doses of antimonials. It is astonishing how much may be done for local diseases in this way, and for foul irritable ulcers especially. I am very sure, from considerable experience in this branch of surgery, that more benefit is to be derived in many cases from a few doses of medicine judiciously administered, than from all the local applications that can be thought of. I cannot, however, speak in the same terms of blood-letting, which some have highly recommended ; indeed, very few cases of irrita- ble ulcer have fallen under my notice requiring this operation. As most patients among the lower orders come into hospitals and alms-houses with their ulcers inflamed and in a very foul state, the best local application to begin with is a warm poultice, just large enough to cover the sore, and not so large as by its weight to create pain. Much will depend upon the condition of the ulcer as regards the continuance of the poultice. Ge- nerally the patient's pain is soon relieved by the application, and the ulcer improves rapidly under it. But in four or five days the surgeon will find it expedient, in most cases, to lay it aside and substitute some other dressing. As long, however, as the poultice agrees with the ulcer it should be continued,.even until cicatriza- tion is completed. The carrot often forms an excellent poultice for the irritable ulcer. It should be finely grated and applied in a raw state, or boiled to a soft pulp. The powder of the bark of slippery elm, made into a jelly by boiling water being added to it, agrees remarkably with the irritable and most other ulcers. Fomentations are highly extolled by some writers, but the diffi- culty of application renders them almost useless. Unctuous sub- stances disagree with the irritable ulcer, except the materials be extremely mild and perfectly fresh. Sir Everard Home highly praises common cream in those irritable ulcers with which warm applications disagree. After the sensibility of the ulcer has di- minished, a weak solution of the argentum nitratum will he found one of the best applications that can be emploved. Opium given 152 Irritable Ulcer. internally mixed with poultices, or sprinkled in the form of pow- der over the sore, is well adapted to remove pain, and is fre- quently indispensable. The elevated position of the limb, and perfect rest are essential in this species of ulcer. Every thing like pressure and handaging must be avoided. Indolent, Ulcer. 153 Section III. Indolent Ulcer. The indolent is the most common of ulcers, and is almost pe- culiar to filthy, dissolute and intemperate persons. It is the species of ulcer with which the wards of alms-houses and hos- pitals are crowded, which is so frequently seen amongst com- mon soldiers, sailors, and people in the ordinary walks of life. From the simple and irritable ulcer it differs materially, both in symptoms and external character. The granulating sur- face has a flat and shining aspect, and is covered partly with a pellicle or crust of a whitish or dark gray colour, so tenacious as to be inseparable from the ulcer without considerable force. Sometimes the sore is perfectly dry or free from matter, but ge- nerally there is a profuse discharge of a viscous, cohesive, fluid, intermediate between pus and coagulating lymph. The edges of the ulcer are elevated, protuberant, smooth and rounded; hence a very deep cavity is apparently formed, when in reality the base of the ulcer is very little below the level of the sound skin. For a considerable distance beyond the ulcer the parts are swollen and indurated, and the whole limb enlarged. In nine cases out of ten the leg is the seat of the indolent ulcer, and the nearer the disease approaches the ankle the more difficult it is to cure. So trifling is the pain in most instances, that the pa- tient is hardly sensible of the existence of the sore. It is possible for the simple or irritable ulcers, from neglect or bad treatment, to become indolent, and assume all the ap- pearances just described, or the indolent ulcer may exist from the first independently of the others. In that case the external characters will differ in some respects, from those pointed out as peculiar to the disease in its advanced stage. The granula- tions are pale, flabby, large and rounded, bleed from the slight- est scratch, and rise oftentimes in a fungus form above the level of the skin. This is what Sir Everard Home would term an " ulcer in parts too weak to carry on the actions necessary for Vol. I. 20 154 Indolent Ulcer. its recovery," and what is usually denominated by writers the "fungous ulcer," but which, in reality, is the first stage, or at any rate a variety only of indolent ulcer. This variety may, and often does, accompany an ulcer with carious bone, sprouts from the mouth of a sinus or covers the surface of many specific ulcers. From whatever source it springs its characters are uni- form, and its disposition so truly indolent, that it cannot, without impropriety, be referred to any other head. Another variety of the indolent is the varicose ulcer, or that disease which sometimes precedes, at other times follows, a vari- cose enlargement of the veins of the leg and thigh. This has been looked upon by some as a particular species, but its cha- racters in most respects are so allied to those of the common in- dolent ulcer, that it ought not to be placed in any other rank. The cavity of this ulcer is not unusually deep, and its bottom presents nearly the same appearance as the indolent ulcer in its advanced stage; the edges of the skin, however, bounding the sore are not tumid. In shape the ulcer approaches to the oval, with its longer diameter vertical. The pain is not acute, but rather deep-seated and extending along the venous trunks. These trunks are distended and knotted, in some cases, quite to the groin, and their branches displayed in endless tortuosities over the whole leg. The ulcer itself generally occupies the inner side of the leg. Treatment of the Indolent Ulcer. When the indolent ulcer has continued for months or years, and the patient's constitution is enfeebled by disease or worn out by intemperance, very little benefit may be expected from any mode of treatment. Almost every surgeon has met with cases of this description; and it is by no means uncommon, on the other hand, to see stout and healthy looking patients walk- ing^ about orlying in the wards of an alms-house, with one or both legs covered with large and insensible sores of twenty years' standing, which have been brought at different periods almost to a close, but in a few days have broken out afresh and Indolent Ulcer. 155 become as large as ever. Many such patients are to be found, in Europe especially, who nourish their diseases to gain a live- lihood by begging, or to secure a permanent abode in some public charity. In this country too I have known patients to irritate their sores by picking them with pins through the ban- dages, in order to prevent the healing process.. As soon as an ulcer shows a disposition to become indolent, which may be known in recent cases by the rounded and fun- gous form of the granulations, the surgeon should resort, with- out delay, to escharotics, adhesive straps, or the roller. Under this treatment a cure will often be accomplished in a few days. When the sore has become so truly indolent or callous, as to remain insensible under the strap and bandage, additional means should be employed. The edges must be pared away by the knife, and the whole surface pencilled with the vegetable or lunar caustic. By these means the older surgeons often suc- ceeded after the failure of all other remedies. There are many ulcers of the leg which burrow in the cellular membrane and spread extensively, owing to the fascia beneath them remain- ing entire. Such sores seldom heal until the fascia is slit up or pared away. In general the best application to begin with, when the indolent ulcer is very foul, is a common poultice of bread and milk or linseed, followed up by an oak bark poultice, and continued two or three days. After this, adhesive straps, the leg being previously shaved, may be applied in such a way as not to encircle the whole limb, but two-thirds merely—care being taken to leave spaces for the escape of matter. Over the straps, beginning at the toes, we plage, with moderate firmness, a cotton, flannel or serge roller, and continue it up the limb as high as the knee. Under this treatment, the sore improves so rapidly that the patient is frequently able to walk about and at- tend to his business, without the exercise interfering with the cicatrization. Experience proves that sores healed in this man- ner are less apt to break out again, than those cured by rest and the horizontal position. There are some patients, however, that cannot take exercise without its occasioning an increase of the ulcer; though there is reason to believe, that this arises too fre- quently from an improper or sloveuly mode of applying the bandage and straps. Many ulcers require, in addition to pressure, highly stimu- 156 Indolent Ulcei. lating applications,—such as repeated touches with lunar caustic, savin in powder, or mixed with yellow basilicon, cantharides, capsicum and other varieties of pepper, the gastric juice of ani- mals, decoction of walnut leaves, nitric acid, diluted in the pro- portion of fifty drops to a quart of distilled water, lime water and laudanum, unguentum hydrargyri nitrati, corrosive subli- mate, camphor, chloride of soda, creosote, the carbonates and phosphates of iron, &c. Dr. Underwood highly extols the black basilicon, and represents it as infinitely more efficacious in all cases than the yellow. With some ulcers, however, milder ap- plications answer a better purpose,—such as rhubarb in powder, either alone or combined with crude opium, tincture of myrrh, &c. The best cicatrizer, according to Dr. Physick, for most indolent ulcers, is simple cerate and British oil—an ounce of the former to two drams of the latter to begin with, gradually increasing the quantity of the oil. But as a general rule in the treatment of all ulcers, the surgeon must not neglect to change his dressings repeatedly; for it has been ascertained beyond all doubt, that sores flag, and are put back for weeks, by the im- proper continuance of a medicine which at first and for a short time, produced excellent effects. Constitutional remedies often exert great influence over indo- lent ulcers. In the wards of the Blockley Hospital I have suc- ceeded, in numerous instances, by the use of the blue pill and other preparations of mercury, after most other medicines had been tried for months ineffectually. When the patient's constitution has been prostrated by intem- perance, and other similar causes, the internal use of carbonate of ammonia, of wine, brandy, opium, &c, will prove of immense service. Indeed, in most instances of the kind, ulcers cannot be healed without the use of such remedies. Where sinuses exist, well directed pressure by bandages will do a great deal; when these fail, the tract must be laid open by the knife. Fungous granulations are easily repressed by red precipitate, blue vitriol, or adhesive straps. So long as any portion of carious bone remains, the ulcer will keep open in spite of every dressing; in these cases, the gastric juice, nitric, and other acids, often prove serviceable, by acting upon and re- moving the earthy parts of the bone. The surgeon should not be too officious in cutting away bones apparently carious, otherwise Indolent Ulcer. 157 he will soon find all the symptoms aggravated, and the bone in a little time rendered really carious. Nature is generally more efficient in such cases than art. The ulcer accompanied by varicose veins, will generally heal under adhesive straps,the roller,or laced stocking; but in many instances, these veins become so large as to require an opera-^ tion, without which every effort on the part of the surgeon to close the sore will prove fruitless. This operation will be de- scribed at a future period under the head of Diseases of the Veins. See Underwood's Surgical Tracts, containing a Treatise upon Ulcers of the Leg, edit. 3d, 1799— Whately's Practical Observations on the Cure of Wounds and Ulcers on the Legs, without Rest, 1799—Home's Practical Observations on the Treatment of Ulcers on the Legs, considered as a branch of Military Surgery, &c, edit. 2d, 1801—B. Bell on the Theory and Treatment of Ulcers, in vol. 2d, of System of Surgery, edit. 7, p. 214 —Thomson on Inflammation, p. 423— Roux's Narrative of a Journey to London in 1814,- or, a Parallel of the English and French Surgery, edit. 2, 1816, p. 127—The Lectures of Sir Aslley Cooper, m by Tyrrel, vol. 1—Stafford's Essay on the Treatment of the deep and excavated Ulcer, 8vo. London, 1829. 158 Specific Diseases. CHAPTER VI. SPECIFIC DISEASES. Under this head I propose to arrange certain diseases which it appears to me cannot be treated of with propriety in any other place, inasmuch as they are closely connected with inflamma- tion and its terminations, and with other subjects discussed in the foregoing pages. Some of these diseases may appear per- haps to belong to the practice of medicine. In a limited point of view this is really true; but it is equally obvious, that a large share of their pathology and treatment must come within the ^surgical department. Besides scrofula, cancer, fungus m haematodes and syphilis, there are specific affections not so ob- trusive to the senses, but sometimes equally formidable and not less difficult to cure. Section I. Scrofula. Without attempting to explain or reconcile in this place the discordant, multifarious, and too often wild and hypothetical views regarding the nature of scrofula, it may be sufficient to state that we know very little of its origin, of the circumstances respectively calculated to modify the forms and variations under which it appears in the different textures of the body, or of the method of cure. We are perfectly familiar, however, with its effects both constitutional and local, and with the symptoms by which it is characterized. In most instances, certain premonitory signs noticed by all writers, are very perceptible long before the disease itself be- Scrofula. 1J*9 comes evident. The complexion is extremely delicate, of a lively red colour mixed with a beautiful white, and the red of the lips approaches to a carnation tint; but the lips themselves, the upper especially, are thick and protuberant. The pupils of the eyes are dilated, and the conjunctiva remarkably clear and free from vessels. The eyelids drop unnaturally, and give to the countenance a melancholy but interesting expression. The head is large and protuberant at the occiput, the neck short, the lower jaw thick and fleshy, the eyes of a light gray or blue colour, the belly swollen and prominent. These signs, taken collectively, undoubtedly manifest the scrofulous constitution ; but some of them are at least equivocal, such as the colour of the eyes, which are, perhaps, as often dark as light, and in some instances ex- tremely black. The hair is generally straight and wiery, and often of a jet black colour. Sometimes, however, it is almost white. Children are more subject to scrofula than grown persons, and ' the disease may show itself at any period between infancy and puberty; it may appear also in almost any texture of the body, and is certainly not, as some authors have imagined, peculiar to the lymphatic absorbent system. But the lymphatic glands un- doubtedly are more susceptible of the disease than other parts, especially the glands of the neck and mesentery. Next to these the lungs and spongy parts of the bones are most apt to suffer. In whatever situation a scrofulous tumour may be met with, it uniformly exhibits the following appearances and symptoms. At first there is simple enlargement without pain or unnatural heat; in a short time, however, the patient complains, if the tu- mour be pressed upon, and the warmth of the part is sensibly augmented by several degrees. In this state, or without any ma- terial change, the disease may continue for months or years, and afterwards disappear spontaneously. Commonly it follows a dif- ferent course—gradually taking on inflammation, and at last ter- minating in abscess and ulceration. Long before the abscess breaks, the skin assumes a dark purple or leaden colour, and re- tains it in many instances for a considerable time, after the sore has cicatrized. The matter discharged from the abscess is thin, glecly, and mixed with flocculi or small portions of a substance 1G0 Scrofula. resembling cheese. The discharge sometimes continues for many weeks; in other instances, the openings from which it is poured out rapidly enlarge, and the whole tumour or its remnant is con- verted into an ulcer peculiar in appearance and difficult to cure. When a scrofulous abscess follows an enlargement of a lympha- tic gland, it might be supposed that the matter was formed with- in the substance of the gland; this, however, is not invariably the case—the gland sometimes remaining entire and the matter having only formed around it. This particular state is ascer- tained by the probe, by the circumstance of the tumour undergoing no diminution, and occasionally by the separation and evacuation of the unaltered gland itself. Scrofulous abscesses of large size seldom proceed from a single gland, but from a cluster of glands united by inflammation. When such enlarged masses are seal- ed in the neck, they sometimes by pressure impede respiration and deglutition. The scrofulous ulcer usually puts on the following appear- ances. The edges are thin, smooth, obtuse, of a pale red or purple hue, and overhang the ulcer, the bottom of which is deep and the granulations loose, indistinct, of a faint rose colour and glossy aspect. From the sore is discharged a thin, curdled colourless, offensive matter. This ulcer is never painful, unless inflamed by rude treatment, improper applications, or carious bones; in that case, the whole surface is changed, becomes of a fiery red colour accompanied by fungous granulations, elevated and retorted edges, and a profuse discharge of watery matter. Although the nature of scrofula is involved in great obscuri- ty, there are certain occasional causes which appear to exert considerable influence in bringing the disease into action. These are particular degrees of cold, especially when conjoined with moisture, irregularities of diet, meager and unwholesome pro- visions, an impure or tainted atmosphere generated in crowded manufactories, hospitals and schools, deficient clothing, external injuries, fevers, mercurial frictions, want of exercise, filth, fa- tigue, mental anxiety, &c. Of all these causes a cold, damp and variable climate is the most powerful in inducing the disease; and next to this, perhaps, derangement of the digestive organs, from improper and particular modes of living. It is well known Scrofula. 161 that Mr. Abernethy, within the last few years, has endeavoured to show by a variety of illustrations that a great many local diseases derive their origin from disorder of the digestive func- tions. The same train of reasoning has been applied by Carmi- chael and Lloyd to the explanation of scrofula, and it appears to me, with very considerable success. With regard to the here- ditary, or adventitious origin of scrofula, much diversity of opi- nion still prevails: it seems to me, however, that the advocates of each side of the question have chiefly erred in admitting the influence of one to the entire exclusion of the other. I have no hesitation in stating that I believe in the hereditary transmis- sion of scrofula, and am at ihe same time fully persuaded that it may take place in a perfectly healthy constitution when ex- posed to the influence of the different occasional causes above enumerated. Treatment of ScYofula. • There can be no stronger proof of the difficulty of curing scro- fula, than the circumstance of the immense number of articles offered at different periods, as constitutional, specific, and local remedies—such as bark, mercury, antimony, cicuta, hyoscia- mus, belladonna, opium, dulcamara, aconitum, cold and warm bathing, mineral waters, &c.; all of which and many more have been highly extolled by some writers, and as pointedly con- demned by others. I believe, however, that it is now generally acknowledged that these means, when they do prove servicea- ble, only act by invigorating the system or by keeping the sto- mach and bowels loose and free from acidity. If so, a sufficient hint is furnished the practitioner to select those articles best calculated to produce such effects, without incommoding the patient by imparting too much tone, or prostrating him unne- cessarily by profuse evacuations. With this view small doses of mild purgatives, such as magnesia, rhubarb, sulphur, castor oil, and the blue pill, should be prescribed occasionally. With- out a strict regard to diet, however, these purgatives will an- swer very little purpose. It must not be understood that the Vol. I. 21 162 Scrofula. patient is to live scantily, and on very meager nutriment; on the contrary, his system should be supported by a light and moderately nourishing diet, consisting chiefly of plain animal food and such other articles as the stomach can easily digest. Conjoined with this treatment, tonics, particularly bark, used alone or combined with the preparations of iron, the tincture of iodine, a decoction of sarsaparilla or of althaea, an infusion of cascarilla, a change of climate, or removal from a cold and damp to a dry and warm situation, flannel next to the skin, covering the extremities as well as the body, and other warm clothing, together with moderate exercise, will do more for the patient, perhaps, than all the reputed specifics ever imagined. Scrofulous tumours or abscesses are seldom benefited by lo- cal applications; when very large and indolent, blisters, stimu- lating liniments, frictions and issues have been used with ad- vantage. The older surgeons often extirpated indurated scro- fulous glands, and according to their own accounts with success. Such an operation, however, can very rarely, if ever, prove ne- cessary. For the scrofulous ulcer many different applications have been recommended. The best, I conceive, are dry lint, mild ointments, the iodine cataplasm, slightly astringent washes and moderate pressure. If the sore should become indolent, the black basilicon, nitrate of silver, and other remedies formerly recommended for the common indolent ulcer, may be required. Dupuytren has used in obstinate scrofulous ulcerations, a pow- der composed of one hundred and ninety-nine parts of calomel to one of white arsenic, and with very considerable benefit. See White on Struma—Burns' Dissertations on Inflammation, vol. 2, p. IAS, edit. 1812—Hamilton's (~of Lynn Regis Hospital J Observations on Scrofulous Af- fections—Bussel on Scrofula, 1808—Thomson on Inflammation—CarmichaePa Essay on the Nature of Scrofula, with Evidence of its Origin from Disorder of the Digestive Organs, 1810—Lloyd's Treatise on the Nature and Treatment of Scrofula,- describing its Connexion with Diseases of the Spine, Joints, Eyes, Glands, &c, 1821—Alibert's Nosologic Naturelle, ou les Maladies du Corps Hu- main distributes par Families, torn. 1, p. 441—Henning's Critical Inquiry into the Pathology of Scrofula, 1815—Goodland'a Practical Essay on the Diseaaes of the Vessels and Glands of the Absorbent System, 1814. Cancer. 163 Section II. Cancer. Notwithstanding the numerous treatises on cancer within the last twenty years, and the great encouragement held out by societies for investigating its nature and treatment, we are now almost as much in the dark concerning the disease, as at any former period. All that can be done under these circumstances, is to point out in a general way, the symptoms and appearances which, according to the best writers, constitute the disease, and to notice such remedies only as are acknowledged to possess some efficacy. By the term scirrhus, which is usually considered the fore- runner of cancer, is understood a preternatural density or indu- ration of the soft parts, not easily resolved and very prone to ulceration. Besides these characters, genuine scirrhus is desig- nated by certain external marks, and by a peculiar internal structure. The whole tumour is unequal on the surface, un- commonly heavy, and the skin covering it puckered and of a faint bluish or leaden hue. The pain also is vehement and of a peculiar kind—at first prurient, but afterwards lancinating and compared by many patients to the gnawing of an animal. In a longer or shorter time, the tumour is apt to form adhesions with the integuments above, and the muscles below. In this condi- tion the disease may remain for months or years without mate- rial alteration, but eventually the skin cracks in one or more places, and from the fissures is discharged a thin, acrimonious and fetid matter, which excoriates the adjoining parts, and hur- ries on the ulcerative and sloughing process. Not unfrequently a large cavity is produced, as it were suddenly, from the whole surface of which there is an immoderate discharge of bloody, ill-conditioned matter, in smell approaching to ammonia. This cavity is rapidly filled up by a hard, irregular fungous mass, which protrudes beyond the edges of the sore, and often bleeds profusely of its own accord, or from the slightest irritation. Around the ulcer thus formed, the skin continues of a purple 164 Cancer. colour, and its edges remain extremely hard. The surface of the sore is of a dark red colour, and has a peculiar glossy lustre. The margins are elevated and irregularly serrated. Many pa- tients are worn out by irritation and hectic soon after the tumour takes on the ulcerative action, others live for years—the ulcer proving apparently so far beneficial as to arrest temporarily the extension of the disease. When examined by dissection the scirrhous tumour exhibits the following appearances. In the early stage a small, very com- pact, and central nucleus is found, resembling cartilage in con- sistence, from which radiated and narrow bands proceed in irregular lines towards the circumference of the tumour. These bands are intersected transversely by others of a fainter appear- ance, and conjointly form a plexus or net-work which encloses a softer and more pulpy substance. However, as the tumour advances towards ulceration, these variations of structure become less distinct and are finally blended together, or else the pulpy matter is converted into a dark fluid of a greenish cast, or of a jet black colour, and enclosed in cysts formed of the radiated bands. Sometimes these cysts are filled with a perfectly pellucid fluid, are of different sizes, extremely numerous, and resemble exactly the common hydatid. According to Burns, these cavi- ties are never absent, and are to be considered the most certain evidence of the existence of scirrhus. When the scirrhous tu- mour is recently removed from the body, and the transparent cyst opened with a needle, the fluid immediately spurts out to a considerable distance, owing apparently to a contractile power in the cyst itself. Such effects have been witnessed by different surgeons, and remarkable instances of the kind are recorded by Le Dran, Carmichael and others. It is not yet ascertained in what particular texture of the body cancer originates, or whether it be confined indeed to any tex- ture. According to Pearson,- the disease seldom, if ever, com- mences in an absorbent gland. It is still also a disputed point, whether cancer be a local or constitutional disease. There is so much evidence, however, now extant in favour of the former position as to leave very little doubt on the subject, and indeed to render it very questionable whether cancer ever becomes, strictly speaking, a constitutional affection. Some surgeons en- tertain the belief that cancer is an hereditary disease, and cases Caneer. 165 now and then occur which seem to favour such an idea. In a high- ly respectable family of North Carolina, the disease has occurred in four sisters, and in all the mamma was the seat of it. The two eldest were operated on in that State, the disease returned and both died. From the third (Mrs. General G.) I removed the breast ten years ago, and there has been no return. The fourth * (Mrs. II.) I performed the operation on in October, 1835, with every prospect of success, though the operation was the most extensive and difficult I have ever performed or witnessed for that disease. Sir Astley Cooper and other writers, have recorded similar~examples of the disease being thus met with in indivi- duals of the same family. As regards the immediate cause of cancer, innumerable hy- potheses have been framed. That which approaches nearest to truth, it seems to me, ascribes the disease to animalcular origin, or, as contended by Adams and Carmichael, to the presence of hydatids—thus giving to cancer an independent vitality. This theory will not appear so absurd as some have imagined, when it is recollected that many cutaneous diseases, especially itch, arise beyond all doubt from insects which may be distinctly seen by the eye or microscope,—that worms are found in the liver, urinary bladder, arteries* veins, among the humours of the eye, and in many other situations where their presence is little suspect- ed—The exciting causes of cancer are often sufficiently manifest. In many instances the disease may be traced to a blow or some other external injury, by which (he organization is altered and a predisposition given to morbid action, or, in other words, such a condition of the part brought about as to afford a nidus particularly suited to the lodgement and growth of independent beings.f Treatment of Cancer. It is now generally acknowledged that internal medicines are incapable of removing cancerous complaints, however benefi- Since dead. f See Carmichael on Cancer, p. 273. 166 Cancer. cial certain articles may prove in arresting their progress and in relieving pain. The same observation will apply, with few exceptions, to all local applications. Without recounting, there- fore, the numerous specifics proposed at different periods, it may be observed, that by rigid abstinence, or a close confinement to a very low vegetable diet, amounting to little more than bread and water, and that in quantity barely sufficient to sustain life, scirrhous and cancerous tumours have been reduced to so small a compass as scarcely to be perceptible; but the moment the pa- tients have relapsed into their former modes of living, all the symptoms have returned, and often in an aggravated form. There are few patients, at any rate, courageous enough to en- counter such a system, or to sustain it long enough to produce even temporary relief.—With regard to local remedies, expe- rience demonstrates that such only can be relied on as will era- dicate every particle of the scirrhous or cancerous mass, and that the knife only, or very active caustics are sufficient to accomplish this purpose, but often fail from unskilfulness or the advanced stage of the disease. These sentiments, I believe, will accord with those of the most experienced members of the profession; but it is proper at the same time to state, that within a few years past Mr. Carmichael of Dublin, a highly respectable and intel- ligent surgeon, and one who appears to have enjoyed most ample opportunities of treating cancerous diseases, variously situated, and in different stages, unreservedly declares that he has effect- ed complete cures by ferruginous and arsenical preparations. Hitherto this practice has not been pursued to any extent in the United States; but it emanates from authority so deservedly high as to entitle it justly to a full trial. See Pearson's Practical Observations on Cancerous Complaints, 8vo. 1793— Home's Observations on Cancer, connected with Histories of the Disease, 8vo. 1805 —Johnson's Practical Essay on Cancer, being the substance of Observations to which the annual prize for 1808 was adjudged by the Royal College of Surgeons of London, 8vo. 1811—Carmichael's Essay on the Effects of Carbonate and other Preparations of Iron upon Cancer, with an Inquiry into the Nature of that and other Diseases to which it bears a relation, 8vo. 1809, 2d edit.—Lambe'a Reports on the Effects of a Peculiar Regimen on Scirrhous Tumours and Cancerous Ul- cers, 8vo, 1815—Burns' Dissertations on Inflammation, vol. 2, p. 177—Adams on Morbid Poisons—Neale on Animate Contagion, London, 1831. Cancer of the Eye. 167 Cancer of the Eye. Section III. True carcinoma of the eyeball is seldom met with, though a disease bearing considerable resemblance to it and allied to fun- gus haematodes is not unfrequent. The former occurs chiefly in old, the latter in young subjects. Formerly the two affec- tions were confounded, and then cancer of the eye was con- sidered almost peculiar to children under twelve years of age. Subsequent observations tend to establish the reverse. Cancer usually commences in the anterior parts of the eye, and speedily destroys vision by involving the cornea, iris, and crystalline lens in one confused mass. The whole globe of the eye is gradually enlarged, and becomes very painful from the distention of its coats and the inflammation which ensues. Soon afterwards the cornea gives way, and a soft, irregular, tubercu- latcd, very vascular fungus sprouts forth, and is so luxuriant as to attain in a short time the size of a large egg or apple—project- ing beyond the lids and covering a considerable portion of the check. The colour of the fungus varies in different cases, ac- cording to the state of inflammation—being in some of a bright red or scarlet hue, in others of a chocolate brown or deep pur- ple cast. So very vascular and tender is this morbid growth, that the slightest touch is sufficient to induce profuse hemorrhage, and so often does this occur spontaneously, or by ulceration, that the patient is soon reduced exceedingly low. According to Scarpa, this soft pulpy fungus becomes hard and warty before it as- sumes a very malignant character. The same writer expresses his belief that the disease, with the exception of the lachrymal gland, never originates in any other texture than the conjunctiva. I have met with one instance, however, in which the caruncula lachrymalis was primarily affected, and subsequently the globe of the eye—the disease having extended regularly from one to the other. In another case, that of a gentleman of North Caro- lina, who, some years ago, came to Philadelphia to consult me 168 Cancer of the Eye. on his disease, a tumour formed deep in the inner side of the left orbit, and after several years' growth pushed the eye forward, and so far beyond its natural limits as to create considerable deformity. A small fluctuating tumour about the size of a mar- ble occupied the upper part of the inner canthus of the eye, and the parts all around this seemed of a stony hardness. I deter- mined, by way of ascertaining the nature of the complaint, to cut through the orbicular muscle and penetrate towards the bot- tom of the orbit—taking the soft tumour as my guide. After accurate examination, this was found of a deep blue colour, re- sembling in appearance exactly the common fox grape, and con- taining a thin fluid, like ink, but changeable when exposed to varied light. This sac and its contents being removed, a solid tumour, which served as the base of the sac, was felt at the bot- tom of the orbit, surrounding apparently the optic nerve, and was extremely sensible to the touch. It was evident, both to Dr. Physick, who assisted in the operation, and to myself, that no benefit would result from a further dissection, unless the globe of the eye were also removed. This was not advised, as vision, notwithstanding the protruded state of the eye, was still perfect. The wound was therefore closed and healed by the first intention. The patient returned home, with a determina- tion to submit at a future period to the removal of the whole contents of the orbit, should the eye be disorganized by fungus and other characteristics of cancer. About sixteen years ago, he fell, whilst walking in a field, upon a sharp-pointed tobacco stalk, which entered at the precise spot afterwards occupied by the encysted tumour; and to this circumstance he attributes his disease.*_ Both eyes are seldom affected simultaneously with carcinoma, nor does it often happen that the destruction of one is followed by disease in the other. Upon dissection the cancerous eye commonly exhibits the following appearances. All the coats are very much thickened and indurated, and their insterstices occupied by a whitish fibrous mass, intermixed with pulpy matter. The humours are ab- sorbed, or so changed as not to be recognised, and their places filled up by fungus or small cysts containing a transparent fluid. Sometimes the whole cavity of the eye is distended by the same This patient, as I have since ascertained, recovered perfectly. // n. JJrmrn/ivm AliAiry 6y V ' Oi/>son. J-.'n,//.r/',-i/.''v i ~.7>Wv{tf. Cancer of the Eye. 169 substance that is interposed between the coats. The fungus, when examined minutely, appears to be made up of cells filled with matter resembling the pulp of a decayed pear or apple. In the advanced stages of the disease, the optic nerve is thickened and discoloured often as far as its origin. The drawing in Plate IV. affords a very striking illustration of the form and colour of the carcinomatous eye. It was taken from a woman sixty years of age, a few days before I removed from the orbit the whole diseased mass. Although previously much reduced by repeated hemorrhage, she recovered in less than a month, and never, as far as could be ascertained, had any return of the complaint, and lived many years after the opera- tion. Treatment of Cancer of the Eye. Nothing less than complete excision of the whole disorga- nized mass from the orbit will answer any purpose, and unfortu- nately, in most instances, this operation is so long delayed that the patient's chance of recovery, after he does submit, is exceed- ingly diminished. The first step of the operation is to divide the tarsi at each angle of the eye by an incision half an inch in length. This enables (he surgeon to separate the lids widely, and thereby to get free access to the conjunctiva and ball of the eye. As soon as the conjunctiva is divided, the ball becomes very loose and may be easily turned out. A common scalpel, rather narrow in the blade, will be found more convenient than any other in- strument; and by this the whole operation may be completed. Sometimes the curved scissors will be found useful in clipping off diseased portions adhering to the lining membrane of the orbit, or in removing the lachrymal gland, which ought always to be taken away. In dividing the optic nerve, the surgeon must be careful not to pull out the eye too forcibly, lest unne- cessary pain be created or injury sustained from tearing the nerve. During the dissection blood will flow copiously from the diseased mass or from individual arteries, especially the branches of the ophthalmic ; these, however, seldom require the Vol. I. 22 170 Cancer of the Eye. ligature, and the hemorrhage generally stops in a little time af- ter the removal of the tumour, or is readily suppressed by lint, with which the orbit must be filled after the operation. The eyelids should not be touched unless they have suffered from the disease. In favourable cases, granulations sprout rapidly, and in three or four weeks fill up the orbit so completely, as not to leave more deformity than usually arises from the loss of an eye under any other circumstances. See Desault's Works by Smith, vol. 1, p. 87; also Chopart and Desault's Traiti des Maladies Chirurgicales et des Operations qui leur conviennent, tom. 1, p. 176 — Wardrop on Fungus Hsematodes, p. 93—Scarpa on the Eye, by Briggs, chap. 21, edit. 2d.—Travers' Synopis of Diseases of the Eye. s A 7Jr,///•// /7V////j\',ft!//;■ A' f'.t'i £>////://•eases ; and I have known such mis- takes attended with very serious consequences. From cancer, to which it bears a greater resemblance than any other affection, it differs in the following respects. The tumour of fungus hae- matodes is large, soft and elastic, and to the touch imparts so deceptive a sensation of fluctuation, that a lancet has often been pushed into it—under an idea that it contained purulent matter. The scirrhous or cancerous tumour, on the contrary, is hard, so- lid, and incompressible, and in the advanced stages frequently shrivelled or contracted. Fungus nematodes, when dissected, is found to consist chiefly of a soft, pu'py, tenacious, medullary- like matter. Cancer, when examined in the same way, exhi- bits a hard, fibrous substance, resembling cartilage, which occu- pies the centre of the tumour as a nucleus, and from this centre white narrow bands proceed irregularly towards the circum- ference. Fungus haematodes is almost invariably met with amongst children and young persons—cancer may be said to be almost peculiar to the old. Fungus haematodes occurs in or- Fungus Hamatodes. 197 gans which cancer never attacks—such as the brain, liver, kid- neys, and spleen. Other distinctions might be pointed out, but these are sufficient to designate the complaint. The eye, according to late European writers on that organ, is particularly subject to fungus haematodes. *In this country I have never seen more than five or six cases of the disease; these differed materially from cancer of the eye. The retina and optic nerve are the textures in which fungus haematodes usually commences, and the first symptom is an obscurity of vision, oc- casioned by a small shining tumour which occupies the bottom of the posterior chamber, and may be distinctly seen by looking into the pupil. This tumour slowly increases, advances into the vitreous humour, and, finally, reaches the iris, behind which it appears so much like cataract as to be with difficulty distin- guished from that disease. Soon after the whole eyeball loses its spherical form, becomes irregular or protuberant, the cornea ulcerates, and a large, soft, dark red, or purple fungus is sent forth. When the diseased mass is removed by an operation and examined, it is found to consist of medullary-like matter through- out, and so exactly resembling in other respects the structure of fungus haematodes as to render further description unnecessary. The circumstance of fungus haematodes commencing generally at the bottom of the eye, its attacking almost invariably children and young subjects, and the peculiar structure of the morbid mass, are sufficient proofs that the disease is distinct from cancer, which usually occurs in old people, originates in the anterior parts of the eye, and when dissected presents appearances very different from those just pointed out. The testicle, \\ hen affected by fungus huematodes, sometimes resembles hydrocele so closely, that the most intelligent and ex-, perienccd surgeon is unable to decide between the two diseases. This deception, he wcver, cannot eriWe- a very long time; for after the fungus hamiatodes tumour -attains a moderate bulk, / the constitution shows evident marks of contamination, and the lymphatic glands, of the thigh and groin are sensibly enlarged. It is hardly possible to confound the schirrhous testicle with fun- gus haematodes of the same organ. The one is verv firm in its texture and extremely heavy—the other soft, fluctuating, pulpv, and generally free from pain. When dissected, the structure of fungus haematodes of the testicle is better marked, perhaps, 198 Fungus Hcematodes. and affords more striking evidence of the genuine disease than is met with in any other part of the body. Besides the testicle, fungus haematodes occurs primarily in the thyroid gland, lungs, liver, spleen, kidney, female breast, uterus, ovarium, and some other parts, and in every instance exhibits characters too distinct and regular to leave any doubt of its being unallied to cancer, or any other affection with which we are acquainted—notwithstanding the assertion of some of the French surgeons to the contrary. The drawing in Plate VI. is introduced to illustrate the com- mon appearance of fungus haematodes when seated on the extre- mities. The disease occurred in a boy nine years old, com- menced about the middle, but finally involved the whole thigh, and in a few months proved fatal. Plate VII. represents a fungus haematodes of enormous dimen- sions, seated upon the shoulder and arm. The woman was six- teen years old when the tumour was first perceived—about the size of a marble.' During foii]^ years it gradually increased, and a short time before her death threw out a most prolific fungus, which sloughed away a few hours before the drawing was made, and left the large ulcerated cavity seen on its surface. The tu- mour remained for many months free from fungus and ulcera- tion, until an opening was made with a lancet by an ignorant em- piric, who supposed the swelling to be an abscess. Dissection, however, proved it -to be fungus haematodes, filled with a sub- stance resembling brain, but much firmer in texture than usual. The surface of the tumour, as the drawing shows, was uncom- monly smooth and free from protuberances, and in this respect differed from the disease usually met with. V Treatment of Fungus Htunatodes. As regards the treatment of fungus haematodes very little sa- tisfaction can be afforded; for in the whole range of surgical dis- ease there is no affection so truly alarming or so intractable in its nature. In vain are internal medicines and local applica- tions prescribed ; they do not even palliate the complaint. Even y/yjii A'/ ''■"W'.v '"'>-•. ;>.// ,t./H/i(/ '■■".;; II J » /'. 17/. Dnrwn /i-i'i/i .Yi/f/i/Y /t ll.'/r/A'-, fiiii/mvi'tf /v /'. 'JiW'itut. Fungus Ifirmalodes. 199 extirpation of the tumour, and that too in its very incipiency, answers so little purpose, that there is hardly a case on re- cord where the operation has succeeded. One of the most ex- traordinary and interesting cases perhaps ever related, in which the fairest trial was given, without effect, to repeated and most extensive operations, is detailed by Mr. Allan.* The patient suffered during thirteen years from a very large tumour which occupied the left hip. When it attained the size of a child's head, it was dissected out by Mr. Newbigging, of Edinburgh, ap- parently with success; for the wound healed and the patient felt perfectly well. At the end of nine months, however, it grew again, and in seventeen months from the first operation, a second was performed by Mr. Russel, upon a tumour as large as the two fists. The wound soon healed, but in nine months fol- lowing the tumour recurred, and soon equalled in size a very large mamma. A third operation was now undertaken by Mr. Allan, and so extensive was the dissection, that the wound was as large as the crown of a hat. In a few weeks it healed per- fectly ; but the tumour appeared again in seven months. The late Mr. John Bell was then consulted, and performed a fourth operation upon it—the tumour at the time being as large as the head of a child eight years old. Several months after, the diseased mass was reproduced, and from the surface a fungus sprouted, in shape and size resembling a large cauliflower. This, Mr. Allan removed by ligature, and the patient for the time was relieved. His constitution, however, was completely ruined, and although he lived for several months afterwards, he died at last quite ex- hausted by the long-continued discharge from the fungus—near- ly eight years having elapsed from the time of the first opera- tion. This case plainly shows how little we are to expect from extirpation; and it only remains to say that nothing less than amputation of a limb, when the disease happens to be so situated as to admit of it, will afford any chance whatever of saving the patient's life, and that even this resour.ee is frequently unavail- ing—owing to the stump assuming the same morbid action, or to a thorough contamination of the internal organs. An interesting case of fungus haematodes of the neck, which occurred in my practice five or six years ago, well calculated • See Allan's Surgery, vol. i. p. 264. 200 Fungus Hivmatodes. to illustrate the foregoing remarks, and some other particulars may be introduced into this place, from the twenty-sixth number of the American Journal of Medical Sciences, 1834, as drawn up at that period by myself. " George Washington Reynolds, seventeen years of age, came to Philadelphia from Delaware in November, 1832, and placed himself under care of Dr. Horner, on account of a tumour of the size and shape of a cocoa-nut, which occupied the whole of the right side of the neck. Dr. Horner referred him to me, and at the same time requested the opinion of Dr. Physick on the case. The friends of the patient stated that the swelling had made its appearance five years before, that it arose without evi- dent cause, and had gradually increased to its present magni- tude. The boy now sought relief on account of the difficulty of breathing and of deglutition he experienced, and which in- creased with the growth of the tumour. In other respects he felt no inconvenience from it; his complexion was florid and healthy, and his constitution apparently sound and vigorous. In consultation, it was determined that nothing less than extir- pation would afford a chance of recovery, and I was requested to undertake the operation. Previously, however, I thought it adviseablc to reduce the patient by blood-letting, low diet, and other antiphlogistic means, both to diminish hemorrhage, and to guard against inflammation. Having fulfilled these indica- tions, 1 commenced the operation, (November 20th,) assist- ed by Drs. Horner, and J. R. Barton, in the theatre of the Alms-house Infirmary, in presence of several hundred students. The patient was placed, at full length, on a narrow table, his head inclined to the left side and supported by a pillow. An incision two inches long was made over the course of the caro- tid, low in the neck, and that vessel tied by a single ligature. Over the most prominent part of the tumour, commencing im- mediately under the angle of the lower jaw, and extending nearly seven inches, another incision was made through the in- teguments; continuing the line thus chalked out, layer after layer of condensed cellular membrane, of fasciae, and the fibres of the platysma myoides, were successively divided, as well as those of the sterno-mastoideus, which last muscle was spread out by pressure of the tumour, and converted into a thin mus- cular expansion, intimately incorporated with the platysma, and Fungus Hamalodes. 201 rendering it difficult to distinguish one from the other. During this stage of the dissection the internal jugular vein was exposed, tied by two ligatures, and divided between them. The ends of the vein were then dissected from the surface of the tumour and turned to one side. In order to get round the tumour, and raise it from the cavity in which it was deeply imbedded, it be- came necessary to separate the integuments, fascia, platysma, and other coverings. This proved very difficult, and was not accomplished without great risk, owing to the distribution of the par vagum and descendens noni nerves, both of which lay on the surface of the tumour, and were closely attached to it. I soon found it was impossible to get out the tumour, and at the same time preserve the descendens noni. 1 therefore cut it across. Instantly a slight shudder passed over the patient's frame; but the effect was momentary. I determined, however, not to divide the par vagum—dreading the result either imme- diately or remotely. I was obliged, therefore, to dissect along the edge of the nerve for five inches, and succeeded in detach- ing it from the tumour to which it had formed a very close ad- hesion. This was the most painful and difficult part of the operation, and nothing but the uncommon composure and for- titude of the boy, perhaps, enabled me to accomplish my pur- pose—for he remained during the whole operation motionless, and neither complained, sighed, nor groaned. The par vagum having been thus pushed aside and out of danger, I continued the dissection, taking up occasionally small vessels, sometimes separating with the handle of the knife the adhesions between the tumour and a firm fibrous sac, in which I now found it en- closed, at other times using the edge of the knife until I reached the base of the tumour, which was intimately connected with the pharynx and oesophagus, and to remove it from which re- quired every possible precaution. In this, also, I at last suc- ceeded, though not without the division of four or five vessels, which at first shed blood freely, but were soon tied, or shrunk of their own accord. The action of the pharynx and oesopha- gus was distinctly seen, even at a distance, whenever the boy imitated the action of swallowing, or took fluid by the mouth. The cavity left by the tumour was even larger than had been anticipated, owing to the influence of pressure upon all the sur- rounding parts. To guard against return of hemorrhage, the, Vol. I. 26 1 202 Fungus Hcematodes. patient was left on the table for twenty minutes, and the edges of the wound held together temporarily. No hemorrhage oc- curring, the wound was dressed regularly by adhesive slraps, &c, and the patient put to bed. The operation lasted thirty- four minutes. The tumour having been cut open and examined in presence of the class, was found to consist of a medullary-like matter, of rather firmer texture, however, than that usually met with in fungus haematodes. The idea was at once impressed upon my mind, and for the first time, that such indeed was the na- ture of the disease. The unusually healthy appearance of the boy, and in particular his florid complexion, (circumstances so uncommon in fungus haematodes, which is almost invariably ac- companied by a sallow, cadaverous countenance,) had prevent- ed any of us from entertaining suspicion of the kind. There was not, moreover, the elastic feel, and deceptive sensation of fluctuation, so characteristic of fungus haematodes. 22a?. Slight cough and fever, tongue furred. 23rf. Pulse and cough increased. Patient kept on barley wa- ter. 24/A. Slight uneasiness of chest; no increase of fever, and lit- tle thirst; tongue very red with white scurf. 25th. Redness over whole abdomen, resembling erysipelas, but no pain; administer enema. 2Gth. Redness of abdomen diminished after injection. 27th. Redness gone ; wound partially united, but suppurating abundantly. Barley water continued. 28M. No fever. Tongue nearly natural. 29lh. Wound closed, except where ligatures emerge. December 1st. Patient complains of being starved; barley wa- ter continued notwithstanding. 8th. Diet increased to tea and bread, morning and even- ing. lllh. Small ligature came away from corner of wound under ear. 22a?. Ligatures pulled away from veins. 27th. Ligature from carotid came away. January 3d.—Wound entirely healed, and patient discharged, apparently in good health. Some weeks afterwards the boy returned to town, with a tu- Fungus Hamatodes. 203 rnour half the size of the original one, occupying the same situa- tion. The cicatrix had ulcerated, and there was discharged from the opening a sanious ill-conditioned matter. Fungus, also, was presented at the opening, and seemed to extend within the interior of the swelling. The patient's countenance was pale and ghastly, his skin of a waxy-yellowish hue, and his body emaciated. I saw that nothing more could be attempted for his relief. It was evidently a case of fungus haematodes. He was advised to return home, and shortly afterwards died in a dread- ful condition. Remarks.—There are two points connected with the opera- tion just detailed, which give it an interest it might not, in other respects, perhaps, be entitled to—the application of a ligature to the internal jugular vein, and the division of important nerves. It is an opinion generally received among surgeons, that large veins cannot be tied without great risk of inflammation of their internal surface speedily following, and proving fatal by extend- ing to the heart. Such certainly has been the result in nume- rous instances in European practice, but it is equally certain that the occurrence in this country is extremely unusual, for out of a great many instances in which I myself have tied varicose saphenae veins, and have seen the operation performed by others, I have never met with a single case of injury, much less of death, from such a cause. The only instance, indeed, that has ever come to my knowledge of death from tying the saphena vein, occurred a few years ago in this city in the practice of a respectable surgeon. There were circumstances, moreover, connected with that case, which rendered it very doubtful whether the unfavourable issue was owing to the operation, or to other causes. I think it very probable, therefore, that the constitutions of patients in this country, (owing to all classes of people being well fed and clothed, and little exposed to hard- ships,) are generally superior to those of Europeans, and as such more capable of resisting the operations of injury or disease. Whether this be true or not, however, it is certain, judging from the details published by European writers, that the patients that have fallen a sacrifice to phlebitis, occasioned by the ligature of veins, have very generally been among the lowest classes, whose constitutions were of the worst kind, and whose operations were performed in the crowded hospitals of large and unwholesome 204 Ftoigus Hcematodes. towns. I do not wish to be understood, however, to say that there is no danger from including a large vein in a ligature. On the contrary, I am well persuaded that there is always more or less risk, much greater risk, indeed, than would follow the tying of a large artery. I only mean to imply that there is less danger in tying a vein than is commonly imagined. Influenced by this opinion I ventured, in the case I have related above, to tie the internal jugular in two places. There are only a few examples on record, I believe, in which this vein has been tied, and most of them had a successful termination. The operation was first performed, there is reason to believe, by Dr. Simpson, of St. An- drews, in Scotland, eighty years ago, and the patient recovered without a bad symptom. Mr. Simmons, of Manchester, in Eng- land, also tied up the internal jugular and with a similar result. Giraud has recorded a case in which a French surgeon at Tou- louse, tied the trunks of the common carotid artery and internal jugular for a wound from a musket-ball. The patient had no unfavourable symptoms as far as the sixth day; but it is not stated whether the man recovered. In this country the internal jugular has been lied by Dr. Stevens, of New York, and by Dr. Morgan, of Auburn; by the former in 1828, and by the latter in 1833. Both patients recovered. Some interesting remarks on the ligatures of veins, in which cases and experiments have been detailed, have been published by Trousseau, and may be found in the 14th volume of the " Archives Generates de M6de"cine." The author is induced to conclude that there is less danger from tying a vein than is commonly imagined, and that the danger is often owing to prematurely pulling the ligatures away, and other mismanagement on the part of the surgeon. Fatal cases of wounds of the jugular veins have been reported, and the death of the patients attributed to the introduction of atmospheric air. The division of the descendens noni in the case of Reynolds produced little or no inconvenience, it will be seen, to the pa- tient; owing no doubt to this nerve being chiefly destined to sup- ply the muscles of the neck, and holding no important connex- ion with the vital organs. The dissecting up the par vagum, by which it was more or less disturbed, probably gave rise to the erysipelatous inflammation of the abdomen—this nerve having an intimate relation to the stomach, intestines, &c. A Flat* ITT. Gibsons case ot'Tianaur at the Xeck Eti/fnaaU. fry JDraytuii, fi.ih Fungus Hxmatodes. 205 division of it during the operation would probably have produced great disturbance in the animal economy, or have led, remotejy, to the patient's death. The only further remark I deem it ne- cessary to make in relation to this case is, that could I have known the tumour to have been of the nature of fungus haema- todes, I should certainly not have undertaken to remove it—upon the ground, that there is not a single well-attested case on record in which this inveterate malady has been successfully removed by extirpation, and very few where the patient has recovered after amputation. See Plate 8th. See Pott'a Works, vol. 3, p. 223—Burns' Dissertations on Inflammation, arti- cle Spongoid Inflammation, vol. 2, p. 132—Hey's Practical Observations in Sur- gery, p. 239, edit. 3d—Abernethy's Surgical Works, vol. 2, p. 56, article Medul- lary Sarcoma— Wardrop's Observations on Fungus Hxmatodes or Soft Cancer, in several of the most important Organs of the Human Body—LangstafTa Cases of Fungus Hxmatodes, in vol. 8, part 1, of Medico-Chirurgical Transactions, p. 272 —Langstaff's Cases of Fungus Hxmatodes, Cancer, and Tuberculated Sarcoma, in vol. 9, part 2, of Medico-Chirurgical Transactions—Roux's Journey to London p. 189—Boyer's Treatise on Surgical Diseases, by Stevens, vol. 1, p. 318, article Bloody Fungus—Scarpa on the Eye, by Briggs, edit. 2d.—Stevena' Cases of Fun- gus Hxmotodes of the Eye, in the New York Medical Register, p. 117—C. Bell's Surgical Observations, article Soft Cancer, p. 365—Delpech's Prdcia EUmeniaire des Maladies Chirurgicalea, tom. 3, p. 480—Baillie's Morbid Anatomy—Travera' Synopsis of Diseases of the Eye. 206 Gonorrhoea. Section- XII. Gonorrhoea. Gonorrhoea, or at least a purulent discharge from the ure- thra, may be considered a disease of very ancient date; for we find it expressly enjoined in the Levitical law,* that " when any man hath a running issue out of his flesh," or a yovoppvet, as the Septuagint terms it, he must be secluded or restrained from sexual intercourse, in order to prevent contamination. It is still a matter of doubt, however, whether the disease now termed virulent gonorrhoea, was implied in the passage referred to, or merely that discharge from the urethra which often takes place without the application of any morbid poison, arises from irrita- tion, severe exercise, fluor albus, immoderate use of the geni- tal organs, and known to surgeons under the name of simple gonorrhoea. But these are matters of very little importance at the present day, except as regards the question—whether go- norrhoea and syphilis be of the same or of a different nature. The symptoms of the virulent gonorrhoea are a slight titilla- tion or uneasiness of the glans penis, a pouting or timidity of the lips of the urethra, more or less redness or inflammation about the prepuce and glans, together with a general -fulness of the whole penis. These are soon followed by a discharge from the urethra, of a thin whitish fluid, at first resembling common mu- cus, but speedily changing into a thick, tenacious, purulent mat- ter, of a yellow colour and peculiar smell. Considerable pain is now felt along the urethra and perineum, the urine is discharged in a thin wire-like or forked stream, accompanied with a burning heat or severe scalding. By this time the inflammation attains • See Patrick's Commentary on the third book of Moses, chap. xv. p. 245— also Clark's Commentaiy on the Bible, xvth chapter of Leviticus. Gonorrhoea- 207 a considerable height, the glans penis becomes swollen, tense, of a bright red colour, and its surface has a peculiar shining aspect, as if glazed or highly polished. The pain and ardor urina are increased in proportion as the inflammation rises, and the colour of the discharge, from the same cause, changes from a deep yellow to a greenish tint. Oftentimes the glans penis is exco- riated, and there is a copious discharge not only from the urethra, but from the whole internal surface of the prepuce. These are the ordinary symptoms of the complaint; they are liable, how- ever, to be more or less modified by peculiarities of constitution and by other causes; hence we find some patients to suffer immensely, whilst others experience very little inconvenience during the whole course of the disease. A very painful affection frequently accompanies gonorrhoea, and is known by the name of chordee. This consists of an in- voluntary erection of the penis, which generally occurs at night, while the patient is warm in bed, and is so severe as to prevent sleep. It arises during the height of the inflammation, and is always one of the most troublesome symptoms that the patient has to contend with. The penis is drawn downwards or bent into a semicircular shape; and if the inflammation runs high, and the erections continue to recur repeatedly, coagulable lymph is effused into the cells of the corpus spongiosum, the sides of which are agglutinated in such a way as to prevent the future dis- tention of the cells, to an extent equal to that of the corpora ca- vernosa, and the penis ever afterwards, during erection, remains crooked and deformed. There are other symptoms also which occasionally take place during the violence of the inflammation. These are a frequent and irresistible inclination to pass urine, owing to the inflamma- tion having extended along the whole course of the urethra as far as the bladder. So severe is the pain in some instances from this cause, that the patient is afraid or unable to evacuate a single drop of urine, and a total suppression ensues, which adds greatly to his distress. From the bladder the irritation extends to the rectum and adjoining parts; a tenesmus takes place and becomes exceedingly severe and troublesome, there is an acute lancinating pain shooting from the neck of the blad- der above the pubes; the small glands along the track of the 208 Gonorrhoea. urethra, whose ducts open into that passage, are enlarged, and sometimes suppurate and discharge externally through the skin. The glands of the groin likewise are frequently affected in a similar manner, and the vas deferens, testicles, ureters, and kidneys often sympathize with the inflamed urethra and blad- der. But of the sympathetic affection of these different organs, that of the testicle, known by the name of hernia humoralis, is the most common. It usually occurs about the decline of go- norrhoea, and frequently after the inflammation and discharge have entirely ceased. At other times it takes place suddenly during the height of the inflammation, and then the discharge as suddenly ceases, and the pain leaves the urethra and fixes upon one or both testicles, which " seem," as Mr. Hunter has expressed it, " in many cases rather to be acting for the urethra than for themselves, an idea applicable to all sympathies." Ge- nerally, however, only one testicle is affected at a time, though the transition of the disease from one to the other is often ex- tremely rapid. In either case, there is first a soft, diffused swelling of the testicle, which soon becomes hard and very pain- ful. The hardness is most remarkable at the epididymis, and the pain from that part extending up the cord and along the loins, frequently so acute as to induce rigors, fever, sickness of stomach and great derangement of the digestive organs. These symptoms may continue for a considerable time, and give rise to permanent enlargement of the testicle, or they may disappear in a few hours or days, as suddenly as they were induced, without the gland having sustained any injury. In general the swelling diminishes in proportion as the discharge from the urethra is increased, and when it is fully established entirely disappears. Women are not so liable to gonorrhoea as men, nor do they suffer as much from it—owing to the insensibility of the vagi- na compared with that of the urethra. It is not easy, indeed, in every instance to determine the existence of the disease in a female, so slight is the pain and so equivocal the discharge; though I have met with several cases, in which the inflamma- tion ran so high and produced such intolerable anguish, that the patients were unable to leave their beds. Gonorrhoea has often been confounded with fluor albus; but close attention to the Gonorrhaa. 209 symptoms peculiar to each complaint will be sufficient, in gene- ral, to distinguish them. Most violent inflammation, and even total extinction of sight, has followed the accidental application of gonorrhoeal matter to the eye. I have met with several cases of this description, two or three of which originated from the patients washing the eye with their own urine, (while they laboured under gonorrhoea,.) in order to relieve a common inflammation of that organ—a prac- tice exceedingly frequent among the vulgar. The disease will be further noticed under the head of ophthalmia. Gonorrhoea may terminate spontaneously or " wear itself out," or else degenerate into a disease commonly known by the name of gleet, which is characterized by the discharge from the ure- thra of a white, limpid mucus, destitute of virus, and proceeds from a relaxation or debility of the lining membrane of the pas- sage—a consequence very apt to follow inflammation of all mu- cous membranes. Such at least is the account usually given of the disease by writers, though I very much question the accuracy of their statements, and am inclined to believe that the discharge denominated gleet, is, in most instances, in truth a chronic gonor- rhoea, and as such capable of communicating infection. There is also a mucous discharge from the urethra attending other dis- eases of that passage, particularly stricture, which I am persuaded is often considered a gleet, and treated accordingly; but this is certainly not infectious, and differs widely from the discharge which follows a gonorrhoea. Treatment of Gonorrhaa. The remedies for gonorrhoea are constitutional and local. The former are chiefly indicated in the commencement or during the height of the inflammation, while the latter may be Vol. I. 27 210 Gonorrhea. employed at any stage of the disorder. In severe cases and in plethoric habits, blood-letting, purgatives and low diet will ge- nerally all prove necessary. Considerable experience, however, in the treatment of this disease has taught me, that steady purging is more to be relied on in lessening the inflammation and in removing pain, than even copious depletion by the lancet. Repeated and small doses of jalap or rhubarb, combined with the supertartrate of potash, I have found extremely useful; in- deed, in many cases I have prescribed the cremor tartar alone in such quantities as to produce both purgative and diuretic ef- fects, and continued it steadily for two or three weeks with the greatest advantage, after most other remedies had failed. Be- sides purgatives, stimulating diuretics often prove highly ser- viceable, both in the inflammatory and chronic stages of gonor- rhoea. The balsam copaivie is more decidedly beneficial than any other remedy of the class. It had long been used in the advanced stages of gonorrhoea, but Dr. Chapman was the first to prescribe it during the height of the inflammation, or from the very commencement of the attack. So far back as the year 1806, I well remember to have heard him express his decided conviction of the superior efficacy of the remedy when thus ad- ministered. Dr. Armstrong, in his work on scarlet fever, speaks of the practice as novel, and seems to attribute its intro- duction to a Dr. Dawson, who it is stated, had prescribed the medicine with great success for more than twelve years, in the very commencement of virulent gonorrhoea. Dr. Chapman's claim to priority, however, is most unquestionable. For many years past, I have employed the remedy very extensively, both in the recent and advanced stages of the complaint, sometimes with most decided effect, but in other instances without the slightest alleviation of the symptoms. This may have pro- ceeded from the bad quality of the medicine, which, it is well known, is often ruined by adulteration. The cubebs, another stimulating diuretic, formerly much employed in the treatment of gonorrhoea, has recently been highly extolled as possessing very superior power:-. From numerous trials, however, I am inclined to believe that its virtues have been greatly overrated. Within the last few year* tincture of iodine has been ex- Gonorrhaa. ^ tolled by Richond* as a most vahiable remedy in gonorrhoea, particularly when employed after full effect has been derived from low diet, leeches, &c. Demulcents, by blunting the acri- mony of the urethral discharge and by exciting the action of the kidneys, are always used with advantage in gonorrhoea, and should never be neglected. The local remedies for gonorrhoea may be applied either to the penis itself or to the urethra. For several years past, I have been in the habit of prescribing a warm bread and milk poultice in the very commencement of the disease, and always with the ut- most advantage. To derive full benefit from the application, the prepuce should be retracted, and the glans penis completely buried in the poultice, which should be as warm as the patient can bear it, and renewed as often as it becomes cold and stiff. By persevering in the use of the poultice for a few days all the symptoms are mitigated, and the way paved for mild and warm injections—such as rose wafer, thin solutions of gum Arabic, flax seed or opium, weak decoctions of oak bark, &.c. These check the discharge gradually and often effect a cure. As the ardor urinae and discharge diminish, more astringent injections may become necessary. Those commonly employed are solutions of the acetate of lead, of white, green, and blue vitriol, alum, borax, &c. They are all inferior, however, to a solution of the nitrate of silver, a medicine that has been strenuously commended lately in the cure of every stage of gonorrhoea, but which I have used extensively for the last eighteen years, and with the greatest success. By commencing with two grains of the caustic to an ounce of water, and gradually increasing the strength of the solution until the patient feels it sensibly, a cure may be produced in a very short time. Some surgeons com- mence with twenty grains to the ounce; but great irritation, suppression of the discharge, and swelling of the testicle have followed the practice. In some instances, I have derived con- siderable advantage from the caustic, when mixed with oil and introduced into the urethra on a small bougie. The nitric acid, properly diluted, was a favourite remedy with Vigaroux, an eminent French surgeon. Dr. Physick has also employed it very successfully in several obstinate cases of gonorrhoea. The * Annalesde la Medicine Physiologique, 1S27. 212 Gonorrhoea. vinous tincture of opium I have often used with great advantage in the early stages of gonorrhoea. At first it should be consider- ably diluted, but afterwards may be used pure.* As chordee is one of the most troublesome attendants on go- norrhoea, it should be checked as soon as possible. Camphor, combined with opium and given in large doses, will be found singularly efficacious in arresting its progress. Hernia humoralis being generally dependent upon suppres- sion of the urethral discharge, induced by irregularities, debauch, the use of strong injections, &c.; the first object of the surgeon * Any of the following formulae of injections may be employed in the early or inflammatory stages of gonorrhoea. $< Liq. plumb, acetat. ... gutt. vi Aqua distillatae,.....§iv M. & Liq. plumb, acet. .... gutt. vi Opii purif.......9i Aquae distillata,.....§vi M. fy Zinci acetatis, .... grs. x Aqua distillate,.....§vi M. * Zinci sulphatis, .... grs. iv Aqua distillatae,.....§v M. 5» Acidi muriatici, .... gutt. x Aqua distillata,.....2}V M. g< Acidi nitrici,.....gutt. xij Aqua distillata, - - - - - §vi M. g< Vini Opii,......j§i Aquae distillatae,.....§iij M. fy Balsami copaivae,.....31 Mucilaginis acacia,.....§ss Aqua rosa, .....%vi M. Gonorrhoea. 213 should be to re-establish the running. This may often be ac- complished by warm poultices, large enough to cover the whole penis and testicles, or by the introduction of a bougie into the urethra. With this treatment, general and local blood-letting should be combined, together with purgative?, while the patient is confined to the horizontal posture, and the testicles supported by a bag truss or handkerchief. For the relief of the irritable bladder and rectum, I know of no remedies so effectual as the warm bath, opiate glysters, and warm poultices or fomentations to the perineum. Gleet, when it really proceeds from gonorrhoea, and is not connected with stricture of the urethra, will generally be bene- fited or cured by stimulating injections,* blisters to the perineum, the internal use of cantharides, the muriated tincture of iron, tincture of cubebs, and by the introduction of plain or medicated bougies. The remedies for gonorrhoea in women do not differ from those required for men, except in being used stronger or in larger doses. * The best injections for gleet are those composed of the sulphate or acetate of copper, of the supersulphate of alum, of the oxymuriate of mercury, of the ammoniaret of copper, &c. Any of the following formula will frequently answer, and if one fail another should be tried. Bt Cupri sulphatis, .... grs. ij Aqua distillata, .... -viiij M. Bt JEruginis praparata, - - - grs. x Olei amygdala, ... - 3 iv M. gt Aluminis supersulphatis, - - - grs. iv Aqua distillata, .... giv M. Bt Liquoris cupri ammoniati, - - - gutt. xx Aqua rosa,..... 3,v M. ^ Liquoris hydrarg. oxymuriatis, - - gutt. iiij Aqua distillata,..... 5,v M. 214 Gonorrhoea. Consult Hunter's Treatise on the Venereal Disease, by Adams, p. 58, Londoti, 1810—B. Bell's Treatise on Gonorrhoea T^rulenta and Lues Venerea—Swediaur'a Practical Observations on Venereal Complaints—Adams on Morbid Poisons, edit. 2d—Sawrey's Inquiry into some of the Effects of the Venereal Poison, 1802— Carmichael's Essays on the Venereal Diseases which have been confounded with Syphilis—Carmichaers Observations on the Symptoms and Specific Distinctions of Venereal Diseases—Jeffrey's Practical Observations on Cubebs, London, 1821— Johnston and Bartlett's Report of Cases of Gonorrhoea, in Edinburgh Medical and Surgical Journal, vol. 14—Roberton's Remarks on the Internal Use of Cantha- rides in Gleet, &c. in Edinburgh Medical and Surgical Journal, vol. 2, p. 134, Syphilis. 215 Section XIV. Syphilis* It may perhaps with truth be said, that previous to the time of the illustrious Hunter no very accurate views were enter- tained respecting the nature of syphilis or lues venerea. This great pathologist, aware of the confusion and obscurity in which the disease had been involved from loose and fallacious descrip- tions of its symptoms, and of the ill consequences which often resulted from confounding affections in reality very opposite to each other, endeavoured to establish the true character of the venereal ulcer, as contradistinguished from other ulcerations to which the genitals had been subject from time immemorial. The fidelity of his details and accuracy of his distinctions have been amply acknowledged by most subsequent writers; within a few years, however, new facts have accumulated, or at least forms of disease apparently new have been brought forward, which, if admitted to be strictly venereal, are calculated to sub- vert all former distinctions, and in defiance of precepts founded upon data supposed to be firmly established, are likely to in- volve in utter confusion and perplexity all knowledge of the disease or of the method of cure. But fortunately, many of Mr. Hunter's facts, and the inferences which he drew from (hem, are confirmed and supported, unintentionally, by the advocates of the new-fangled doctrines and the promulgators of new dis- eases. Most of these diseases, it is well known, have been de- scribed with great precision and accuracy by Celsus, in his chapter u de obscae?iarum parlium vitiis," upwards of twelve centuries ago, and long before syphilis was known to exist. That the venereal disease appears now under the exact forms described by Mr. Hunter, I shall ever be firmly persuaded, so long as I observe the symptoms and appearances daily met with in patients, to correspond with his descriptions. What changes the di-ea4c may have undergone in Europe, I cannot say: but in this country, s>o fai as numerous opportunities of treating it 216 Syphilis. can be depended on, I have no hesitation to declare, that the old-fashioned chancre, so minutely and accurately portrayed by Hunter, is exceedingly common, and may be seen at any time in full luxuriancy. These remarks are not made to invalidate the statements of the respectable European and American wri- ters, who contend for the existence of a pleurality of venereal poisons, but merely to express a belief, that diseases resembling syphilis, and often confounded with it, are by no means unfre- quent; and that genuine syphilis, as it was understood by Mr^ Hunter, is still known, however modified occasionally by pecu- liarities of constitution, climate, &c. Under this impression, I shall proceed to treat of the primary symptoms of syphilis, com- mencing with chancre. Chancre, or the true syphilitic sore, usually begins with a slight redness or inflammation on some part of the genital organs, at- tended with pruritis or itching. This itching is soon converted into pain,.and a pimple is in a short time formed, filled with pus, which upon bursting leaves an excavated ulcer of a circular shape, with hard and a.brupt edges, and a surface coated with a gray tenacious matter. The base of the ulcer is thickened and indurated, and the parts surrounding it for some distance con- verted into a tumour so distinct and circumscribed, that it may be elevated by the fingers, and feels like a hard and moveable body beneath the skin. This description will particularly ap- ply to chancre when seated on the glans penis; some variation is observable, however, when the prepuce or fraenum is affected. In such cases the inflammation is generally higher, the pain more considerable, and, instead of a regular pimple filled with matter, the chancre often follows directly a slight excoriation or abrasion of surface. When seated on the common skin of the penis or scrotum, the matter discharged from the sore soon dries and forms a scab, which quickly drops off, and is succeeded by an- other of larger size. Wherever situated, chancre commonly pre- serves certain general features that serve to distinguish it from common sores, the edges of which are usually smooth and shel- ving—while those of chancre are jagged and vertical. But, per- haps the most characteristic sign of genuine primary syphilitic ulceration is the indurated base; and so long as this continues, even although the sore may have healed, little doubt will remain of the presence of disease. Syphilis. 217 Chancres may occupy any part of the surface of the body, but they occur more readily on mucous membrane than on the common skin. When situated on the penis, they are usually met with along the fraenum, behind the corona glandis, in the mouth of the urethra, or on the internal surface of the prepuce. Among females, the parts commonly attacked are the labia, the nymphae, and the entrance of the vagina; though, not unfre- quently, very large and virulent chancres appear on the peri- neum, the outside of the labia, near the anus, or on the hip. Sometimes the lips, eyelids, or edges of the nostrils are covered with chancres—from (he inadvertent application of syphilitic matter by the fingers. The fingers, themselves, if their extremi- ties be pricked or sore, may suffer from handling chancres, or from delivering infected women. The period at which a chancre appears after the application of the venereal virus is very uncertain. Sometimes the disease follows in twelve or fifteen hours; at other times several days elapse; and in a few instances no ulceration takes place for two or three months. There is reason to believe that a chancre, so small as scarcely to be perceptible, sometimes exists; and, again, that absorption of the virus now and then follows from the most insignificant scratch, or from an abrasion of the surface of the penis so slight as to escape the patient's notice. So long as the chancre is confined to the penis, or any other part it may hap- pen to occupy, the disease may be considered strictly local; in a greater or less time, however, if not arrested in its progress, the virus extends to the system through the medium of the ab- sorbents, and gives rise to secondary symptoms. The first evi- dence of its approach towards the system, is generally an en- largement of the lymphatic glands in the vicinity of the sore, known by the name of bubo. Bubo always takes place in those lymphatic glands in the immediate neighbourhood of the chancre, while the deep-seated or remote glands remain uncontaminated, or at least do not en- large or suppurate. As chancre generally occupies some part of the penis, the glands of the groin are the ones commonly af- fected. Sometimes several glands are enlarged and form a clus- ter; but, according to Mr. Hunter, one gland only is usually affected. A bubo does not invariably follow a chancre, and yet the system is not less liable in such cases to contamination. This Vol. I. 28 218 Syphilis. circumstance, amongst others, has induced some surgeons to be- lieve that bubo does not arise, as is commonly imagined, from the absorption of venereal virus, but from an inflammation in the extremities of the lymphatics excited by the chancre.* Such an idea appears not improbable, and yet it must be recollected that the matter of bubo is infectious, which could hardly hap- pen from simple irritation excited by inflammation. Why the glands, however, contiguous to the sore should suffer while the distant ones escape, is not easily explained; for, upon the sup- position of the virus being absorbed, it should follow that, by passing through the whole, all should be equally liable to dis- ease. Bubo seldom arises from a chronic chancre, but usually makes its appearance soon after the chancre is established. It is more apt to follow a chancre on the prepuce or fraenum, than one situated on the glans penis, and is late or early in its appearance, according to the degree of inflammation existing in the sore. Oftentimes a bubo remains stationary for weeks, neither tending towards resolution nor suppuration ; in general, however, it is of a bright scarlet colour, exceedingly painful, and quickly runs into suppuration. Occasionally it takes on the erysipelatous in- flammation. The ulceration which follows a bubo does not dif- fer from that of common chancre, and the matter from it is equal- ly infectious. The bottom of the ulcer is hard and solid to the touch, and the surface either of a dark red or brownish colour, or of a yellowish cast. Very extensive ulcerations now and then follow a bubo. I have seen each groin and the greater part of the pubes laid bare, or entirely divested of integument. In some constitutions buboes degenerate into insensible and very troublesome fistulae, that resist every application. Sometimes the skin covering a bubo entirely closes, but not uniting with the parts beneath leaves a hollow, from which in a short time a thin serum is dis- charged through small holes or pores formed in the skin. In such cases the integuments generally assume a leaden or bluish colour, and have an unhealthy aspect. Buboes frequently arise from other causes than the absorp- tion of venereal virus—from wounds or injuries of the foot, from colds, fevers, the mechanical irritation of mercurial oint- * See Allan's Surgery, vol. i. p. 200. J Syphilis. 210 ment applied to the leg or thigh of the affected side, from go- norrhoea, &c. Such swellings cannot be distinguished always from the true syphilitic bubo, and much mischief has resulted from severe and unnecessary salivations, under an imaginary idea of venereal taint. The surgeon should, therefore, careful- ly inquire into the history of every such complaint before he ventures to give a decided opinion respecting its nature. Bubo should be looked upon as one of the primary symptoms of syphilis; for so long as the venereal virus is detained in the glands or their vessels, it may be considered as only on its way to the system. When the lymphatics themselves are inflamed from a chancre, there is usually perceived a hard cord, which runs from the sore along the back of the penis towards the pubes or groin. The secondary or constitutional symptoms of syphilis pre- sent themselves under several forms, which usually appear in regular order or succession. The parts first attacked are the throat, nose, mouth, tongue and skin ; and next to these the periosteum, fasciae, tendons, bones, ligaments, eyes, ears, &c. Frequently the skin is the texture first affected; but the throat, as far as my observation extends, commonly affords the earliest evidence of absorption of the venereal virus. The disease ap- pears in the form of ulceration, and usually occupies the tonsils. So slight is the pain in most instances, that the discovery of the sore is often accidental. When examined, the ulcer will be found coated with an ash-coloured or brownish matter, that gives it a foul or unhealthy appearance, while the surrounding parts are slightly inflamed and tinged with a copper cast. In the advanced stages of the disease the ulcer is excavated, or, as Mr. Hunter has expressed it, " dug out." These marks will be sufficient to distinguish it from other ulcerations to which the throat is lia- ble; though in some instances the resemblance to common sore throat is so striking as to deceive the most experienced practi- tioner. In general, however, there is less inflammation and pain in the venereal sore throat than in the common forms of the disease. As the ulceration advances, one or both tonsils, the uvula, velum palati, membranous part of the Eustachian tube, and even the epiglottis, may be entirely destroyed—giving rise to permanent deafness and incessant cough, and endangering the 220 Syphilis. patient's life from suffocation, by permitting solids and fluids to enter the larynx. In many instances a communication is established between the nose and mouth—from the ulceration having destroyed the soft parts and bones of the palate. At other times the disease travels along the Schneiderian mem- brane, undermines the septum and cartilaginous part of the nose, destroys the periosteum covering the thin and delicate bones, which are soon rendered completely carious, and crumble away, leaving the nose sunk and ruined, the features dreadfully de- formed, and the patient in the most loathsome condition, with foul and fetid matter flowing perpetually from the nostrils or into the throat, and a breath so extremely offensive as to ren- der the sufferer hateful to himself and disgusting to his friends. Venereal eruptions, or cutaneous blotches, do not always possess uniform characters; though the symptoms in general are sufficiently decided to enable us to form a correct diagnosis. In many instances the whole skin becomes discoloured or mottled, or covered by an efflorescence, which is often preceded by ge- neral indisposition—such as fever, restlessness, headach. At other times circular patches appear in distinct spots on different parts of the body, each of which proceeds from an indurated lump of a pale red colour. The patch slowly enlarges, and in a little time its centre is rendered flat and becomes incrusted with whitish scales. These gradually desquamate and are succeeded by others of a similar appearance, until at last the skin cracks and dis- charges matter, which soon hardens on the surface and forms a scab of a dark brown or copper colour. This seldom extends beyond half an inch in diameter, and after a time drops off and leaves an ulcerated surface, which gradually spreads, deepens, and becomes covered with a thick, fetid, greenish matter. The parts commonly occupied by venereal eruptions, are the back of the neck, the forehead, breast and groin. Frequently the palms of the hand and soles of the feet are affected. The extremities of the fingers and toes are also liable to suffer; in which case, the surface beneath the nail becomes red and ten- der, and the nail soon drops off. The periosteum and bones are next in order of contamina- tion. All the bones do not appear to be equally susceptible of impression from absorption of the virus. Those thinly covered by integuments, or situated near the surface of the body, par- Syphilis. 221 ticularly the cranium, clavicle, sternum, tibia, radius and ulna, are most liable to suffer. The first evidence of the disease having reached the periosteum and bones, is an enlargement or tumour called a node, which increases slowly, never attains a very large size, and is seldom painful until it has existed a con- siderable time. At last, however, the integuments covering the tumour become red and inflamed, deep-seated and acute pain is^ felt in the part, and extends from it to a considerable distance, often throughout the limbs, especially at night when the pa- tient lies warm in bed. In a greater or less time the swelling loses its hard and solid consistence, becomes soft and fluctuating, ulceration takes place on the most prominent part, and soon opens a communication with the interior, from which is dis- charged an ill-conditioned, glairy matter. The bone may now be felt rough and bare, or completely carious. When the node is sealed on the skull, both tables are often perforated with nu- merous holes, and resemble in some respects a piece of worm- eaten wood. Patients who have suffered from repeated attacks of syphilis, and have taken large quantities of mercury, often have the bones greatly enlarged and thickened throughout their whole extent. When examined, also, such bones are found much heavier than usual. When a node proceeds from inflam- mation of the periosteum alone, the swelling may frequently be removed entirely ; but it seldom wholly disappears, when once the substance of the bone itself has been involved. All the secondary symptoms of syphilis are preceded or ac- companied by more or less constitutional derangement; but this is oftener observed during the latter stages of the complaint than at any other period. The.fever is either periodical or constant, and generally assumes the hectic form. Sometimes, it is so se- vere and unrelenting as greatly to reduce the patient's strength, producing restlessness, emaciation, diarrhoea. At other times, it seems to be the immediate cause of his death. Secondary symptoms of every description are distinguished from the primary, in not communicating a specific or infectious disease, similar to that arising from chancre or bubo. This has been proved in the most satisfactory manner, by the experi- ments of Mr. Hunter. Besides the venereal sore throat, blotches, and affections of the bones, there are other symptoms that have been generally 222 Syphilis. considered belonging to the secondary order. These are vene- real warts, condylomalous tumours, alopecia, or falling off of the hair, syphilitic ophthalmia or iritis, and other affections, some of which are not strictly venereal. Venereal warts are very apt to follow chancres, and usually occupy the same situations. They arise by a narrow neck or pedicle, and are expanded on the surface—resembling a mush- room. They are sometimes exceedingly painful, and bleed pro- fusely upon the slightest touch. Frequently the whole glans penis or vulva are completely covered by these excrescences. Condylomalous tumours usually occupy the verge of the anus. They are firm and fleshy, broad at the base, irregular on the surface, and frequently ulcerate and become very trouble- some. Alopecia does not invariably follow the secondary symptoms of syphilis, even when the system is thoroughly contaminated. In many cases, however, large quantities of scurfs or scales form about the roots of the hair, which are soon loosened and drop out, leaving the scalp perfectly bare. The eyebrows, also, not unfrequently fall off, and are seldom regenerated. Iritis will be noticed when we treat of ophthalmia. There are many diseases which bear a considerable resem- blance to the primary and secondary forms of syphilis. These have been described by different writers, under the name of pseudo syphilis, and other similar appellations. The question concerning the identity of syphilis and gonor- rhoea, might next be entered upon. Immense difficulties, how- ever, necessarily attend an inquiry of this sort,—especially as the most opposite conclusions have been drawn from experi- ments performed by surgeons of equal intelligence and respecta- bility. Thus, Mr. Hunter, from experiments made upon him- self, as now generally understood, and upon other patients with the matter of gonorrhoea and of chancre, was induced to declare that the diseases were essentially the same, but often produced opposite effects—owing to the difference in the nature of the textures to which they were applied. Again—Vigaroux, in support of the same opinion, details the cases of six French- men, who had connexion with the same woman in rapid succes- sion ; the first of whom had a chancre, the second and third a gonorrhoea, the fourth and fifth a chancre, and the sixth a bubo. Syphilis. 223 On the other hand, Mr. Benjamin Bell has furnished an account of several experiments, some of which were performed by me- dical students upon (hemselves, with the matter of gonorrhoea and that of chancre,—the former of which was applied to the glans penis both by simple contact, and by innoculation, without producing more than a slight inflammation and discharge from the surface, while the matter of chancre, introduced into the urethra, instead of creating gonorrhoea, produced chancre within the passage. Similar results have been obtained by other sur- geons of the first respectability, all of which tend to establish the reverse of Mr. Hunter's position, and to prove that the two diseases are totally distinct from each other. How are such con- flicting discrepancies to be reconciled, and with what prospect of success can we enter upon an investigation, which seems to have puzzled and defied some of the ablest men that have ever attempted to unravel its mysteries? The arguments on each side of the question, at any rate, are too numerous to be introduced into an elementary work of this description ; but I have no hesi- tation to affirm my belief in the existence of two distinct and separate poisons, each of which is capable of producing effects peculiar to itself. Treatment of Syphilis. It is well known, perhaps, that within a few years an attempt has been made, chiefly by the British army surgeons, to remove the different forms of syphilis without the use of mercury; and in proof of the efficiency of the plan, the results of experiments, made upon the most extensive scale, have been brought for- ward, and are so well attested as to leave no room to question the accuracy of the details or the correctness of the inferences drawn from them. From an official document, published by Sir James M'Grigor and Dr. Franklin, it appears that nineteen hundred and forty cases of primary venereal ulcerations on the penis were cured without mercury, between December, 1816, 224 Syphilis. and December, 1818; and that during the same period, two thousand eight hundred and twenty-seven chancres, the greater number of which were characterized by a hardened base, were cured with mercury. Out of this number the average period occupied in the treatment of chancres, unattended by bubo, by the non-mercurial plan, was twenty-one days—those with bubo, forty five days. On the other hand, it is stated, that the chan- cres unaccompanied by bubo, and treated with mercury, re- quired upon an average thirty-three days for their removal, and fifty days when conjoined with bubo. From these data the in- ference is plain, that primary syphilitic sores may be cured in a shorter time without the use of mercury than with it; and this conclusion has actually been drawn by the advocates of the non- mercurial plan of treatment, whilst, at the same time, they ac- knowledge the utility of mercury under particular circumstances, and admit that certain cases prove obstinate or incurable unless this medicine be employed. With regard to the greater or less frequency of secondary symptoms, after the removal of primary sores treated by mercury, or without it, the amount of evidence afforded up to the present time is, that such symptoms are most common when mercury has not been employed, but, on the other hand, that those troublesome and severe affections of the bones— nodes, caries, &c, formerly so common, hardly ever follow the non-mercurial course, and that all the other secondary symptoms are milder and more easily subdued when mercury has not been used. It must not be concealed, however, that there are still many respectable and intelligent surgeons, both in Britain and in other countries, who not only condemn the anti-mercurial practice, but doubt the accuracy of many of the statements furnished by the army surgeons; and contend that there is every reason to believe that the patients, supposed to have been cured without mercury have taken the medicine surreptitiously, employed secretly caustic applications to their sores, or that cures have followed from the mercurial dressings, acknowledged by the army surgeons themselves to have been used in numerous in- stances. But these inferences, and suspicions, it appears to me, are unjustifiable, inasmuch as the cases brought forward in sup- port of the practice are too numerous, and the authority of the surgeons loo respectable to admit of any doubt on the subject. Syphilis.' 225 Whilst it must be acknowledged, then, that the venereal dis- ease, contrary to the tenets of Mr. Hunter, does not become progressively worse and worse unless arrested by the use of mercury, and that complete cures have been effected in nume- rous instances by different remedies, yet it remains to be ascer- tained how far these remedies can with certainty be depended upon, the particular cases to which they are adapted, and the circumstances under which mercury may be dispensed with or administered with advantage. It is true that this has already been attempted, but not upon so sure a foundation as to induce us to lay aside altogether a remedy which we know to possess un- doubted sanative powers, and which we have reason to believe will be followed by few ill consequences, if judiciously employed. As chancre, in its commencement, must be considered strict- ly a local disease, local remedies will often prove sufficient to arrest its progress or effect a cure. It is proper, therefore, in every instance, provided the inflammation does not run very high, to touch the sore repeatedly with some escharotic—such as the lunar caustic or the caustic potash. These lessen the irritability and convert the chancre into a simple ulcer, which speedily heals without contaminating the system. If, however, the chancre has existed for some time previous to the applica- tion of the caustic, in all probability no benefit will result, owing to the virus having extended beyond the sore, which indeed, un- der such circumstances, may be rendered worse, or at least larger, by the caustic. It may then become necessary to employ internal remedies, and there are none so effectual, in certain cases, as mercurial preparations. Of these calomel and the blue pill will be found the most useful. The former may be given alone in the dose of a grain, morning and evening, or in combination with opium, which prevents the medicine from passing off by stool; the latter may be administered two or three times a day in the propor- tion of five grains at each dose. In general the blue pill should be preferred to calomel, inasmuch as it is milder and more gra- dual in its operation. With particular constitutions, however, it disagrees—owing, perhaps, in some instances, to an improper mode of preparing the medicine. Conjoined with the internal use of mercury, its application to the skin in the form of inunction will sometimes prove absolutely Vol. I. 29 226 Syphilis. necessary. Two or three drams of the ointment should be rubbed on the inner surface of the thighs, every morning and evening by an assistant, until the greater part of it disappears. If pimples or ulcerations arise from the friction, which is often the case, the rubbing should be discontinued or transferred to the legs and arms. Sometimes an inflammation is excited in the course of the absorbents by mercurial friction, from which a bubo arises. Under these circumstances, it must be laid aside immediately. In no instance can it be necessary to push the mercury, as it is termed, either for the cure of a chancre, or any other stage of syphilis. Nothing more will at any time be required than to touch the mouth lightly, or produce a gentle ptyalism. From inattention to this many patients have suffered immensely, and others have lost their lives. It must not be supposed, however, from any of the remarks above made, that mercury must be used necessarily, either in large or small quantities in the generality of cases. On the contrary, many cases are met with where the use of that medicine may be entirely dispensed with. Perhaps, then, as a general rule, it may be stated, that the surgeon should endeavour to remove chancres and other primary symptoms of syphilis by the antiphlogistic system and other simple constitu- tional remedies, and after full trial of these should the sores re- main stationary or spread, that mercury may be then resorted to in the manner already staled. As local applications to the chancre, several articles will prove highly serviceable. The black wash, prepared by adding two drams of calomel to an ounce of lime water, 1 have used with the utmost advantage. The mixture should be well shaken pre- vious to its application, and the cavity of the chancre covered by the thick powder that afterwards settles at the bottom of the vial. Dry lint sometimes forms an excellent application to a chancre. When the sore requires stimulating, I have known no articles so useful as the compound ointment of the acetate of lead, the yellow wash, citrine ointment, and the diluted tincture of the muriate of iron. In recent chancres the chloride of sodo forms an excellent application. Some chancres spread and become extremely indolent, or else are converted into indurated excrescences which occasionally attain a large size and feel like an ordinary scirrhus. At other Syphilis. 22? limes the ulcer burrows or creeps from one part of the penis to another, opens the cells of the corpus spongiosum, and gives rise to profuse hemorrhage, and eventually, if not arrested, destroys the penis. In all these cases I have derived great benefit from the internal use of the phosphate of mercury, cautiously ad- ministered in doses of half a grain twice a day, and locally from adhesive plasters, which, by drawing together the edges of the sore, often promote their reunion. To obviate erections, which frequently cause the chancre to spread by breaking up the adhesions as fast as they are formed, the use of camphor and dulcamara will be found indispensable. Sometimes chancres, instead of becoming indolent, take on acute inflammation, which may run so high as to terminate in mortification and loss of the penis. In bad constitutions this stale is frequently brought about by the operation of mer- cury. When this happens, the medicine should instantly be laid aside, and the patient placed on a low diet, whilst blood- letting and purgatives are freely employed, together with warm poultices to the penis, and opiate and other injections between the glans and prepuce. If the chancre is accompanied by phymosis, Or paraphymosis, as often happens, we should never think of slitting up the pre^ puce, during the height of the inflammation, as sloughing would be very apt to follow, or at any rate the cut edges be converted into chancres. Simple and unimportant as an operation of this kind may appear, I have known mortification and death to fol- low from it in one instance, which occurred not long since in the practice of a respectable surgeon of this city. The true practice, in all such cases, is to combat (he inflammatory symptoms by appropriate remedies. In spite of all our efforts, it frequently happens, that the dis^ ease is not removed, but pursues its course towards the system, and appears next in Ihe shape of bubo. To prevent this from terminating by suppuration, blood-letting, purgatives, and other parts of the antiphlogistic system should be immediately resorted to. These, unaided, will often prove sufficient to discuss the swelling or to procure resolution ; but in some instances this pur- pose cannot be effected until the system is placed under the in- fluence of mercury ; and the sooner, therefore, this event can be brought about the better. It may be proper, however, to state, 228 Syphilis. that mercury, when employed in irritable constitutions, instead of resolving a bubo, will sometimes cause it to suppurate and to degenerate into a troublesome sore; and again—that the same effect may occasionally arise from the inflammation produced by the mechanical operation of friction, in the act of introducing the mercury into the thigh of the affected side. Whenever there is reason to suspect that inordinate irritation proceeds from either of these causes, the mercury must be discontinued and the patient confined to the horizontal position, in order to keep the parts as still as possible, whilst, at the same time, cold saturnine solutions are applied constantly to the groin; or what frequently answers a betler purpose, the tumour may be covered by a blister, which has always been a favourite remedy with Dr. Physick in the early stage of bubo. Some surgeons, under simi- lar circumstances, recommend leeches to the swelling. I have known, however, great irritation and troublesome ulcerations to follow from the bites of these animals when applied to the in- flamed gland, and therefore seldom prescribe them in such cases. Should these remedies fail, and suppuration become inevita- ble, then warm poultices should be applied to the groin until the matter is discharged. Sometimes it happens that suppuration is established, and yet the matter is afterwards absorbed and the skin remains entire. If there is reason to think such an event probable, the poultice should be laid aside, and a simple dress- ing substituled. On the other hand, when the matter is copious- ly secreted, and at the same time backward in its approach to the surface, the abscess should be opened by the lancet or caustic. The former I prefer in every instance, as it gives less pain than the caustic and discharges the matter at once. Dr. Parrish informs me, that he has sometimes treated suppurating buboes very successfully, by making a number of small openings through the skin, discharging the matter gradually, and after- wards pressing the sides of the cavity togelher by a soft sponge or compress. When ulceration, which frequently follows a bubo, proves ob- stinate and spreads, the applications recommended for chancre, particularly the black wash, should be tried. K the edges of the sore become hard and insensible, they may be pared away with the knife or destroyed by repeated touches with caustic. Syphilis. 229 Indeed, the whole surface of an ulcerated bubo is often rendered so indolent as to require a very liberal use of caustic, savin powder, and other articles equally stimulating. The treatment of secondary symptoms must depend upon the extent of the disease. In general, mercury will not be ne- cessary. There are certain preparations of that medicine, how- ever, which seem particularly adapted to the advanced stages of syphilis. The muriate of mercury or corrosive sublimate, has acquired in this particular a very high reputation, and as I think de- servedly ; many practitioners, indeed, very much depend upon it throughout every form of the complaint. Mr. Pearson, how- ever, whose opportunities of testing the anti-venereal powers of various medicines have been very extensive, holds it in low es- timation, when applied to the treatment of primary symptoms; whilst he admits that it is " peculiarly efficacious in relieving venereal pains, in healing ulcers of the throat, and in promoting the desquamation of eruptions." There are various modes of administering the article, which, if given in large doses and in an improper vehicle, will frequently give rise to excessive thirst, burning in the throat, nausea, vomiting and other violent symptoms. For several years past I have used the medicine in all the consecutive affections, and frequently with advantage, in doses of thirty or forty drops of a solution, composed of a grain of the salt to an ounce and a half of water, and given two or three times a day. As a gargle, also, in venereal sore throat, there is no application more effectual. Should the corrosive sublimate, internally administered, prove insufficient to touch the mouth or remove the disease, the blue pill and calomel may be resorted (o; and if (hese also fail, (here is another mode, and the most expeditious we are acquainted with, of introducing the medicine into the system—by fumiga- tion. This practice was known at a very early period, and indeed employed extensively in every form of syphilis, in preference to the internal use of mcrcuiy. It appears at one time to have been abandoned, but afterwards revived by Lalouette, a cele- brated physician at Paris, who states, that during the space of thirty-five years, he had cured by means of it, upwards of four hundred patients, after all the ordinary remedies had failed. 230 Syphilis. Upon the recommendation of Mr. Abernethy, I commenced many years ago, this plan of treatment, and found it greatly to exceed my expectations,—producing in a very short time a de- cided impression, after the system had resisted, for weeks or months, the operations of calomel and the blue pill. It is well known, indeed, that there are many patients upon whom these and most other preparations of mercury fail to induce a salivant effect—which is afterwards brought about very speedily by fu- migation. This circumstance has been adduced as an objection to the general employment of the remedy, inasmuch as it is dif- ficult to introduce into the system a sufficient quantity to ensure permanent benefit—owing to the rapidity with which the mer- cury operates when thus administered. There are two or three modes of conducting the fumigating process} one of which, and perhaps the most simple, is to seat the patient, who is previously stripped to the skin, in a common arm chair, and surround the whole body, with the exception of the head and neck, with thick blankets. Beneath the chair is then placed a common iron pot or chafing dish, full of live coals, and over this a thin sheet of iron, the surface of which, when" heated must be strewed with some mercurial preparation, capable of volatilization. The fumes ascending, penetrate the skin in every direction and enter perhaps the lungs. A co- pious perspiration is usually the result of the operation; and to prevent the patient from taking cold, he should be carefully wrapt in the blankets and conveyed to bed. Another method more complicated, and perhaps not more effectual, is to enclose the patient in a box, resembling a sedan chair, having an opening at the top to let out the head, and another at the bottom holding a small furnace. The prepara- tions usually employed in either process are factitious cinnabar, the black sulphuret of mercury, or else a gray powder, formed by mixing together four ounces of calomel, two drams of aqua ammoniae and six ounces of distilled water. This powder is se- parated by filter, and dried, and is preferred by Mr. Abernethy to any other in use. The great advantage possessed by fumigation over the com- mon modes of introducing mercury is, as before mentioned, its speedy operation, which renders it particularly valuable in cer- tain ulcerations of the throat and nose, which are rapidly spread- Syphilis. 231 ing and threaten destruction to the delicate parts amongst which they are seated. From experience, I can recommend the plan in all such cases, with the utmost confidence. Nor have I found it less effectual in dispelling venereal discolorations of the skin and blotches. Besides mercurial preparations, there are others equally effi- cacious in breaking up the remnants of syphilis. These are the mineral acids used singly or conjointly, certain vegetable ex- tracts, particularly sarsaparilla, guaiacum, mezereon, adminis- tered in the form of decoction or mixed with sirups, and general- ly containing more or less of corrosive sublimate—such as the sirup of Cuisiniere, the depurative ptysan of Vigaroux, the rob anli-syphilitique of Laffecteur, the tisane of Feltz: all which, in particular cases, often prove extremely serviceable, in relieving pain, healing ulcerations, or in restoring constitutions enfeebled or injured by the abuse of mercury. Of the acids, the nitro- muriatic, as used by Dr. Scott, in the treatment of hepatitis, and by Sir Charles Bell, for secondary syphilitic symptoms, will be found the most convenient and serviceable. Nodes are often extremely difficult to remove. In general, they are benefited by sarsaparilla, and by external applications, such as the linimentum hydrargyri ammoniatum.* As an internal re- medy, arsenic has been found highly serviceable in obstinate nodes. Dr. Dewees informs me, that he has successfully pre- scribed the medicine in such cases for the last twenty years. Venereal warts may be removed by the knife or scissors, and sometimes by the application of acetic acid, the compound pow- ders of rhubarb or savin, the muriated tincture of iron, butter of antimony, finely levigated arsenic, &c. • The following formula of this medicine will answer for a variety of surgical purposes. r<. Ung. hydrargyri fort. Adip. suilla. praep. sing. §i Camphors, 3'ij. Ammonia liq. ^iv. First rub the camphor with a few drops of alcohol, and then with the ointment and lard; and lastly, add by degrees, the liquor am- monia; and mix the whole together in a glass mortar. , Consult Hunter on the Venereal Disease, by Adams—Benjamin Bell on Lues Venerea—idams on Morbid Poisons—Sawrey'a Inquiry into some of the Effects of the Venereal Poison, 1802—Swediaur on Syphilis, &c. tranalatedby Hewson— Abernethy'a Surgical Worka, vol. 1—Blair's Essay on the Venereal Disease, and 232 Syphilis. ihe Effects of Nitrous Acid and other analogous Remedies, lately proposed as Sub- stitutes for Mercury, 1808—Pearson on the Effects of various Articles of the Ma- teria Medica in the Cure of Lues Venerea, edit. 2d, 1807— CarmichaeVs Essays on the Venereal Diseases which have been confounded with Syphilis, 1814— CarmichaeVs Observations on the Symptoms and Specific Distinctions of Venereal Diseases, 1818—Rose's Observations on the Treatment of Syphilis, with an Account of several Cases in which a Cure was effected without Mercury, in Medico-Chirur- gical Transactions, vol. 8—Hennen's Observations on Syphilis, in h>'s Principles of Surgery, p. 488—Evans' Remarks on Ulcerations of the Genital Organs, 1819 —Bacot on Syphilis, 1821—Charles Bell's Report on the Use of the Nitro-Murialic Acid Bath in certain obscure Cases of Syphilis, in his Surgical Observations, vol. l,p. 338. Fractures. 2S3 CHAPTER VII. FRACTURES. The bones are all subject to fracture; though some yield more readily than others. In general, the long or cylindrical bones more frequently suffer than the short or flat ones, inasmuch as they serve a greater number of purposes, and are commonly under the influence and direction of large and powerful mus- cles. A bone may be broken either by a direct blow, or by force applied to both of its extremities at the same moment. In the former case, the fracture occurs at the spot upon which the in- jury is immediately received; in the latter, the bone commonly yields about its centre or at some intermediate portion. The muscles are generally more or less concerned in the production of fractures, and in many instances, without any other co-ope- rating power, break the largest and strongest bones. At other times the bones themselves, from old age and diseases, are ren- dered brittle and are easily fractured, either from external vio- lence or muscular action. A patient of mine, a Mr. Green, residing near Trenton, in Jersey, has a son, now nineteen years of age, who, from infan- cy, up to the present period, has been subject to fractures from the slightest causes, owing to an extraordinary brittleness of the bones. The bones of the arm, fore-arm, thigh, and leg, have all been broken repeatedly, even from so trivial an accident as catching the foot in a fold of carpet whilst walking across the room. The clavicles have suffered more than any other bone— having been fractured eight times. What is remarkable, the Vol. I. 30 234 Fractures. boy has always enjoyed excellent health, and the bones have united without much difficulty or much deformi'y. The above was published in 1821; since then this patient died in the twen- ty-third year of his age, from partial dislocation of the first and second vertebrae of the neck, after a painful illness of fourteen weeks. Altogether he had experienced livcnty-four fractures. An interesting case of fragilitas ossium was reported to me in December, 1828, by Dr. Melteaur of Virginia. The follow- ing are the particulars. " Alexander Mc* * * •'■-, a native of Scot- land, about seventy years of age, rather below the common stature, of ruddy complexion, neither lean nor corpulent, of a sprightly, though irritable and pugnacious disposition, had al- ways enjoyed excellent health, an inhabitant of Petersburgh, Virginia, for twenty-five years, was so remarkable for his great liability to fracture his bones, that if he were seen a quarter of a mile from his dwelling it was very common,'to hear some one say, " there goes old Ellick, I'll engage he will break some of his bones before he returns." He assured me, says Dr. M., that it always appeared to him from early infancy, that his bones were more easily broken lhan other person's, and that he be- lieved he could break the bones of the fore-arm at any time, by pressing them between his thumb and fore-finger—that he had several times fractured the ulna, radius, os humeri, clavicles, in giving blows. " None of his bones," continues Dr. M., " seem exempt from this extraordinary brittleness, for since my resi- dence in Petersburgh, I know of ten or twelve fractures of dif- ferent bones. I think it probable more may have occurred during the same period; for latterly, the accident having become very frequent, his domestics managed his case, having, from their experience, become expert bone-setters. The tibia, fibu- la, os femoris, have been broken several limes from a sudden twist of the body, and from efforts to save himself from falls. His thigh bones have been broken when attempting to get on horseback. His ribs have also been frequently fractured from slight causes. His speedy recovery astonished all who were acquainted with his case; for seldom, in any instance, has he been confined more than three weeks." Dr. Elkinton, of this city, has also furnished me with a case of fracture of the bones, produced, there is reason to believe, by muscular action, conjoined with extraordinary brittleness of the Fractures. 235 Osseous texture. " In January, 1827, says he, while practising at Haddonfield, New Jersey, six miles from Philadelphia, I was called to see Mr. Benjamin Barrett, a respectable man, about forty years of age. Ho was seized with a fit, but when I ar- rived, had become tranquil; some medicine was directed for him, and as he was subject to epilepsy, I left him in charge of careful attendants. On my third visit, three days subsequently to his first attack, being alarmed at the contracted state of the pupil and other indications of disordered brain, a blister was ordered to the back of his neck, and upon removing his clothing a fracture of both arms was discovered above the elbow. Not- withstanding my investigations were made with the strictest scrutiny, I could not ascertain that the patient had received any injury either by falling out of bed or in any other manner. The only explanation I was enabled to assign for this strange occur- rence, was obtained from the report of his friends. They stated, that during the night of his attack, while struggling in a fit, a very distinct noise or crack was heard, which, to use their own expressions, seemed as if he were breaking his bones. I have not the least doubt but that both fractures occurred at the time the noise was heard, from the force of muscular contraction operating on a system possessing some peculiarity in the orga- nization of the osseous structure. This opinion was strength- ened on mentioning the case to my senior colleague, Dr. Hen- dry, who had frequently attended the patient, and remarked at the time, it zvas very common for J\Ir. Barrett to have his bones brO' ken. In a short time the bones were perfectly reunited." My friend, Dr. Goddard, an accomplished young physician of this city, has, likewise, detailed to me a case of fragilitas os- sium, equal in interest to either of the foregoing—the particulars of which 1 here state. "September xJ7, 1832, Martin Stevenson, between three and four years old, fell from a step six inches in height, and frac- tured his thigh. When called to him his mother informed me lhat he had twice before fractured this thigh from very trifling causes. She also stated, lhat she herself had suffered from frac- lure once in (he right (high, and fvc times in the left. She first broke her left thigh, and found upon recovery, that the right from sustaining the principal part of her weight was very 236 Fractures. painful, that at last it gave way on making a slight exertion, and shortened as much as the other had, during the cure, but has not been broken since. She also informed me that her bro- ther, at thirteen, had suffered two fractures of one thigh and nine of the other, as well as two of the arm; besides which, one of his hip joints had been dislocated, from all of which he has perfectly recovered, with the exception of the deformity. Martin's thigh was firmly united in five weeks, and he was run- ning about as usual. These people are of very short stature, and have small bones. "January 16, 1833, Martin, whilst eating his supper, fell from his chair, and fractured both bones of the fore-arm, for which he is at this moment under treatment. He is now four years and one month old, and has had four fractures. " Since the communication of the above case of ' fragilitas ossium,' in the person of Martin Stevenson, he has had four bones fractured. On the twenty-ninth of May, 1833, a little girl took hold of the fore-arm (which had previously been broken) rather rudely, and fractured the ulna; it was well in about three weeks. This was on the left side. On the 9th of September following, Martin tripped and fell down two stairs (about twelve inches high altogether) and fractured the humerus radius and tibia of the right side. They were all united and the apparatus taken off by the 5th of October, not quite four weeks. He is now quite well and as lively and playful as any boy of his age." Along with my friend Dr. Caspar Morris, of this city, I at- tended a lady, five years ago, whose case was, in many respects, similar to those just detailed. During the winter of 1836, Dr. Morris, also, attended Martin Stevenson three times with frac- tured thighs. Fractures are most frequent during very cold weather. On this account many have supposed that cold affects the texture of bones, and predisposes them to give way. But the true expla- nation is, lhat persons in walking while the ground is hard and slippery, make unusual efforts to sustain themselves, by which the muscles are rendered tense and thrown into full action, and if they happen to fall, the two powers combined—the resistance of the frozen earth and inordinate muscular exertion—very Fractures. 237 readily produce fractures and sometimes more important inju- ries. Fractures have been divided into different species—according to the extent of the injury, and the particular direction in which the fibres of the bone happen to yield. Thus, we have a sim- ple, compound, and complicated fracture; and again, a trans- verse, oblique, comminutive, and longitudinal fracture. By the term simple fracture is understood a mere separation of bony fibres, unattended by severe contusion or external wound. From this, a compound fracture differs, in being conjoined with an external wound, or with a protruded bone. A complicated frac- ture implies that the bone is broken at more than one place, or is combined with luxation, with laceration of one or more large vessels, or rupture of ligaments, tendons, &c, or with a gun- shot wound. A fracture is said to be transverse, when its di- rection is perpendicular to the axis of the bone. It is denomi- nated oblique, when it deviates from the perpendicular direc- tion. In comminutive fracture, the bone is broken into several pieces or crushed into fragments. A longitudinal fracture runs parallel with the axis of the bone. The signs of fracture are not always very decisive. In ge- neral, however, crepitation, or that particular noise or sensa- tion produced by rubbing together the fragments of a broken bone is more to be relied on than any other, and is an almost certain indication of fracture. Added to this, there is usually more or less deformity, pain, swelling, inability to use or move the limb. But these symptoms may attend luxation and other injuries, and are therefore not unequivocal proofs of fracture. Besides, it is possible for a patient actually to labour under frac- ture of one or more bones, and yet, from interlocking of the fragments, or from a sound bone serving as a splint and sup- porting the broken one, no distortion will be perceived. Many instances are related of patients walking about, under these cir- cumstances, for some time after the accident.* The prognosis in fracture will depend very much upon the extent of the injury, the constitution and age of the patient, the direction of the fracture, and the particular bone broken. Com- plicated and compound fractures will prove more dangerous than any others, especially if they occur in old people and in bad • See Dorit v's Elements, vol. i. p. 113, and Allan's Surgerv, vol. ii. p. 60. 23S Fractures. habits of body. An oblique fracture is commonly more diffi- cult to manage than a transverse one, owing to the fragments of bone overlapping—from muscular contraction. It is possible, however, for the ends of a bone, when 1 roken transversely, to pass each other; though fhis seldom happens unless the cause of the fracture act with uncommon violence, or some subsequent force be applied. In either case, the parts will sustain more in- jury and the danger will be greater than if the bone were broken obliquely, and by a moderate force. The direction of displacement, or derangement of the frag- ments of a broken bone, must always depend either upon the force by which the accident was produced, upon muscular ac- tion, or upon the weight of the body, or that of the injured part. Sometimes the derangement is angular, sometimes lon- gitudinal or parallel with the axis of the bone, in other in- stances in the direction of its diameter, and again—in that of its circumference. Treatment of Fractures. The general indications in the treatment of fractures are, to prevent or subdue inflammation, and to coaptate and retain the fragments in contact by appropriate mechanical means, until they are restored to their pristine condition through the medium of callus. The former are best accomplished by the antiphlo- gistic system and by position—the latter by extension, counter- extension, splints and bandages. By extension is understood a force applied to the lower frag- ment, sufficient to remove it from the superior fragment; by counter-extension, a power calculated to resist the operations of extension. These means are not necessary, however, or ap- plicable to all fractures. Frequently coaptation, or a proper adjustment of the fragments by the fingers, will answer every purpose. In other instances, position, splints and bandages are only required. The bandages, usually employed in fractures, are made of coarse muslin or hummum, an article, from its flexibility and roughness, peculiarly adapted to lit accurately and adhere close- Fractures. 239 ly to any part of the body. The muslin should always be washed before it is used and the selvage or rough edge torn off Ban- dages should, if possible, be free from seams, which by pressure often excite irritation or produce wells in the skin, that annoy the patient more than the fracture itself. The single-headed roller and the bandage of Scultetus have superseded most others, and arc adapted to a great variety of purposes. The roller is chiefly employed in fractures of the upper extremities, the bones of the chest, &.c. In general, it accommodates itself best to the shape of the part when somewhat narrow. The bandage of Scultetus is chiefly useful in fractures of the thigh and leg. It consists of numerous strips or pieces of the same breadth, and of equal or unequal length, according to the shape of the part it is intended to surround. Each piece over- laps the other about two-thirds. The great value of this ban- dage arises from the facility with which it can be removed and reapplied, without disturbing or moving the limb. It will be more particularly described hereafter. To apply a roller or any other bandage with neatness and ef- fect, a great deal of practice will be required. A student should be very careful, however, not to fall into the error I have known some young surgeons commit, from aiming at feats of dexterity and despatch—by drawing the roller with immoderate tightness in order to make it lay smooth and hide rough edges—a prac- tice well enough on the dead subject, but followed by pain, ob- struction of the circulation, and other ill consequences when-ap- plied to the living bodyr. Again—the more a surgeon accustoms himself to roll up his bandages with his own hands, the more dexterity will he acquire in applying them. Splints, are made of different materials—of pasteboard, binders' boards, wood, and tin. Binders' boards, however, an- swer a better purpose than the others in most fractures, inasmuch as they adapt themselves, when moist, to the shape of the injured part, and, when dry, have sufficient strength and stiffness to re- tain the position given to them. Common pasteboard is too thin and flexible to give any support to a fractured bone, and tin, from its hard and unyielding nature, cannot be employed without creating pain or uneasiness. Wooden splints are chiefly adapted to fractures of the long and large cylindrical bones__as (hose of the thigh and leg. In general, splints should at least 240 Fractures. equal in length the fractured bone; sometimes they are required longer. Within the last few years a very useful splint has been contrived by an ingenious physician of the Eastern States. It is composed of felt, (or the material of which hats are made,) and_.apparently soaked in shellac varnish; when warmed it be- comes extremely soft and flexible, and adapts itself readily to the slightest inequality of a limb, and afterwards hardens and ac- quires all the firmness of wood or of binders' boards. The time necessary for reunion and consolidation of fractures, must vary according to the age and constitution of the patient, the situation and extent of the fracture, and some other circum- stances. Young and healthy subjects recover in a shorter time than old and infirm, and the process of reunion is sooner com- pleted in a small than a large bone. From two to eight weeks usually elapse before consolidation is established, but a much longer time will be required for perfect restoration of the injured part. Fracture of the Nose. 241 Section 1. Fracture of the Nose, fyc. The bones of the nose may be fractured and driven in by a blow; or they may be crushed by the passage of a wheel, or by a gun-shot. In either case there is commonly more or less con- cussion of the brain. Sometimes the impulse is communicated to the septum, and thence transmitted to the delicate cribriform plate of the ethmoid bone, which is broken up and forced upon the brain—producing violent symptoms, and even death. Such accidents, however, are rare; and the usual symptoms are severe pain, copious flow of blood, and difficulty of breathing. If the case has been neglected, permanent deformity may ensue—from lateral distortion or depression of the bones. From the same cause, also, incurable epiphora or fistula lachrymalis may re- sult. The cheek and upper jaw bones are seldom fractured, except by a gun-shot wound, or from the application of very great vio- lence. In two instances 1 have known a considerable portion of the alveolar process broken off along with the teeth, from im- moderate force employed by an ignorant dentist in an attempt to extract a large stump. The antrum maxillare in one of the patients was completely exposed. Le Dran has furnished an in- teresting case of fracture of the upper jaw, in which four of the molar teeth, along with their alveolar processes, were broken up and forced under the roof of the mouth. Vol. I. 31 242 Fracture of the Nose. Treatment of Fracture of the Nose. The nasal bones when fractured should be elevated and re- placed as soon as possible, otherwise the pain and tumefaction become so great, that it is not easy to discover the direction of displacement; and before these symptoms can be reduced, the bones may become fixed in their unnatural situation, and create great deformity and fistula lachrymalis. A case of the kind has been related by Boyer. To restore the fragments to their proper places, the end of a female catheter, or a strong probe, or any similar instrument, may be introduced into the nostrils and used as a lever, while the fingers are employed externally in modelling the parts to their natural shape. After the fragments have been elevated, they generally preserve their situation without the assistance of quills, lint, and other contrivances advised to be stuffed into the nostrils, which cannot prove serviceable, but on the contrary must add to the irritation. The remainder of the treatment con- sists in removing the inflammation, after which the bones soon become firm, and a cure follows. Fractures of the upper jaw, and bones of the cheek seldom require any olher remedies than those calculated to subdue in- flammation. When large portions of the alveolar processes to which the teeth adhere, have been broken, and remain only at- tached to the soft parts, it has been proposed to replace the fragments and secure them, by fastening the insulated teeth with silk or wire to those in the sound part of the bone. This was successfully practised in Le Dran's case, but I much question the necessity of the measure. Fracture of the Lower Jaw. 243 Section II. Fracture of the Lower Jaw. The lower jaw, notwithstanding its mobility, is frequently fractured. The fracture may take place at or near the sym^ physis, between the symphysis and angle, at the angle itself, or in the condyloid or coronoid processes. Sometimes it is fractured in two places—on each side of the chin; in which case the chin is insulated, and there are three fragments and two fractures. The coronoid process, being covered and protected by very strong and fleshy muscles, is seldom broken; nor is Ihe condyloid much exposed to such injuries. A separation of the jaw at ihe sym- physis is usually met with amongst young subjects; though I have seen one instance of it in a man beyond forty years of age. Fracture commonly takes place on one side only of the jaw, and the most frequent seat of it is intermediate to the sym- physis and angle. The direction of the fracture may be oblique or transverse; except in fractures of the alveolar ridge,in which case the direction will be longitudinal. The signs of a fractured lower jaw are generally very dis- tinct and evident. Crepitation can almost always be observed, and upon looking into the mouth the teeth will be found irre- gular and oftentimes loosened. When the chin has been insu- lated by a fracture on each side of it, it will be drawn down- ward, considerably below the level of the adjoining fragments, bv the action of the muscles of the throat inserted into its point. Fracture of the neck of the condyloid process may generally be distinguished by the grating noise and pain produced in the neighbourhood of the ear when (he jaw is moved, and by the 244 Fracture of the Lower Jaw. circumstance of the condyle being dragged^ forward by the ac tion of the pterygoideus externus muscle. Treatment of Fracture of the Lower Jaw. The surgeon having carefully examined the injured parts, and replaced such teeth as are shaken or loose, runs his fingers along the margin of the jaw, models the parts into proper shape, and closes the mouth firmly, making the lower teeth rest fairly against the upper. Then a cotton or linen compress of moderate thickness, reaching from the angle of the jaw nearly to the chin, is placed beneath and held by an assistant, while the surgeon takes a roller, four or five yards long, an inch and a half wide, and passes it by several successive turns under the jaw up along the sides of the face and over the head; now changing the course of the bandage, he causes it to pass off at a right angle from the perpendicular cast, and to encircle the temple, occiput and fore- head horizontally by several turns; finally, to render the whole more secure, several additional horizontal turns are made around the back of the neck, under the ear, along the base of the jaw, over the point of the chin. To prevent the roller from slipping or changing its position, a short piece may be secured by a pin to the horizontal turn that encircles the forehead, and passed backwards along the centre of the head as far as the neck, where it must be tacked to the lower horizontal turn—taking care to fix one or more pins at every point at which the roller has crossed. This simple method of securing a fractured jaw I have practised very successfully for several years. The operation is more easily performed than described, but may be well under- stood by examination of the sketch in Plate IX. Whatever plan may be pursued in bandaging the jaw, there can be no necessity for the interposition of pieces of cork be- tween the teeth, or for pulling a tooth to nourish the patient, J2L IX Fracture of the Lower Jaw. 245 or for the introduction of the gum elastic catheter through the nostrils for the same purpose, as there is always sufficient space between the teeth to enable the patient to imbibe broth or any other thin fluid placed between his lips. During the cure the jaw should be kept as still as possible, otherwise deformity is apt to ensue. 246 Fracture of the Vertebra:. Section III. Fracture of the Vertebrae. The bones composing the spinal column are seldom frac- tured. Such accidents, however, when they do occur, are al- ways the result of great violence, and are generally followed, immediately or remotely, by most severe symptoms or by death. In some cases there is violent concussion of the spine without fracture, which gives rise to paralysis of the lower ex- tremities; but this subsides in a little time and the patient re- covers. The effects of fracture are more permanent, and al- though at first not always severe, may terminate most unfavour- ably. Sometimes an effusion of blood is found upon dissection, either on the outer or inner surface of the spinal sheath ; at other times the spinal marrow is compressed or wounded by a projecting fragment of bone. From either cause high excite- ment and paralysis ensue, and at a later period inflammation and suppuration within the membranes of the spinal marrow. So copious, indeed, in some instances is the matter, that it tra- vels along the sheath, and is lodged at a great distance from the injured part. It is this thickening of the sheath from inflam- mation and suppuration within its cavity, that is the cause of death in nine cases out of ten. This explanation was first given by Sir Charles Bell, the only writer that appears to have taken a correct view of the pathology and treatment of injuries of the spine. Fractures of the vertebrae produce different effects, according to the particular situation of the bone injured. If the fracture lake place above the fourth cervical vertebra, death follows al- most instantaneously—owing to the injury sustained by the phrenic nerve. When the fracture occurs below the fourth ver- Fracture of the Vertebra. 247 tebra, there is usually paralysis of the arms and difficult respi- ration, and death follows in four or five days. Fractures of ihe dorsal vertebrae are succeeded by paralysis of the lower extremities and by great torpor of the intestines. In some cases, the abdomen becomes enormously distended from quantities of air, contained within the bowels. The patient seldom lives beyond the third or fourth week. When the lumbar vertebrae are fractured, the bladder and rectum lose their powers of retention, and the urine and faeces pass away involuntarily; the lower extremities are completely paralyzed and perfectly insensible to the most powerful stimu- lus, while the beat and circulation in the limbs are but slightly if at all diminished. Death follows at a later period than after similar injuries of the cervical and dorsal vertebrae; though the patient seldom survives beyond five or six weeks. Fracture of the spinous processes of the vertebrae is seldom fol- lowed by any serious consequences, unless accompanied by violent concussion or some other injury. Treatment of Fracture of the Vertebra. From what has been said it will appear that little benefit may be expected in most cases from any treatment that can be adopt- ed. It was long ago proposed to cut down upon the injured part, and remove by the trephine the displaced portion of bone compressing the spinal marrow. Such an operation was actu- ally performed by Mr. Henry Cline, but without success. I concur, however, entirely with Sir Charles Bell, in thinking " that the palsy is a consequence of the swelling of the mem- branes, and proceeds from inflammation; and if you cut down upon the bone and saw it out, and expose these membranes, you will not only increase the swelling and thickening of the in- volving membranes, but you will most probably raise such di- rect inflammation and mischief as to cut off the patient sudden- 248 Fracture of the Vertebrae. ly."* Should the patient survive the immediate effects of the in- jury, the urine must be drawn off frequently by the catheter, and such measures taken as are calculated to obviate inflammation within the sheath of the spinal marrow. Afterwards stimulating frictions, issues, &c. may perhaps prove serviceable. It is much to be regretted that Sir Astley Cooper should have added the weight of his high authority in sanction of the puerile idea that a surgeon is justified in trephining the spine, upon the ground (certainly untenable) of fracture of the vertebrae being " similar to depressed fracture of the cranium." Independently of other considerations, the circumstance of the bodies of the vertebrae being the parts generally fractured, (in which case the surgeon would be obliged to cut through the spinal marrow to reach the fracture,) would preclude the possibility of the opera- tion, or, at least, of any benefit resulting from it.t • Surgical Observations, vol. i. p. 160. \ See Sir Charles Bell's Lectures on Injuries of the Spine, &c. 4to. 1824. Fracture of the Ribs. 249 Section IV. Fracture of the Ribs. The ribs may be fractured from a direct blow or from force applied to their extremities. In the former case an internal angular derangement will follow,—in the latter the angle will be salient externally. Owing to the extremities of the ribs being strongly connected to the sternum and spine, the fractured por- tions cannot overlap or pass each other ; but derangement may oc- cur in almost any other direction, though the angular is most com- mon. Boyer has declared that derangement cannot happen in the direction of the diameter of a rib: this, however, is a mis- lake, as specimens in my cabinet sufficiently prove. Fracture of a rib may be transverse, oblique, compound, com- plicated, and comminuted. The transverse are most frequent, although the oblique are by no means uncommon. The compli- cated are most dangerous, and may be combined with rupture of the intercostal arteries, emphysema, and injuries of the lungs, It is not always easy to discover a fracture of the rib. Some- times there is a distinct crepitation, and then the nature of the accident is rendered very plain. The presence of emphysema also affords almost certain evidence of the existence of fracture. Generally the patient complains of difficult respiration, especially when lying in the recumbent posture, and of sharp, pricking pain in the seat of the injury, which is increased upon making a full inspiration, or upon coughing. Vol. I. 32 250 Fracture of the liib^. Treatment of Fracture of the Ribs. Little benefit commonly results from an attempt to coaptate the fractured ends of a rib. When the force, however, causing the injury has been very violent, and the fragments have been driven internally or towards the pleura and lungs, well-directed pressure upon each extremity of the rib may cause them to re* sume their former position. On the contrary, pressure applied to the fracture itself will become necessary when there is angu- lar derangement externally. But the chief indication in the treatment is to oblige the patient to breathe by the diaphragm and abdominal muscles, in order to keep the intercostal mus- cles at rest while the process of reunion is taking place. This is accomplished by a broad roller, passed circularly about the chest, and made to envelop the greater part of it, placing a single compress, if the derangement be external, over the frac- tured part and under the roller, and two if the derangement be internal—one at each end of the rib. These co-operate with the bandage in forcing the fragments into their proper places. Con- joined with this treatment, general blood-letting and elevation of the patient's shoulders by pillows placed behind his back, will prove extremely useful. Should hemorrhage take place from a wound of the intercostal artery, or emphysema follow from a wounded lung, the treatment formerly pointed out, un- der the head of Wounds of the Chest, must be pursued. Fracture of the Sternum. 251 Section V. Fracture of the Sternum. Fracture of the sternum is usually the result of considerable violence; hence the mischief that ensues is not always confined to the bone, but extends to the sensible membranes and organs within the chest: these inflame and suppurate, and not unfre- quently considerable collections of pus take place in the anterior mediastinum—either from the immediate injury, or from subse- quent caries of the bone. I have met with several cases of the kind, and had occasion, several years ago, in the Blockley Hos- pital, twice to trephine ihe sternum in two different patients, on account of caries and lodgement of matter. Fracture of the sternum may be known by the.incessant gra- ting of the fragments upon each other during respiration, which is so remarkable in some instances as to be heard a considerable distance. Besides this sign, which is very decisive, there are others—palpitation of the heart, difficult respiration, severe pain and troublesome cough. The bone will sometimes be found broken in three or four pieces. The direction of the fracture is commonly transverse. Treatment of Fracture of the Sternum. The chief indications in the treatment of this injury, are to pre- vent or subdue inflammation, and to appease the incessant cough and difficult respiration that usually attend. The former are best accomplished by repeated blood-letting,—ihe latter by opiates, and by supporting the patient in bed in a sitting posture. 252 Fracture of the Sternum. Quiescence of the chest, also, is essential, and readily effected by a roller drawn with sufficient tightness to impede the action of the intercostal muscles. Should matter form beneath the sternum, or collect within the mediastinum, an opening may be made cautiously with the crown of a trephine—so small as not to exceed half an inch in diameter. The same instrument, aided by Hey's saw, bone nippers, and forceps, will also answer for removing carious por- tions of bone—at the same time bearing in mind, not to be too officious-in picking away or scraping the bone, which by such means may be rendered diseased or made to exfoliate, when, if it had been left to nature, it might have recovered. Experi- ence, however, has taught me, latterly, that the operation of the trephine, just referred to, is seldom productive of lasting benefit. In patients upon whom I have operated, since the cases men- tioned above, 1 have found the caries to return, and eventually death has taken place,—apparently from phthisis pulmonalis. Fracture of the Clavicle. 253 Section VI. Fracture of the Clavicle. The clavicle, from its exposed situation and delicate form, is peculiarly subject to fracture. It may be broken by a force di- rectly applied to it, or by a counter stroke. In the latter case, the effect is generally produced by a fall upon the point of the shoulder, or on the hand, which is instinctively put forward to save the body. From either cause fracture is most common about the middle or vaulted part of the bone, usually oblique or transverse, and seldom compound or complicated. The accident is easily distinguished from other injuries—by cre- pitation, by the depression of the humeral beneath the level of the sternal fragment, by the shoulder, (of which the clavicle is the support or stay,) falling forward upon the breast and sinking below the level of the opposite shoulder, by the inability expe- rienced by the patient in carrying the hand to the head without bending the fore-arm and dropping the head to meet it, and by the particular attitude which most patients assume to relieve themselves from pain—supporting the injured limb with the op- posite hand, and inclining the head and body towards the affect- ed side. Fracture of the clavicle may occur at or near the humeral or sternal extremities of the bone. The former seldom happens, owing to the thickness and strengh of the humeral portion, and to its close connexion with the scapula, to which it is tied by very firm and unyielding ligaments. Fracture of the sternal end is commonly the result of counter-stroke. 254 Fracture of the Clavicle. Treatment of Fracture of the Clavicle. As the shoulder sinks and approaches the sternum, after the clavicle is fractured, it follows lhat the chief indications in the treatment are, to elevate it again to its natural height, and at the same time to carry it backwards and outwards, and there retain it by an appropriate apparatus. The two first indications had long been acknowledged as necessary, but the third and most important of all—that of keeping the shoulder outwards—was originally suggested by Desault, who, upon the principles just .pointed out, has devised an apparatus for reducing and main- taining in contact the fragments of bone, infinitely more effica- cious than any other ever invented, at the same time extreme- ly simple in construction, and composed of materials easily ob- tained in any situation, however remote. This apparatus consists of three rollers, each three inches wide and seven or eight yards long—a pad, the shape of a wedge, composed of pieces of old linen, four or five inches broad, three inches thick at the base, and in length equal to the humerus,—three compresses—a small sling for supporting the fore-arm—and a piece of linen or muslin large enough to cover the bandages and envelop the whole chest. The surgeon directs an assistant, while the patient is in a standing or sitting position, to elevate the arm of the injured side and keep it extended at a right angle with the body. He then takes the pad, and placing its base or large extremity in the arm-pit, has it held closely to the body. See Plate X. The end of one of the rollers is now placed on the pad, and fixed by two or three circular turns around the body; the roller next ascends obliquely over the front of the chest to the sound shoulder, passes over this posteriorly, under the arm-pit, appears again in front of the chest, makes a circular turn nearly around the body, ascends from behind to the sound shoulder, passes n. x. lJr.,m,.m'/■. .? JJr.nrn fr.mi, lift, tiy T. Sully .i/Eiujrav.-.l hj C.tl.MM* Fracture of the Clavicle. 255 over it and under the arm-pit, appears again on the back of the chest, and finishes by circular turns which cover the whole pad and fix it securely to the body. See Plate X.fig. 2. The next step of the operation is to reduce the fracture or restore the ends of the bone to their proper places. To ac- complish this, the surgeon lakes hold of the arm, carries it downwards, lays it closely along the pad, bends the fore-arm across the chest, runs his fingers along the clavicle, and adjusts the fragments. The deformity disappears in an instant, and the principle upon which the bone is replaced immediately un- derstood—the arm being converted into a lever of the first kind serves as the handle or power, while the clavicle forms the re- sistance and the pad the fulcrum or prop. To keep the bone in its position, the surgeon nexl takes a second roller, whilst an assistant maintains the arm in contact with the pad, and com- mencing at the arm-pit of the sound side, carries it to the shoulder of the injured side, and thence by oblique and cir- cular turns around the body and arm, gradually descending, (each cast overlapping the other, and tightened in proportion to its descent,) until it passes under the elbow as far as the mid- dle of the fore-arm; this fulfils the second and most important indication—to retain the shoulder outwards. See Plate XI. fg-l. The third and last roller must now be applied. Commencing at the arm-pit of the sound side, the surgeon carries the roller obliquely upwards over the injured shoulder, (previously co- vering the clavicle with the compresses,) down on the poste- rior part of the arm, under the elbow, obliquely upwards across the chest to the arm-pit whence it started, over the back to the shoulder of the affected side, across the compresses down in front of the arm, under the elbow, across the back to the sound arm-pit,—from which it commences again to run the same course until the roller is exhausted. The bandage, when thus applied, forms a double triangle—one appearing on the back, the other on the breast—and serves to retain Ihe arm ami shoulder in their elevated position. Sec. Plate AY. Jig. 2. The different turns or casts of the three rollers being firmly fastened to each other by numerous pins it <-'iily remains to ap- ply the slinc, (made of a piece of common roller passed around 256 Fracture of the Clavicle. the hand and wrist, and pinned above to one of the bandages,) and to cover the whole with the large muslin cloth. The last 1 have never employed, as the rollers have always remained suf- ficiently firm without. The patient is relieved of pain from the moment the arm is secured by the second roller, and when the operation is finished is generally able to walk about without inconvenience. In a few days, however, the bandages become more or less relaxed or discomposed, and must be replaced. There are some sur- geons, however, who object to the bandages of Desault, upon the ground, chiefly, of becoming loose, and seem extremely averse to a renewal of them, as if the trouble of replacing a dressing did not fall as much within their province as its original application. Others have expressed idle fears about excoriation, high inflam- mation, mortification, from the rollers being drawn with im- moderate force. It is perhaps possible, (though I have never witnessed it,) if the bandages are put on in a slovenly manner, as they too often are, whether forcibly drawn or relaxed, and suf- fered to remain until they become foul, that excoriation may follow; and so it may from any other bandage or species of clothing. But it is the business of the surgeon to guard against such things, to lay his bandages smooth and flat, and to remove them as soon as they become loose, wrinkled or twisted. As to high inflammation and mortification ever having followed from Desault's bandage, the idea is irresistibly ridiculous and unworthy of serious refuta- tion, and only proves that those who have advanced the assertion know very Utile, practically, about such matters. Indeed, I have commonly observed, that the surgeons who are most loud in their condemnation, and extravagant in their assertions about these bandages, have never applied them, never had control of a pub- lic infirmarv, where such accidents are commonly met with, and have enjoyed very limited opportunities in private practice. The only inconvenience that 1 have ever known to result from the ap- paratus, has occurred from pressure on the large and flaccid mammae of old and fat females; but this so rarely happens, that it can hardly be considered as an objection to the general practice. On the contrary-, the simplicity of the apparatus, the facility of obtaining the materials of which it is composed, and its efficiency Fracture of the Clavicle. 257 when properly applied, (compared with the difficulty of procuring or fabricating machines made of straps and buckles, and quilted bands and bolsters, all of which must be made by regular work- men, and a separate machine adapted to the size of each indivi- dual, during which days may elapse while the patient is suffering,) must, in the eyes of every sensible and experienced person, de- termine at once in favour of Desault's particular plan. Vol. I. 33 258 Fracture of the Scapula. Section VII. Fracture of the Scapula. The scapula, owing to its great mobility, is seldom fractured; though it is often contused, and sometimes so severely as to give rise to collections of matter between it and the chest. The acro- mion process and lower angle of the scapula are more frequent- ly broken than any other parts. The coracoid process, owing to its retired situation, is scarcely ever injured. I have met with two cases only of this accident. The first occurred several years ago in the person of the late Charles Car- roll, Esq., of Carrollton, who was upset in the carriage of Mr. Bagot, the British minister, and, by a violent fall upon the shoul- der, fractured the coracoid process. The patient being remark- ably thin, I was able to feel distinctly the movement of the frag- ments of bone upon each other. I afterwards met with a similar accident in a sailor. Fracture of the acromion may be known by the change in the form of the shoulder, which is sunk and flattened—being drawn downwards by the weight of the arm and the action of the deltoid muscle—by the pain, crepitation and mobility of the acromion, which are readily produced by raising and depressing the arm. Fracture of the neck of the scapula is sometimes met with. The accident is liable to be mistaken for dislocations of the humerus at the shoulder. Cases of the kind are reported by Sir Astley Cooper. The lower angle of the scapula, when fractured, is drawn forwards by the serratus anticus major, and is so completely in- sulated as to be easily distinguished by its inequality and unna- tural position. Longitudinal fractures of the scapula seldom occur, and are attended with little displacement, owing to the manner in which the muscles covering the surface of the bone are ar- ranged. Fr-aclurc of the Scapula. 259 Treatment of Fracture of the Scapula. These accidents are usually accompanied with so much con- tusion, as to render the removal of the inflammation that fol. lows an object of greater importance than the treatment of the fracture itself. So profuse, in some instances, has been *he se- cretion of matter beneath the scapula, as to require the opera- tion of the trephine for its evacuation; at least the scapula has been perforated with this view, although the proceeding has al- ways appeared to me unnecessary, from a persuasion that the abscess, under any circumstances, might be reached by pene- trating the soft parts on either edge of the bone. Fracture of the acromion merely, is easily reduced and se- cured by elevating the arm to its natural height, fixing a pad in the axilla by a roller around the body, and binding the arm lo the pad by a second roller, after Desault's manner of treating the fractured clavicle. When the lower angle has been separated from the body of the scapula, it is hardly possible to overcome the action of the serratus anticus muscle, so far as to restore the fragment to its former position; by a thick compress, however, placed in front of the fragment, and there retained by a roller passed around the chest, the arm being afterwards fixed by an additional roller or sling, the fractured portions may be made to approximate so closely as to leave little or no deformity. Sometimes the pa- tient recovers sooner when confined to bed during the whplq treatment. 260 Fracture of the Arm. Section VIII. Fracture of the Arm. The humerus is very subject to fracture, and may be broken at any portion of its length—at its head, neck, middle or con- dyles. Byr the term neck of the humerus is understood, among surgical writers, lhat portion intermediate to the tuberosities of the bone and the insertion of the pectoralis major and latissi- mus dorsi muscles. Except in old subjects the neck of the humerus is not often fractured; but among these the accident is by no means uncom- mon. In young persons the epiphysis is sometimes separated from the shaft of the humerus. In either case, the upper frag- ment is drawn outwards by the action of the subscapularis and teres minor, while the lower one is pulled inwards by the la- tissimus dorsi and pectoralis major. At the same time the weight of the arm, by keeping down the lower fragment, pre- vents it from overlapping the upper. Sometimes, though rare- ly, the lower fragment is forced outwards. Fracture of the head of the humerus is occasionally met with, and arises for the most part from a violent force directly ap- plied, or from a gun-shot wound. That portion of the bone ar- ticulated with the glenoid cavity, there is reason to believe, in all such cases, is either absorbed or changed in figure. Three or four well marked cases of the kind are contained in my ca- binet, in all which the head has lost its spherical form, is very much diminished and rough and flattened next to the scapula. Similar examples are recorded by different writers. Fractures of the neck or head of the humerus have been con- founded with luxation, and much mischief has sometimes fol- lowed the mistake. These accidents, however, are easily distin- guished by any one familiar with the structure of the joints and the parts in its vicinity. When fractured, the head of the bone Fracture of the Arm. 261 still remains in the glenoid cavity, and the rotundity of the shoul- der is thereby preserved. In luxation a hollow may always be felt under the acromion, and a tumour, formed by the displaced head of the bone, distinctly perceived in the axilla, or some other unnatural situation. Besides these signs, which in general are sufficiently indicative of the nature of each case, more or less crepitation may always be perceived when the bone is fractured, but in luxation can never be observed. The middle of the humerus is oftener fractured than any other part of the bone. A direct force, a counter-stroke, or muscular action may each produce the fracture, which is usually oblique or transverse, and easily known by the mobility of the arm at the injured part, by the angular derangement, pain, cre- pitation, &c. The condyles are frequently fractured by violence imme- diately applied to them. When both are broken, a longitudinal fissure commonly runs along the centre of the bone for some distance, and then terminates by a transverse or oblique divi- sion of the shaft of the humerus. When one condyle only is separated, the direction of the fracture is necessarily oblique. These injuries are often followed by high inflammation, anchy- losis, and deformity of the whole arm, and should therefore be carefully distinguished from other accidents to which the elbow joint is liable. Instances are mentioned by Sir Astley Cooper* in which the condyles were fractured just above the elbow joint, and presented appearances very similar to those produced by dislocation of the radius and ulna backwards. When both con- dyles are fractured, the deformity is greater than when one only is separated. In either case the crepitation is commonly very distinct upon impelling the fragments in opposite directions, and pressure upon the olecranon and bend of the arm increases the breadth of the elbow, which can only happen by the recession of the condyles from each other. • See a Treatise on Dislocation and on Fracture of the Joints, by Sir Astley Cooper, 4to, 1 &12, p. 480. 262 Fracture of the *Arm, Treatment of Fracture of the tfrm. The most effectual plan I have ever tried for retaining in ac- curate apposition the fragments of the humerus, when fractured at its head or neck, is that described by Desault. The patient being seated on a chair, an assistant takes hold or the hand of the sound side and makes counter-extension; ano- ther assistant grasps the fore-arm of the injured limb, which is previously placed in a semiflexed position, and makes extension, while the fingers of the surgeon are employed in adjusting the fragments. The surgeon next takes a roller six or eight yards long, and commencing at the palm of the hand carries it up the fore-arm and arm by circular and reversed turns as high as the shoulder, thence across the breast, around the shoulder and arm- pit of the sound side, then across the back to the injured shoul- der, where it is held by an assistant until the surgeon places three strong splints, each two inches wide, and the length of the hume- rus, on the anterior, outer and posterior parts of the arm, and then resuming the roller, which is made to descend towards the elbow, secures them firmly to the limb ; taking especial care to cover their extremities with tow or lint, to prevent inordinate pressure and excoriation. Having proceeded thus far, the surgeon takes a pad, exactly similar to that used for the fractured clavicle, and placing the large end of it in the axilla, (if the lower fragment should be drawn inwards, and vice versa,) lays it along the arm, and se- cures it to the body. Then taking another roller somewhat longer than the one previously applied to the arm, and com- mencing at the arm-pit of the sound side he carries it to the injured arm and fastens it to the body and the pad, precisely af- ter the manner of the second roller for fractured clavicle. The pad being fixed serves the purpose of a fourth splint for the arm, while it affords support to the fractured portion, upon which a common splint can have very little purchase. It only remains to suspend the fore-arm, which is fixed upon the breast in a sling, and to secure the different turns of the rollers by pins or stitches. Fracture of the Arm. 263 Fractures of the middle of the humerus are readily managed by a single roller, and by four splints of unequal length. The roller must commence at the hand, (a rule to be observed in all' fractures of the arm and fore-arm,) and extend as high as the shoulder, where it is held by an assistant while the surgeon sur- rounds the arm with the splints, which are secured to the limb by the remainder of the roller carried towards the elbow and fore-arm. The hand and fore-arm arc placed across the chest, and sustained by a sling. The condyles, when fractured, are best secured by a roller and two angular splints,—a practice first suggested by the late Dr. Physick to obviate deformity * which is extremely apt to follow all fractures about the elbow joint. The fracture being reduced and the fore-arm bent, a roller is applied in the usual way, and extends as high as the shoulder; the surgeon then takes the splints, (about two inches broad, long enough to extend from the shoulder to the elbow, and from the elbow two or three inches beyond the fingers, in shape somewhat resembling a workman's square,) and applies one on the outside, the other on the inside of the limb, and secures them by the remaining part of the roller. To prevent anchylosis, the dressings should be taken off frequently, and renewed after repeated but gentle flexion and extension of the joint. After two or three weeks the rectan- gular splints may be laid aside, and others substituted more ob- tuse in the angle. • "The deformity alluded to consists in an angular projection of the elbow out- wards. It is most evident when the whole arm is placed at right angles to the body with the thumb upwards, the patient standing erect. In that case, instead of a gentle curve downwards at the elbow, which is natural, the curve is directly reversed." Dorsey's Surgery, edit. 3d, vol. i. p. 168. 264 Fracture of the Fore-arm. Section IX. Fracture of the Fore-arm. The radius and ulna may both be fractured at the same mo- ment, opposite each other, or upon a different level. Usually the fracture occurs about the middle of the bones, and is either trans- verse or oblique, while the derangement is angular, or in the di- rection of the diameter of the bones. The radius is oftener fractured than the ulna, because it is connected with the bones of the carpus, and therefore liable to receive directly any shock communicated to the hand. The fracture occurs near the wrist, at the middle, but rarely at the upper extremity of the bone. Receiving partial support from the ulna, which serves as a splint, the deformity is less than in fracture of both bones. By placing a finger upon the upper ex- tremity of the radius, while the lower part is made to turn on its axis, by moving the hand, the superior fragment, if fractured, will remain stationary; but, on the contrary, if entire, it will move with the rest of the bone, and afford very conclusive evi- dence of the nature of the case. Fracture of the ulna, commonly occurs towards the lower or smaller extremity of the bone, sometimes about the middle, but seldom at the upper extremity. The accident is easily known by the crepitation, deformity and mobility of the lower fragment, when the separation takes place below the elbow. The olecranon, which constitutes the summit of the ulna, may be fractured by direct violence or by inordinate action of the triceps muscle. The former is the most frequent cause, and is generally produced by a fall, in which the patient catches upon the elbow in the act of saving the body. As soon as the Fracture of the Fore-Arm. 265 fracture occurs, the process is drawn upwards by the triceps, and separated a greater or less distance from the shaft of the bone. The space thus produced is increased upon bending the fore-arm, and diminished by extending'it—signs so perfectly decisive of the character of the fracture as generally to render other evidence unnecessary. Sometimes, however, (he (umefaction around the joint is so considerable as to prevent satisfactory examination, at least for several days. The coronoid process is sometimes fractured. One instance of the kind occurred to the late Dr. Physick, and two others are mentioned by Sir Astley Cooper. Treatment of Fracture of the Fore-Jlrm. With the exception of the olecranon, fractures of the bones of the fore-arm should be treated upon the same principle. Whether one or both bones be broken, the limb is placed in the bent position and counter-extension made by an assistant, who grasps the arm above the condyles; another assistant keeps up extension by pulling at the hand, and the fingers of the surgeon are employed in compressing the muscles situated between the bones, in order to force the fragments outwards or in a lateral direction, and (hereby prevent them from encroaching upon the interosseous space. Having restored by these means the natural form of the limb, the surgeon applies two graduated compresses, (about three inches wide, the length of the hand and fore-arm, and half an inch thick at the base,) one on the anterior, the other on the posterior part of the form-arm and hand—the base of each being placed downwards. Over these are placed two splints, equal in length and breadth to the compresses, one in front, the other on the back of the limb, to which they are fastened by a roller. The compresses serve the double purpo<^ Vol. I. 31 266 Fracture of the Fore-Arm. of rendering the limb throughout of uniform thickness, and of creating pressure upon the muscles between the interosseous space. Two splints are quite sufficient to keep the bones firm; indeed, additional ones, by making lateral pressure, would prove in- jurious, and counteract the design of the compresses. The splints in every instance should extend to the extremities of the fingers and afford complete support to the hand, otherwise deformity will ensue, from the radius crossing the ulna and following the movements of the hand. This mode of treatment, without va- riation, will answer extremely well either for the radius or ulna individually, or for fracture of both bones. Fracture of the olecranon requires a very different manage- ment, and is not so easily secured. Instead of flexing the fore- arm, which would tend to separate widely the fragments, it is placed in the extended position, and there retained, while a rol- ler, several yards long and three inches wide, is applied by cir- cular and reversed turns as high as the elbow, when it is given to an assistant until the surgeon draws down with his fingers the fragment of olecranon attached to the triceps, and brings it in contact with the lower fragment; the roller being then resumed, is passed obliquely by several successive turns around the joint and above the insertion of the triceps, in form of the figure 8; thence it is continued by circular turns up the arm, and made to compress the muscles firmly. The bend of the arm is next filled with lint or tow, and over this is placed a firm splint, long enough to extend from the middle of the arm to the same dis- tance on the fore-arm. The splint is completely covered by the roller, and serves to preserve the extended position and to en- sure the contact of the fragments. When properly managed, the fractured olecranon unites in a much shorter time and with less deformity than is commonly imagined. Under any circumstances, however, it is difficult, owing to the incessant action of the triceps and the little pur- chase offered by the olecranon to act upon, to preserve the frag- ments so closely together as to bring about ossific reunion; in- stead of which a ligamentous substance, abundant in proportion to the space between the fragments, is secreted, and forms the connecting medium. Owing to this, the arm long remains weak, and sometimes never recovers its former strength. Fracture of the Fore-Arm. 267 When the coronoid process is fractured, there will be a con- stant tendency to displacement of the ulna backwards, so that the accident resembles luxation of the bones of the fore-arm pos- teriorly. By pulling the fore-arm, however, and at the same time bending it, the deformity is removed, but quickly returns unless prevented. The best mode of treating the injury is to preserve the limb in the flexed position for several weeks. 268 Fracture of Ihe Hand and Fingers. Section X. Fracture of the Hand and Fingers. The bones composing the carpus or wrist are so compact and firmly united to each other, as to resist effectually any common force applied to them; they are sometimes broken, however, by great and direct violence, in which case the soft parts suffer in proportion. The metacarpus is sometimes fractured by a force immedi- ately applied, but seldom in any other way. In several in- stances I have known these bones very much shattered by the bursting of a gun, while the patients were grasping the barrel with their left hand. In one case a very fine youth* lost his life from carelessly crossing his hands over the muzzle of his piece, and resting one foot on the lock; by which the cock was pushed back, the gun discharged, and the contents driven through both hands, tearing up the metacarpal bones in a shock- ing manner, and producing tetanus in a few days. The fingers are sometimes broken by machinery, mashed by heavy weights, or caught within the fold of a door. In such cases they may be fractured in several places, dreadfully bruised, or nearly divided. When simply broken, without much inju- ry of the soft parts, the accident is comparatively trivial, and easily distinguished by the deformity, crepitation, &c. • Son of G. W., Esq., of Baltimore. Fracture of the Hand and Fingers. 269 Treatment of Fracture of the Hand and Fingers. When the carpal and metacarpal bones have sustained serious injury, we have more cause to dread the effects of inflammation, than any mischief that may result from the fracture merely.' Frequently the necessity of amputation is clearly indicated; at other times an attempt to save the hand or a part of it must be made. The fingers, when simply broken, should be surrounded with a narrow roller, and sustained by four splints made of binders' boards, two of which should extend as high as the wrist, and the others the length of the finger merely. Fingers that have been very much lacerated, nearlv separated, or hanging by shreds, should always be replaced, and reunion attempted ; for it has happened, as in the cases formerly referred • to and detailed by Balfour, that adhesion has been accomplished even after the total separation of one or more phalanges. 270 Fracture of the Pelvis. Section XL Fracture of the Pelvis. The bones of the pelvis are rarely fractured, owing #to their great strength and the unyielding texture of the ligaments by which they are tied together. Such injuries, when they do occur, are always the result of great violence, and on this account usu- ally have an unfavourable termination. Of the individual bones, the innominatum is perhaps most liable to fracture, and commonly from force directly applied, as when a patient is squeezed against a wall or post by the wheel of a cart, or by the passage of the wheel of a wagon, heavily laden, over the hips while lying on the ground. In such cases both bones are generally crushed inwards. The sacrum may be fractured, or severely contused, by falls from a height upon the buttocks, from which more or less con- cussion results, or injury to the sacral nerves. But the most formidable accident is fracture of the innominatum combined with that of the acetabulum, especially when the bones separate so far as to allow the head of the femur to enter the pelvis; in which case the thigh is shortened, and the injury may be mis- taken for luxation. It can be distinguished from it, however, by the crepitation produced by moving the fragments in op- posite directions, and by the eversion of the foot. The os coccygis is sometimes fractured in old subjects, but sel- dom in young ones, owing, in the latter, to the great mobility of the bone. In all cases where the shocks communicated to the pelvis are violent, whether the bones be fractured or not, symptoms re- sembling those from injuries of the vertebrae are apt to arise— such as paralysis of the extremities, incontinence or suppres. sion of the urine, &c. Fracture of ihe Pelvis. 271 Treatment of Fracture of the Pelvis. No benefit will result in these cases from splints and ban- dages, and the treatment should be chiefly directed towards the removal of inflammation, which is best accomplished by copious depletion, low diet and perfect rest. In addition, the catheter, if required, must be used two or three times a day, and care taken, by the application of adhesive plasters to the parts that sustain the greatest pressure, to prevent ulceration and slough- ing. 272 Fracture of the PateUa. Section XII. Fracture of the Patella. Muscular action is the most common cause of fracture of the patella; hence the accident usually occurs amongst dancing mas- ters, circus riders, and persons much accustomed to the exercise of leaping. The bone may be broken, also, by force directly ap- plied to it, especially if the knee be bent at the time the injury is received; in which case the centre of the patella, being un- supported by the heads of the femur and tibia, is the more apt to give way. From whatever cause the accident proceed, the direction may be transverse, oblique, or longitudinal. The transverse fracture, however, is infinitely more com- mon than the rest, and is easily known by the upper half of the patella being mounted upon the anterior part of the thigh four or five inches above its natural position, being drawn thither by the combined action of the rectus, cruraeus, and vasti muscles. Besides this sign, which is very unequivocal, a manifest hollow can always be felt and seen at the knee, into which the finders may be pressed as far as the integuments will allow; the patient, moreover, falls to the ground, is unable to rise without assistance, cannot walk, and is generally sensible at the moment of the frac- ture of an audible noise or smart report. When the fracture is longitudinal, none of these symptoms exist, because the fragments still retain their position, or at least can only be made to separate from each other laterally, or in the direction of the breadth of the knee. Compound and complicated fractures of the patella fortunately are not very frequent; they are always attended with immense risk, and may terminate fatally, or in incurable lameness,. Fracture of the Patella. 273 The patella, when once fractured, ever after remains compa- ratively weak, and is very prone to a recurrence of the injury. This arises from the difficulty, perhaps impossibility, of maintain- ing the fragments of a transverse fracture in exact apposition: bony matter is therefore not secreted in sufficient quantity to fill up the vacuity, and its place is supplied by a ligamentous sub- stance, which, for a long time after the accident, continues soft, and is easily torn. It is true, that bony matter has been found on dissection; but instances of the kind arc so extremely rare as not to affect the general position—that the bond of reunion, ex- cept in longitudinal fractures, is ligamentous. This has, morC' over, been confirmed by the experiments of Sir Astley Cooper, and others, on inferior animals. A fracture of the patella in one limb is very apt to be followed by a similar injury in the other—owing, perhaps, to the sound limb, sustaining for a long time after the first accident, more than its proportion of the weight of the body and performing a great- er variety of offices. Treatment of Fracture of the Patella. Various means have been employed to overcome the ac(ion of Ihe extensor muscles and retain the fragments together; but the plan devised by Desault I have always found the most simple and effectual, A splint two inches wide, long enough to extend from the tu- berosity of (he ischium to a short distance beyond the heel— two rollers, each six yards long and three inches wide—another roller or compress, somewhat longer than the thigh and leg, are the materials of which the apparatus consists. The thigh being bent on the pelvis, and the leg extended on the thi&>h, is sup- ported by an assistant at a considerable elevation, whilst another assistant stands at the pelvis and keeps it fixed. The surgeon then takes the short roller or compress, and extending it on (he Vol. I. 35 274 Fracture of the Patella. anterior part of the whole limb, gives an end to each of the as- sistants who keep it tense. One of the long rollers is next passed around the instep by two or three circular turns, so as to enclose and secure the end of the compress, and is then passed by reversed and circular turns as high as the knee, when it is given in charge to the assistant who stands at the pelvis. The surgeon now makes two longitudinal slits with a penknife or scissors in the compress, corresponding with the situation of the knee pan; through each of these a finger is introduced, and the patella drawn down and placed in contact with its lower por- tion ; the roller is then resumed and carried around the joint, above and below both fragments several times, in form of the figure 8. These oblique turns being crossed by circular ones, the roller is continued up the thigh, and terminates by fixing securely the upper extremity of the compress. The use of (he compress, it will now be seen, is to prevent on the one hand the casts of the roller on the leg from slipping downwards, and on the other those applied to the thigh from ascending by the action of the extensor muscles. The limb being still sustained in its elevated position by the assistant standing at the foot, the surgeon next takes the splint, and placing one end under the ischium lays it beneath (he thigh, leg and heel, then filling up the inequalities of the limb with lint or tow, and padding the parts well, with either of these materials, upon which the greatest pressure is made by the splint, the remaining long roller is passed, commencing at the ankle, around the splint and limb, connecting the one firmly to the other .throughout their whole extent. It only remains to retain the limb in its elevated situation. This is easily accom- plished by forming an inclined plane, composed of pillows, the highest part of which is placed at the heel. Whenever the bandage becomes relaxed, which it generally does in six or eight days, it must be reapplied. The inclined plane should be examined daily, and never suffered to sink be- yond the level at which it was first placed. In sixtv or seven- ty days the.fragments are usually consolidated; but the patient should be very careful not to try, for a long time, the strength of the limb, or to exert more force upon it than the interme- diate ligamentous substance may be able to bear. Fracture of the Thigh. 275 Section XIII. Fracture of the Thigh. The os femoris being very long, somewhat curved, and surrounded by powerful muscles, is frequently fractured. The fracture may take place at the head, neck, shaft and condyles of the bone, either in a transverse or oblique di- rection. Compound and complicated fractures of the femur may also occur, though such accidents are comparatively rare. Fracture of the neck of the femur may happen within the capsular ligament or exterior to it. The former is most com- mon, and met with almost exclusively in very old subjects; the latter may occur at any period of life. Women, moreover, are more liable to fractures of the neck of the bone than men, fromjivhat cause is not exactly known. It seldom happens that the neck of the os femoris is broken by a direct force. A counter-stroke or a twist of the limb, are the most frequent causes of it. Thus, a fall upon the trochanter or upon the feet, by which an impulse is communicated to the bone, will often fracture it obliquely or transversely. The latter direction is most common. A very slight twist of the pelvis or thigh in an old subject will sometimes be sufficient to break the neck within the capsule. I have known it happen from the patient's attempting suddenly to turn round, while the foot remained fixed by some slight irregularity on the floor. The signs of this fracture are in general very evident. In- stead of retaining its natural length, (he limb is drawn up- wards, the shaft of the bone lodged on the ilium, the foot turned outwards, and the trochanter major inclined backwards. In addi- tion, the limb can be restored without difficulty to its natural 276 fracture of the Thigh. length, but reascends as soon as the extension is discontinued; again—upon rotating the thigh on its axis, whilst a hand is laid upon the trochanter, this projection will be found to turn, as it were* upon a pivot, whereas in the entire state of the bone, it describes the arch of a circle, the radius of which is formed by the neck of the femur. Oiher signs have been enumerated ; but these, taken collectively, will generally prove sufficient to in- dicate the nature of the injury. The prognosis, as respects reunion of the fragments after frac- ture of the neck of the femur within the capsular ligament, is as unfavourable as can well be imagined. Scarcely, indeed, is it possible to find on record a well attested example of perfect bony reunion after such an accident. It is true lhat many al- leged specimens of the kind have been brought forward, espe- cially of late years, but few if any have been able to stand the test of rigid scrutiny, and upon examination have turned out to be fractures of the neck of the bone on the outer side of the capsular ligament. Although reunion is never accomplished, however, in some subjects, especially very old and infirm ones, and the fragments remain for ever insulated, it must not be in- ferred that this invariably happens; for even under the greatest disadvantages, nature always makes an effort towards repara- tion, and often succeeds so far as to effect a ligamentous reunion similar in some respects to that which occurs in fracture of the patella and olecranon. Still the joint remains weak, imperfect and deformed, and never able afterwards to sustain the full weight of the body or to encounter shocks which originally it was accustomed to bear with impunity. This imperfect reproduc- tion may be owing to two or three different causes—to the por- tion of bone connected with the acetabulum being deprived of its vascularity or nutriment by the rupture of the periosteum and reflected membrane of the cervix femoris, upon which it chiefly depends for its supply of blood; the quantity which it receives through the medium of the round ligament, and upon which it must now mainly depend, not being sufficient for its support—to a wide separation of the fragments, from muscular action or want of appropriate means to keep them in apposition —and to a copious secretion or accumulation of a serous fluid within the capsule of the joint, which by its interposition and Fracture of the Thigh. 277 circumfusion effectually cuts off all interchange or connexion between the separated fragments. As already remarked, fracture of the neck of the femur may take place exteriorly to the capsular ligament; in this case the diagnostic marks do not differ materially from those pointed out as belonging to fracture of the same bone within the capsule; the result, however, both as respects the deformity and utility of the limb, is very different, for in fracture on the outside of the cap- sule perfect bony reunion, from a full vascular supply, is soon established, and the limb becomes as strong as ever. Fracture of the trochanter major alone, sometimes occurs. In this case, the shaft of the femur, remaining entire, no shorten- ing takes place. The accident may be known by the mobility of the trochanter, and by its being drawn upwards or towards the ilium. The middle of the os femoris, in young subjects, is perhaps more liable to fracture than any other portion of the bone. This arises from its exposed situation, and from its being more under the influence of muscular action. There will be an essential difference in the nature of the accident, especially as regards the result of the treatment, according to the direction of the fracture. If there be a transverse fracture, the ends being fairly supported against each other, little or no deformity will ensue. If the frac- ture be oblique, the ends overlap, and the inferior fragment is generally drawn for several inches upon the posterior surface of the upper fragment, and hence a shortening of the limb, fol- lowed by all those difficulties which have been complained of from time immemorial. The higher, however, the fracture is situated upon the shaft of the bone, the greater will be the over- lapping, because a greater number of muscular fibres will be employed in producing the retraction. The signs indicative of fracture of the middle of the bone, correspond, in most respects, with those of fracture of its neck. Like the condyles of the os humeri, those of the femur may both be broken, or only one. In the former case, crepitation, together with shortening of the limb and a facility of increasing the breadth of the knee by pressing upon the patella, will be sufficient to distinguish the accident from any other affection. Compound fracture of the femur just above the condyles, espe- cially when the fracture is oblique and the superior fragment 278 Fracture of the Thigh. penetrates the rectus muscle, should always be considered a very grievous accident, and liable to terminate in death or am- putation. Treatment of Fracture of the Thigh. Had the surgeon no other difficulties to encounter than such as present themselves after simple transverse fracture of the shaft of the thigh bone, he would have little reason to complain of the defectiveness of art, or of the power of nature in promoting a cure. So different, however, from this is the result of an oblique fracture of the body of the bone, or of a transverse frac- ture of its neck, that it is hardly possible in any case to calculate with certainty upon reunion without more or less shortening and deformity of the limb. The remark will apply most forci- bly to fracture of the cervix femoris within the capsule, and the surgeon should be careful in such cases how he ventures to pro- mise a favourable result, especially in very old subjects. Indeed, as respects these cases, I have strong doubts of the propriety of attempting more for the relief of the patient, than merely keeping him as quiet and as easy as possible, by supporting the hips with pillows and retaining the limb as much in the extended position as can be borne. If extension and counter extension, however, should be deemed admissible, then recourse must be had, I con- ceive, not to the means commonly employed, but to others I shall presently point out. Without recounting the various contrivances that have been used at different periods for effecting extension and counter ex- tension, most of which are detailed at length in the different works written expressly on fractures, I shall merely speak of the means which have commonly been employed in this country within the last twenty or thirty years, and of such recent Eu- ropean and American inventions as may appear deserving of notice. Fracture of the Thigh. 279 The celebrated Desault, it is well known, employed an appa- ratus consisting of a strong splint, long enough to reach from the spine of the ilium to four inches beyond the foot; of another splint, extending from the perineum to the sole of the foot; of a third, the length of the thigh itself. To these were added ex- tending and counter extending bands, junks or long narrow bags filled with chaff* the bandage of Scultetus, a splint cloth, &c. The whole being arranged, extension was made from the foot by passing the band around the ankle, and fixing it to the low- er end of the long splint, counter extension from the perineum, securing the end of the band to the upper extremity of the splint. The late Dr. Physick, having in several instances tried the ap- paratus of Desault, found it defective, chiefly on account of the ob- liquity of the action of the counter extending band, which, owing to the splint not extending above the spine of the ilium, passed across the upper fragment of the femur and forced it outwards. Again—the extending band, by pulling the foot outwards and pressing it against the lower extremity of the splint, sometimes occasioned troublesome excoriation. To obviate these incon- veniences, Dr. Physick modified the apparatus in the following way. The long external splint, instead of terminating at the hip,'was made to ascend as high as the arm-pit, where its ex- tremity was formed like the head of a crutch, and padded to take off pressure from the axilla. Immediately below the crutch- like head of the splint, a hole or mortise was made, sufficiently large to admit the end of a handkerchief or counter-extending band. The lower end of the splint, at the suggestion of Dr. Physick, was altered by Dr. James Hutchinson, then a student at the Pennsylvania Hospital. The alteration consisted merely in attaching to the splint, a little above its lower end, a small block, which, projecting inwards at a right angle with the splint, and being notched at its extremity, served to receive the extending band, and by diverting it inwards, to prevent exco- riation of the external parts of the foot, and to keep up exten- sion precisely in the direction of the limb. Previous to the application of the apparatus thus modified, a common bedstead, between two and three feet wide, the bottom of which is covered with wooden slats instead of a sacking bot- tom, is selected; over this is placed a firm and even mattress, a 280 Fracture of the Thigh. sheet above it, and a pillow for the patient's head. Commencing about the middle of thp mattress, five or six pieces of broad tape, a yard in length, are laid upon the sheet transversely, and placed eight or ten inches from each other. Next a splint cloth, or piece of muslin, a yard and a half long and a yard wide, is placed above the tapes—its longest diameter running parallel with them. Over the middle of the splint cloth, near its upper edge, is then laid, longitudinally with respect to the mattress, a splint of binders' boards, two inches broad, nine long, and above and across the splint the bandage of Scultetus. This is made of a common roller two or three inches wide, divided into strips long enough to surround the thigh and overlap. The first strip is laid near the upper edge of the splint cloth, the second over- laps about an inch and a half, and the others are similarly ar- ranged and in regular succession, until a sufficient number are laid down to equal the length of the thigh. Two bags, filled with chaff or cut straw, extending from the hip to the foot, and four inches wide, are then prepared. Lastly, three silk or Ma- dras handkerchiefs, each about a yard long, previously washed and folded diagonally, and the three wooden splints—the long external one, the internal one reaching from the perineum to the foot, and the short one the length of the thigh—are placed within the surgeon's reach. Every arrangement being made, the patient is placed on the bed by careful assistants, and the injured thigh, (previously stripped of every species of clothing,) laid in the centre of the dressings without disturbing them in the slightest degree. One of the handkerchiefs is then passed around the ankle and instep of the injured limb, somewhat in the form of the figure 8, knot- ted under the sole of the foot, and its ends given to an assistant; another is carried along the perineum, between the genitals and thigh, and its ends, which pass above the pelvis before and be- hind, delivered to a second assistant. By these extension and counter extension are next made, while the surgeon, after having adjusted the fragments and restored the natural shape of the limb, applies the bandage of Scultetus by commencing at the strip last laid down, or that nearest the knee. The ends of this are brought over the front of the thigh and crossed; a second strip secures the first, and in like manner all are made to over- lap until the whole thigh is covered, when the last strip is fas- Fracture of the Thigh. 281 tened by a pin. The two long splints are next rolled in the splint cloth, and, thus covered, are brought alongside the limb, leaving a space merely sufficient for the interposition of the bags of chaff, which are then applied, and serve to fill up ine- qualities and to prevent the splints from irritating the thigh and leg. Now the extending and counter-extending bands are fixed by the assistants in their respective places—one being carried around the notched extremity of the projecting block situated near the end of the external splint and tied to a mortise below it, the other drawn nearly in a line with the body and secured to the mortise at the upper end of the splint. The short splint being laid over the front of the thigh, and the third handker- chief passed around the external splint and the pelvis, the tapes are all drawn around the limb and splints, and tied, and the ope- ration finished. It is well known, lhat in fractures of the os femoris, the ex- tended and semiflexed positions have each been extolled by their different advocates as the most appropriate. The former is the most ancient, and can be traced as far back as the time of Hippocrates. The latter is, comparatively, of modern date, and was introduced into practice chiefly by the celebrated Pott. But though the extended was the position usually employed by the ancients, and by many of the older surgeons, in imitation of them, yet, owing to their rude and imperfect contrivances, very little benefit resulted from the practice, and we are indebted to the distinguished Desault for the first systematic and ra- tional attempt, by extension and counter extension, to over- come difficulties, which were considered almost insurmountable. The indications pointed out by that surgeon having been already stated, let us see how far they are calculated to answer the pur- pose. The lower fragment of bone, drawn by the action of the muscles past the other, is mounted upon the thigh, the limb is shortened and the foot turned outwards; the surgeon draws down the foot and leg, coaptates the broken extremities of bone, places the limb in its natural position, fastens his extending and counter extending bands, and preserves, as he imagines, the limb of its natural length. But are his views really accomplished 1 Can he exert sufficient force to overcome the resistance of the mus- cles and prevent the retraction of (he bone, or if he actually accomplish this for a limited time, do not his bands specdilv Vol. I. 36 282 Fracture of the Thigh. yield, become elongated and twisted like a rope, and by being relaxed, permit the muscles again to act, and the bones to re- sume their unnatural position ? Again—admitting the texture of the bands to be such as not to suffer extension, are the soft parts covering the ischium and ankle (the principal points of action) incompressible ? On the contrary, is not the principal pressure, especially in fat subjects, sustained by them, and what is the inevitable result of this pressure if rigorously kept up? ulcera- tion, and perhaps sloughing. These are difficulties, which every candid man, who has had much experience in the treat- ment of a fractured thigh, will acknowledge to exist, which Desault himself, in part acknowledged, and which every one, who pays the slightest attention to the subject, will find to be strictly true. " Like all other kinds of apparatus," says he, " formed principally of rollers, this is very subject to become relaxed, and requires great attention on the part of the surgeon. It ought to be examined attentively every day, particularly the two extending bandages. As soon as they become relaxed, they must be immediately tightened again: without this precaution, the effect of the apparatus will be lost. Be vigilant also with respect to the compress placed between the roller and the tube- rosity of the ischium. Should this slip, the roller being fre- quently tightened, and pressing immediately on the skin, may produce excoriations and ulcers difficult to be healed, espe- cially in females. The roller itself may slip, and then leaving no longer a solid point of support and action on the tuberosity of the ischium, it makes extension in but an imperfect manner." But are these the only objections ? Has it not been proved by experience that the perineal band, from its transverse action on the thigh, has a tendency to throw the superior fragment of bone outwards 1 Again, does not the extending band, owing to the obliquity of its action, force the foot preternaturally out- wards? It may be answered, perhaps, that the ingenious im- provements of the late Dr. Physick and Hutchinson, upon the ori- ginal apparatus of Desault, have, in a measure, obviated these difficulties. This we are very ready to allow, but still they ex- ist, to a certain extent, and as such impair the value of the whole. So far as my own experience goes, (which amounts to upwards of twenty-seven years, during the greater part of which time I have had the chief control of the surgical cases of large Fracture of the Thigh. 283 hospitals and alms-houses, together with an extensive private practice,) I am ready to declare, that I have never met with a single instance of oblique fracture of the thigh bone, in which I have used the apparatus of Desault, that more or Jess ulceration of the perineum and foot, and shortening of the limb, were not (he consequence. On the other hand it is proper to state, that during the long and extensive practiceof thelale Dr.Physick,cases have occurred in which cures have been produced by the ap- paratus of Desault, as modified by himself and Dr. Hutchinson; and there can be no doubt, notwithstanding the objections al- ready advanced to Desault's splints, that compared with other apparatus and that too proposed as improvements on them, they are in many respects superior. This especially holds good as regards Ihe apparatus of Boyer, which does not differ from that of Desault in principle, but is very inferior to it—being very complicated and expensive, and therefore not adapted to com- mon practice. On the contrary, the greatest advantage pos- sessed by the original contrivance, is its simplicity—the materials of which it is composed being always at hand, or prepared in a very short time. The padded straps of Boyer, although certain- ly better than the bands of Desault, are yet liable, as I have found, to produce more or less of the same inconvenience— ulceration. Upon the whole, it may be stated, that the plan of Desault, as modified by Dr. Physick, is better calculated to fulfil the indications for which it was designed, than any other acting upon the same principle; but that if the same end, namely, ex- tension and counter extension, can be effected, upon a different principle, without injuring the perineum, as shall afterwards be shown, advantages must be gained, which the other can never possess. The semiflexed position, so strenuously commended by Mr. Pott, and followed by the British surgeons, almost without ex- ception, is one against which, as a general practice, many ob- jections may be urged. It must be evident even to the most careless observer, that if the thigh be bent on the pelvis, its out- side resting on the great trochanter, the body of the patient in- clining to the same side, the leg bent upon the thigh, and the whole limb in a state of semiflexion, (the plan advised by Mr. Pott,) that not the slightest power can be exerted upon the limb, either in confining it to one position, or in effecting extension 284 Fracture of the Thigh. and counter extension—the only process by which the broken extremities of bone can be prevented from riding upon each other. U splints are placed on the thigh, while in this position, it is obvious that they can extend only throughout its length, and consequently must either prove altogether inoperative, or, at best, only serve to give lateral support to the limb, with- out effecting, in the slightest degree, its longitudinal extension. The position itself, moreover, independently of other conside- rations, is by no means so easy and comfortable for the patient, as has been alleged, or as might be imagined from the relaxed state of some of the muscles. Indeed experience has suffi- ciently proved, that although immediately after the accident the patient suffers less while the limb is kept in the semiflexed posi- tion than he does when it is placed in the extended one, yet in the course of a few hours, this very position becomes so irksome as hardly to be sustained, and creates an incessant desire to have it changed. On the contrary the extended position, even from the first, is attended with no great inconvenience, and finally is found so free from pain, that there is reason to believe the patient would not voluntarily change it, if permitted so to do. Every one knows indeed, that it is much easier to lie for a considerable length of time on the back than on the side, even while in health; it may easily be conceived then, how tedious and fatiguing must be the patient's situation, when not only his broken limb is confined to an uncomfortable posture, but his body also. Much has been said by the advocates for the semi- flexed position, of the entire relaxation of the muscles of the limb, while in that position. But is this really the case? Certainly not; for however much we may relax the triceps, semitendinosus, semimembranosus, sartorius, gracilis and others, yet there will remain a sufficient quantity of muscular power to draw up the inferior fragment, and counteract all the benefit we might ex- pect from position alone. While it must be acknowledged then, that in the bent position the greatest number of muscles are re- laxed, yet it does not follow that this must be the easiest for the patient, or the most effectual in preventing deformity and effect- ing a cure. Besides these inconveniences, however, attending the bent position, there are others not less objectionable. Much of the superincumbent weight of the body, and the greater part of the weight of the thigh, are sustained by the trochanter. Fracture of the Thigh. 285 This is necessarily productive of great pain, and sometimes of very troublesome ulceration, and on this account renders the semiflex attitude particularly inconvenient, in cases of fracture of the neck of the thigh bone, and more or less irksome and disa- greeable even in the more simple cases. Again—the surgeon finds it impossible, when the thigh is thus situated, to compare its length with that of the opposite thigh, and consequently must be at a loss to know the extent of the shortening and deformi- ty. More or less movement, also, of the fractured portions, must necessarily follow every attempt on the part of the patient to have a stool, and in many cases this cannot be accomplished ex- cept by an entire change of the body- and limb. Should it so happen, lhat both thighs are broken at the same time, an acci- dent which sometimes happens, it must be apparent that Pott's method, allowing it to be free from every other objection, cannot possibly be employed. Lastly, it may be urged, as an objection to the semiflexed position, that after consolidation of the frag- ments has taken place, shortening of the limb from the overlap- ping of the bones is not the only deformity produced; the thigh is seldom straight, and the leg, from being so long bent on the knee, does not recover for a great while, if ever, its natural po- sition, but is suspended in such a way as to prevent the foot from reaching the ground, so long as the stiffness or false anchy- losis exists. The same position is preserved for a greater or less time by the thigh, from the circumstance of its being flexed on the pelvis, and in cases of fracture of the neck of the bone, this position is extremely apt to be permanent, so that the thigh pro- jects preternaturally forward, while the leg being carried back- wards, and suspended from the knee, the whole limb is greatly deformed, and permanent lameness ensues. The slightest re- flection will convince any one, that if under the circumstances mentioned, the limb be placed in the extended position, even although anchylosis should follow both at the hip and knee, and the fragments of bone overlap, yet the patient will derive much more benefit from a limb thus stiffened and shortened, yet straight, than he could, if it were permanently retained in the flexed position. Sensible of the difficulties to be encountered, and of the disad- vantages attending the treatment of fractured thighs by the pe- culiar method of Pott, several English surgeons have endea- 28G Fracture of the Tliigh. voured to retain the semiflexed position, which in some re- spects they consider the most appropriate, and at the same time to keep up extension and counter extension. To accomplish this, Mr. White, of Manchester, was the first, I believe, to pro- pose a triangular frame, so constructed as to form an inclined plane, over which the thigh, flexed on the pelvis, and the leg on the thigh, were placed and suspended, as it were, above the level of the patient's body. Upon this machine an improve- ment was afterwards made by Mr. James of Hoddeson, which consisted chiefly in rendering the angles of union of the inclined boards flexible by hinges, and moveable by a rack, so as to adapt the apparatus to any sized patient, and to change at pleasure the degree of semiflexion. This apparatus has been employed by Sir Astley Cooper, in London, for the last twenty years, and is still considered by him more appropriate than any other.* Sir Charles Bell,f also, apparently without the knowledge that any such contrivance had been before employed, has described and figured a machine differing somewhat in shape, but not in prin- ciple from the one last mentioned. It will be easy to perceive the manner in which any apparatus thus constructed acts. The patient laid on his back, has the limb placed over the inclined boards at an angle corresponding with an easy and relaxed flex- ion. Cushions are placed beneath to obviate undue pressure, and splints secured to the limb to afford lateral pressure. The weight of the body hanging by and operating upon the supe- rior fragment, naturally draws this from the inferior frag- ment, and thereby effects counter extension, while the inferior fragment, supported and fixed by the angle of union of the in- clined boards which operate upon the ham of the patient, main- tains permanent extension. There can be no question that many of the objections to the semiflexed position, as practised by Pott, and followed by the majority of English practitioners, are obviated by this simple and ingenious contrivance, and were I disposed to select that position as more favourable than the extended one, I should certainly to this form of apparatus give a decided preference; but there are objections, I apprehend, even to this, ingenious as it is, which will prevent it from ever coming into general use. Let any one, for the sake of experiment, place • See Cooper and Travers' Surgical Essays. f Operative Surgery, vol. ii. Fracture of the Thigh. 287 beneath his own sound thigh and leg the machine of James or Bell, so as to have the leg secured on one side, the thigh on the other, and the body suspended and supported by the thigh. He will then find, be (he cushions ever so soft, that the position is by no means so comfortable a one as he might have been led to imagine; that the calf of the leg must be firmly and painfully pressed against the flat surface of the inclined boards, that the ham sustains not only the whole weight of the thigh, but that por- tion of the body elevated above the plane on which it would na- turally rest, and under circumstances, too, most disadvantageous; being fixed upon a sharp angle, formed by the union of the two inclined boards, and leaving a surface too inconsiderable to form any other than the most painful support. If he finds this atti- tude painful, and with difficulty borne, for any length of time, by a sound limb, how injurious will he conclude must be the effect produced upon an inflamed and broken thigh, when simi- larly circumstanced ? That extension and counter extension can be produced by this apparatus, and yet the semiflexed position be preserved, there cannot be the slightest doubt. But it is ex- tremely doubtful whether the patient can sustain the torture ne- cessary to carry the operation into full effect. Cannot a mode- rate degree of extension and counter extension, it may be asked, be kept up ? To this it may be answered, take off from the ham the degree of pressure necessary to relieve the patient, the body sinks and is supported by the bed, counter extension is therefore removed, extension is destroyed, and how then does your me- thod differ from that of Pott, except in the patient being placed on his back, and a partial support being given to his limb'! But granting these objections to be unfounded, would the weight of the body be always sufficient to effect counter extension, and prevent the bones from overlapping ? On the other hand, would it not sometimes happen, in large and heavy men, that from too much force being exerted upon the superior fragment, by the weight of the body, inordinate irritation would ensue ? Again— how are we to prevent the rotation of the pelvis, when one limb is suspended on a frame and the other extended and left at liberty ? But, in answer to all this, it may perhaps be said, that the twenty years' experience of Mr. Cooper, and the authority of Mr. Bell, are sufficient to justify the practice. To this it may be necessary to reply, that, with unbounded respect for the 288 Fracture of the lliigh. professional talents of these gentlemen, it is well known that the English surgeons, from time immemorial, have been grossly deficient in the application of bandages, and the management of fractures and dislocations. This does not rest upon bare asser- tion; many of their best writers acknowledge and lament the fact. Let any student now walk the rounds of the Edinburgh Infirmary, or the London Hospitals, and he will there see broken legs crooked and deformed, and without splints, and broken thighs without support, withered and shortened, and almost use- less to the patient. The fault then does not rest with the indi- viduals of the profession, but with their country. "All these changes," says Roux,* "introduced into the art of treating frac- tures, which appear to us so many useful innovations, have not been considered as such by the English surgeons; and for having rejected them, or for not having adopted them, they have re- mained behind us in this important part of surgical treatment." —"The English surgeons very seldom renew the application in the treatment of fractures, and they sometimes scarcely examine the limb at all, during all the time necessary for the formation of the callus. But it must result from this negligence, that the limb is not well kept in its position: the broken parts must, in some measure, be moveable, one on the other, and for that very reason be disposed to yield to all the causes which may displace them. I believe, in consequence of these circumstances, that the English surgeons can very rarely obtain the cure of fractures of the lower limbs, with the least possible deformity."—" Too much attention can scarcely be paid," says Dr. Hennen, (one of the most enlightened surgeons from the days of Hunter to the pre- sent time,) "to the application of the roller; yet candour com- pels me to say, that foreigners of almost all countries excel us in this fundamental part of our art. Our young surgeons may study, philosophize, and reason well; but neither books, reflec- tion, nor arguments, will teach the application of a bandage, without repeated practice."t It will naturally be inquired then, what means 1 propose to substitute for those I have unequivocally condemned, and upon what principles I imagine fractures of the thigh should be treated? To this I reply, that the indications pointed out by • Narrative of a Journey to London, f Principles of Military Surgery. Fracture of the Thigh. 289 Desault and acknowledged by most of the French surgeons, I con- sider the most appropriate, and only condemn the particular mode of carrying them into effect: that to accomplish this, other means may be devised, free from many of the inconveniences al- ready complained of, and equally effectual in keeping up exten- sion and counter extension. These measures may be fulfilled in the following way. Instead of exerting force sufficient to counteract the contractions of the muscles and lengthen the limb by the use of counter extending bands, placed upon the perineum of the injured thigh, the sound limb should be extended, and made to serve as a splint to the broken limb—the foot of the latter being drawn down and se- cured on a level with the former. But these, it will immedi- ately be said, are the principles of Brunninghausen; principles long ago found ineffectual, and justly abandoned. Before this be answered, let us inquire into the particular method employed by that surgeon, and then judge whether the defects proceed from the principle or from the apparatus itself. Brunning- hausen, it is true, laid the patient on his back, kept both limbs in the extended position, and fastened the broken one to the sound by a sort of stirrup, so as to keep both feet on a line, and thus apparently to preserve the natural length of the limbs. But in such cases what is to prevent the patient's body and pel- vis from inclining to (he side of the broken thigh; and if this in- clination take place, will not the superior fragment of the os fe- moris descend and overlap the inferior fragment? Experience has sufficiently demonstrated that such an effect is really pro- duced, and that therefore, although the sound limb is kept fully extended, and the two feet and knees precisely on a level, yet the broken thigh may be shortened to the extent of two or three inches. On this account, no doubt, the method of Brunning- hausen was laid aside, and no attempt that I know of, made to revive his principle until a short time past. This was brought forward by Hagedorn, an eminent continental surgeon, the original account of whose apparatus I have not seen, and shall therefore furnish a description of it from the second volume of the " First Lines of the Practice of Surgery," by Mr. Sa- muel Cooper; a work published in England in 1820. "Perhaps the most simple and effectual apparatus," says Vol. I. 37 29° Fracture of the Thigh. Cooper, " ever invented for fractures of the neck of the thigh bone, is that suggested by Hagedorn. His opinion is, that every apparatus for these cases should be calculated to fulfil the following indications. 1st. It should keep the leg duly ex- tended, and at the same time prevent the foot from being turned outwards. 2d. As all pressure on the muscles of the thigh has a tendency to make them contract, the extension is more effec- tual when applied not to the thigh, but to the lower part of the the limb. 3d. The apparatus must be made as little irksome to the patient as possible. 4th. The patient should not have it in his power to interfere with the extension and reduction. 5th. The apparatus should admit of the employment of fomentations or other applications." " I believe a reference to plate the eighteenth, will convey an adequate idea of Hagedorn's original and ingenious apparatus for the treatment of a fracture of the neck of the thigh bone. The invention appears to me both more simple and more likely to answer every purpose, with less risk of failure, and less inconve- nience to the patient, than either the contrivance of Boyer, or that of Desault." This apparatus, then, as described and figured by Cooper, consists, 1st, of a splint, which for an adult, must be between three and four feet long, five inches broad at its upper end, and about two broad at its lower end. On its inside it is excavated from its highest part down to a littleTelow the calf, where the concavity ceases, in order to afford strength to the inferior end; 2dly, of a foot-board of considerable thickness, pierced with nu- merous slits, and large enough for both feet to rest against; 3dly, of a long pad, intended to be placed between the splint and the outside of the limb; 4thly, of leather contrivances, somewhat like gaiters, designed to connect the feet securely with the foot-board. Each of these leather bandages has four straps, two of which are conveyed on each side of the foot through two of the holes in the foot-board, and fastened under- neath it. The leather of which these pieces of the apparatus are made, should be rather stiff; and well quilted within, or lined with very soft materials. In front each of these foot and ankle pieces admits of being laced, so as accurately to fit the part; 5thly, of a broad linen band, to be applied to the foot in order to keep it inclined inwards. Between this band and the Fracture of the Thigh. 291 instep, some soft materials, or a pad, should be placed. It has four tails, two of which on each side pass through the anterior rows of holes in the foot-board, and are tied underneath it; 6th- ly, of a soft linen band, the use of which is to fasten the splint to the pelvis. Lastly, it is to be understood that between the soles of the feet and the upper surface of the foot-board, soft pads are to be placed." " Hagedorn gives the following directions respecting the mode of putting on the above apparatus. Previously to the re- duction, the splint is to be fastened upon the sound limb, and the two ankle leathers applied. After the reduction, two assist- ants are to keep the limb extended, while the surgeon screws on the foot-board, and places under the sole of the sound limb the pad, or little cushion, which becomes secured in this situation, as soon as the four tails of the ankle leather have been drawn through the first and second rows of slits in the foot-board, and tied underneath it in a couple of surgeon's knots. The sound limb is now to be approximated to the broken one; both are to be put into the most natural situation and position; the other cush- ion is to be interposed betwixt the foot-board and the sole of the fractured limb; the four tails of the ankle leather on the injured member are to be drawn through the first and second rows of slits in the foot-board, and tied; the foot-board itself is now to be screwed to the splint as firmly as possible, and a little wedge, not mentioned in the previous account, pushed into the space be- tween the two screws and the foot-board. Lastly, in order to prevent the toes from being turned outwards, the band is ap- plied across the upper part of the foot, and its tails fastened un- der the foot-board." • " Nothing can be more simple and better qualified than this apparatus for maintaining the extension and holding the foot in any position which may be deemed best, and this without hurt- ing any part by the pressure employed, or causing any kind of serious annoyance to the patient." " As soon as Hagedorn's simple but efficient apparatus," con- tinues Mr. Cooper, " is at all known in England, I have no doubt that it will here be considered by every impartial judge, as the very best contrivance, not only for the treatment of fractures of the neck of the femur, but also for that of all oblique and very troublesome fractures of the same bone, especially, as in (hese 292 Fracture of the Thigh. cases, it would not preclude the application of splints to the in- jured thigh itself." It happened about the time I first read the account of Ilage- dorn's apparatus, as detailed by Cooper, I attended, (with my friend, Dr. Dewees,) a gentleman of this city, who, in walking through an entry in the dark, fell and fractured the right femur obliquely, about its middle, and also the left humerus, in a si- milar manner, just below its neck. The apparatus of Desault was applied, and continued for two or three weeks, but owing to the obesity of the patient, it was found quite impossible to keep up extension and counter extension sufficient to prevent the overlapping of the bones, and shortening of the limb: be- sides this, ulceration of the perineum and ankle, from the ex- tending and counter extending bands, notwithstanding every precaution, soon took place to such an extent, as to oblige us to remove all pressure from the parts, and consequently to render the apparatus inoperative. Under such circumstances I deter- mined to try the method of Hagedorn. I soon found, how- ever, that simple and ingenious as it was, and calculated to ef- fect extension and counter extension to a much greater degree than that of Desault, that it was still imperfect, but susceptible of such changes as would make it a most valuable acquisition. In particular, I found, owing to there being but one splint, and that extending a short distance only above the hip of the sound side, that the injured thigh of the patient was left without sup- port, and no resistance opposed to the natural efforts of the pa- tient to incline his shoulder, body and pelvis to the affected side, and consequently, although the inferior fragment retained its position, from the foqL being secured on a level with the sound foot, and could not therefore ascend, yet the superior frag- ment, carried down by the weight of the body, and by the inclined pelvis, passed the inferior fragment and shortened the limb. It then occurred to me, if 1 construct two splints, each padded or stuffed like the head of a crutch, and long enough to reach from the arm-pit to the foot, and secure these by circular bandages around the body and limbs, and by a foot-board, the necessary support must be given, the pelvis cannot incline, and the broken limb must remain of its natural length. The expe- riment was tried and with the happiest effect; notwithstanding ihe splint could not be carried, owing to the broken arm, as Fracture of the Tfiigh. 293 high as could have been wished. Convinced of the utility, then, of the principles, originally suggested by Brunninghausen, and of the efficacy of the particular apparatus I have contrived, as an improvement on that of Hagedorn, I submit a detailed account of its construction and mode of application. Two splints, half an inch thick, formed at the upper extre- mities like the head of a crutch, five inches wide, immediately below this head, five feet and a half in length and tapering to- wards the lower end, which is about two inches wide, consti- tute a sort of enclosure for the body and limbs, from the arm- pits beyond the feet. The lower end of each splint, to the ex- tent of a foot, is straight, and has six or eight holes, at equal distances, large enough to receive a stout peg, intended to se- cure the foot-board. Shoulders, also, are made in the splint, just above the upper peg hole, for the purpose of preventing the foot-board from ascending. The foot-board itself is made of seasoned tough wood, is an inch thick, about twelve inches long and nine high. At different distances in it, there are three rows of slits, half an inch wide and an inch and a half long, in- tended for the gaiter straps or bandages which secure the feet to the board. Two other slits or mortises, of the same kind, receive the lower ends of the splints, making in all eleven per- forations through the foot-board. The gaiters are made of soft leather, lined with buckskin, or of strong linen, well quilted on the inner surface; are laced to the leg above the ankle by a cord, and have four straps to each, two near the instep, and two near the heel, sufficiently long to pass through the foot-board and ad- mit of being tied on its back part. Antecedent to the adjustment of the limb, and the application of the splints, a bedstead should be selected with a board bot- tom, and over this be placed a thick and firm mattress. If a feather bed be employed, it will be quite impossible to prevent deformity and inconveniences, however well contrived the ap- paratus may be. This is a point, therefore, which should al- ways be insisted on by the surgeon, and if no mattress be at hand, blankets or quilts must be substituted, and laid over the bedstead or floor. The patient is now placed on the mattress, his clothes being previously stripped off, or cut away as occa- sion may require, his body kept perfectly straight, and both limbs placed in the splints. Extension and counter extension 294 Fracture of the Thigh. being made, and the ends of the bones coaptated, the splints previously covered by junks, which are placed on the inner sides, and serve to take off any unpleasant pressure, are next brought closely in contact with the body and limbs. The sur- geon then fixes the gaiters to the ankle, and fastens the foot- board to the splints. The feet, having two small cushions be- neath them to rest on, are next secured to the foot-board by passing the straps through the holes, and tying them on the out- side. It only remains to secure the splints to the body by four or five pieces of roller. As all patients, with fractured thighs, experience more or less inconvenience from the difficulty of having a passage, and as this difficulty will exist with any apparatus, however construct- ed, it becomes very desirable to obviate it as much as possible by employing such means as are the most simple, and at the same time most effectual. The ingenious contrivance of* Mr. Henry Earle, for suspending the patient, temporarily, on a strong canvass or sacking bottom, stretched upon a frame, and raised by pulleys or a jack, however well adapted to an hospital or any large establishment, cannot, from its complex and ex- pensive structure, be introduced into private practice, even in a large city, much less'in country places. Fortunately, how- ever, every possible advantage may be derived by using Mr. Earle's principle, together with the most simple but effectual part of his machine. For several years past, I have used a com- mon frame, seven feet long and three feet wide, upon which is tacked a sacking bottom, having a hole in its centre about the size of the crown of a hat. The sacking bottom is supported by girths passed beneath it and secured to the frame. As this simple apparatus can be adapted to any common bedstead, it may be kept constantly on hand by the surgeon, or manufac- tured at a few minutes' notice, if required, by the most common mechanic in any country place. When prepared it will be only necessary to lay the frame over the mattress, place the dress- ings on the sacking bottom, (previously covered by a sheet with a hole in it corresponding to the one in the sacking bot- tom) and the patient on the dressings, taking care that his but- tocks be exactly adapted to the opening. Upon this very sim- ple contrivance, the patient will lie with as much comfort, as on the mattress, itself, and whenever he desires lo have a stool, Fracture of the Thigh. 295 it will only be necessary for (wo assistants, one at each end of the bed, to raise the frame six or eight inches from the mat- tress, and support it in this situation by a small block, placed at each corner of the frame, or by a moveable leg or foot per- manently attached to the frame. As I have employed this machine upon several occasions. I can speak with confidence of its efficacy, and can recommend it as equal, if not supe- rior, to the original apparatus itself, which 1 have frequently seen in operation in the European and American hospitals. But whether this modification of Earle's bedstead be employed or not, I have ascertained to my satisfaction, that the draw sheet, or dish or pewter pan, articles in common use, in cases of fractured thigh, can with greater facility be employed when the patient's limbs and body are secured by the plan I have ventured to propose, than by any other mode. Indeed, so firm- ly are the limbs supported against each other, and so complete- ly is the body fixed, that the whole may be said to constitute but one piece, and the patient can be turned or raised, and the pan slipped beneath him, without, in the slightest degree, dis- turbing the fragments of bone. It may be well, in the next place, to anticipate such objec- tions as may possibly be brought against the principles and practice I have endeavoured to establish. It will be said, per- haps, that the extended position, above all others, is the most painful and inconvenient to the patient; that spasmodic affec- tions are very apt to occur, particularly upon every attempt of the patient to procure sleep,—that the confinement of one limb, as usually practised, is irksome enough,—that the confinement of both, and of the body also, must be, if not insupportable, painful in the extreme, that the counter extension, which is ex- erted entirely on the acetabulum and thigh of the sound side, will cause the limb to swell, or to become so much fatigued as to produce great distress,—that the gaiters confining the°feet to the board, will cause ulceration of the ankles,—that both limbs, from being kept so long in the extended position, will become stiff or anchylosed,—that the inclination of the body and pelvis to the affected side cannot be prevented, by the lodgement of the crutch-like end of the splint in the arm-pit; for the scapula is a moveable point—being connected to the body chiefly by muscles, which yield to any impulse communicated to them, 296 Fracture of the Thigh. and that, therefore, the superior fragment of bone cannot be prevented from descending and riding over the inferior frag- ment, that in cases where both thighs are fractured, the princi- ple, upon which the apparatus acts, must be destroyed, and con- sequently the practice, in such cases, totally inadmissible. Let us see how far these objections can bear examination. That the extended position is more painful for the first few hours, than the semiflexed one, may, perhaps, be admitted: but it has been proved, beyond all doubt, by Desault, Boyer, Riche- rand, Roux, and many other distinguished French and conti- nental surgeons, that the inconvenience is temporary only, that the muscles soon become accustomed to their position and cease to afford uneasiness; that on the contrary, in the semiflexed posi- tion, however comfortable the patient may feel for a short time after the accident, yet he soon becomes tired, and would give the world to be permitted to extend the limb. With regard to the second objection—that spasmodic affec- tions follow the extended more than any other position, it may be remarked, that this is by no means the case, that starlings or involuntary twitchings annoy the patient exceedingly, after all fractures of the limbs, be the position what it may, especial- ly upon the patient's falling into a doze, from which he is often roused by sudden and violent jerking, and sometimes by a move- ment of the broken ends; but admitting these startings to ac- company the extended more than any other posture, should this be considered a serious objection, when we find it so easy to subdue them by appropriate remedies, such as opium, blood- letting, low diet, topical applications? As respects the third objection, that the confinement of one limb is bad enough, without the confinement of both, it may be asked, if the limb were extended and merely enclosed in De- sault's or Boyer's apparatus, divested of their extending and counter extending bands, would the mere posture and confine- ment be sufficient materially to incommode the patient ? On the contrary has it not been already shown, and even acknowledged by Desault himself, that the chief inconvenience and distress proceeds from the pressure of these bands and the consequent ulceration ? If position itself, therefore, be attended with no unpleasant consequence, certainly the additional confinement of the sound limb can put the patient to no inconvenience, espe- Fracture of the Thigh. 297 cially as the use he could make of it, when stretched upon his back and unable to rNe, would be so very limited as to con- tribute but in the slightest degree to his comfort. Again, the patient is necessarily confined to his back, whether he use the apparatus of Desault or any other. What difference, therefore, can it make to him, whether the splints extend to the arm-pits or not, or whether the body be kept perfectly straight, or be per- mitted to deviate to the right or to the left ? If the system of Desault be rigidly enforced, or if the splint, as advised by Dr Physick, be carried to the axilla and there secured, can the pa- tient then raise himself in bed, or can he relieve himself by al- ternately inclining to cither side? Certainly not; for in either case he is as completely fettered as if lashed to a post. If these views be correct, unquestionably no disadvantage can arise from an additional splint, which does not encumber the patient, but only serves to give him support. The fourth objection relates to counter extension, sustained by the acetabulum and head of the thigh bone of the sound side. Admitting this to produce some uneasiness to the patient, is it not better that it should be borne by a limb uninjured, free from inflammation and devoid of pain, than that the same force should be sustained by a limb acutely sensible, and greatly swollen? But is much force really exerted ? Does the patient actually complain of the fatigue and irritation? This I can only answer by stating, that in the cases in which I have employed the mode I have advised, no such distress has been occasioned. Indeed, does it not seem rational lhat the acetabulum and head of the thigh bone, in their natural state, accustomed as they are to bear at least one half of the weight of the superincumbent parts, should be fully able to support and counteract all the efforts of the mus- cles of a broken thigh, and that too without sustaining the slightest inconvenience ? The fifth objection—that the gaiters will produce ulceration of the ankles, may be answered by stating, that if so, we are no worse off'than if we employed the apparatus of Desault; for his extending band being a single handkerchief, or piece of cotton or linen, will become twisted, and produce more irritation than a band well quilted, and applied to a broad surface. With regard to the stiffness, which follows from a fractured limb, this will be acknowledged to be of little consequence; for Vol. I. 38 298 Fracture of the Thigh. mobility is soon restored upon the patient being able to walk; and even if it were of consequence, it cannot be prevented, and is equally liable to happen in all cases, and in every position that could be devised; and if anchylosis were to follow, which is extremely rare, certainly every one must allow, that it would be infinitely better, in fractures of the lower extremities, to hap- pen in the extended than in the semiflexed position. In the former case, the limb would at least be preserved of its natural length; in the latter it would be shortened, and although the pa- tient might possibly in both instances be lame, yet he would be less so with the limb straight, than crooked. That the scapula is, in some measure, a moveable point, can- not be denied; but it must be admitted, at the same time, that its muscles are numerous and powerful, and as such, would be ca- pable of resisting any common force set against them, especial- ly, as by such application, they would be stimulated to resist- ance. Surely if they are sufficiently strong to support in the erect posture the weight of a very heavy man, by crutches, without the scapulae being much raised, they will at least serve, and that too without an effort, to sustain the body in the recum- bent position, and prevent a descent sufficient to incline the pelvis, or enable the superior fragment to ride upon the inferior. But the fact is, that the arm and scapula do not move so readily as some imagine; the clavicle being attached to the sternum, gives very considerable support to the scapula and arm, inde- pendently of the resistance afforded by the muscles themselves. It must be recollected, however, that counter extension is not intended to be made from the arm-pits, but from the acetabu- lum of the sound side, and that, therefore, any objections on the score of mobility of the scapula must vanish in an instant. The only case in which I have supposed any difficulty might arise, is that of fracture of both thighs at the same time; yet even in that case I have always felt persuaded that the apparatus might be so modified as to answer the purpose. The follow- ing case, reported to me by Dr. Groome, of Maryland, will show how much may be done under the circumstances men- tioned. "On the fourth of March, 1830," says Dr. Groome, "I was sent for to visit Michael Groff, the son of a respectable farmer in the neighbourhood. I found, on my arrival at the house, that Fracture of the Thigh. 299 the young man had been run over by a wagon, and had both his thighs broke—the left in two places, near the middle, and within an inch of the condyles,—the right thigh was fractured about the middle of the bone. Both the left were transverse, the soft parts bruised. The right fracture was oblique, the lower piece of bone being considerably drawn up on the upper portion of the bone. As soon as a straw bed could be got in readiness with a hole left in it to pass his faeces, I placed him upon it, and applied your apparatus, consisting of two long splints, extending from the axilla beyond the feet, with a cross-bar. Extension was effected by handkerchiefs tied round the ankles, and confined to the foot-board. Counter extension, (there being no sound limb to serve as a splint) could not be effected by the acetabulum of the sound side, as in a fracture of the thigh only, was kept up by means of two handkerchiefs carried along the perineum over the hip of each side, and fastened in holes made in the splints about midway between the spine of the ilium and axilla. The splints were padded to prevent excoriation—no other dressings were made use of, and in less than six weeks the splints were removed. During harvest the young man was able to work out in the field as usual. No deformity or lameness now exists, and the strength of the limbs appears to be completely established again. " It is worthy to be noticed, that during the whole of his con- finement the patient did not suffer an hour's pain, or lose a mi- nute's sleep. To what can this absence of pain be attributed but to the want of bandages ? Had I bandaged the limbs accord- ing to the usual mode of treatment, inflammation, swelling, and pain must inevitably have ensued." Several years have now elapsed since I first used Hagedorn's apparatus modified in the manner I have described, both in hos- pital and in private practice, and I can confidently state its supe- riority over every other I have employed or seen applied by practitioners; numerous letters have, also, reached me from dis- tant places, detailing cases successfully treated by it. The late Dr. Faures, of this city, succeeded in restoring to its original length, by means of it, a limb shortened three inches, and after it had remained three weeks in the splints of Desault. Cures have, also, been made in the most satisfactory manner by Dr. Lott, of Jersey, and Dr. Cocke, of Virginia. Three similar cases 300 Fracture of the Thigh. have been reported to me by Dr. Crisp, of West Tennessee. Dr. Brown, an accomplished physician, of Fredericksburg, Vir- ginia, effected in his own person a very perfect cure of an ob- lique fracture of the thigh by the same means. My friend Dr. Corson, of New Hope, in this State, informs me that in a very difficult case of fractured thigh, attended with great deformity and shortening of the limb, he succeeded in producing a com- plete cure by the same apparatus. Dr. Thomas, of North Carolina, has reported to me the following case. " A boy, the property of M. D., aged about fourteen years, in driving a loaded wagon, was thrown from his horse and one or two of the wheels passing over his thigh, fractured it near the middle. Dr. Tuck, an eminent practitioner near Halifax Court House, Virginia, was immediately called and applied the appa- ratus of Desault, by which a cure was effected in seven weeks. Mr. D. then sent for his boy and conveyed him home, a distance of forty miles. The night after his arrival, the boy, while standing, turned his body suddenly round, and again fractured the thigh. Drs. Thomas and Garland were then called in, and applied Dr. Gibson's apparatus, and in seven weeks a perfect cure was effected, without any deformity whatever. The boy stated that he did not experience half so much inconvenience from this as from Desault's splint. Other similar cases might be subjoined, but the apparatus has now been so frequently em- ployed throughout the United States, as to render, I conceive, further details of the kind unnecessary. It has always been a desideratum with surgeons, in the ma- nagement of fractured thigh, to enable the patient, by means of some mechanical apparatus, to evacuate the bowels, without risk of deranging the fragments of bone. Several ingenious contri- vances of the kind, as already mentioned in the preceding pages, have been in use for the" last twenty or thirty years, though the preference has generally been given in Europe and in this country to Earle's Bed. To this, however, and to most others, there are objections, chiefly on account of their complicated and expensive nature, and the necessity the patient is under of lying constantly on the sacking bottom. To obviate these inconve- niences, Mr. Jenks, of Providence, Rhode Island, (a thorough- bred Yankee mechanic, who was so unfortunate a few years ago, as to meet with a complicated fracture of the thigh, and » Fracture of the Thigh. 301 some other bones, in his own person,) has contrived an appa- ratus si triple in the extreme, and so effectual as to remove, I con- ceive, every possible difficulty. The machine is composed of two upright posts about six feet high, supported each by a pedestal—of two horizontal bars, at the top, somewhat longer than a common bedstead—of a wind- lass of the same length placed six inches below the upper bar— of a cog wheel and handle—of linen belts, from six To" twelve inches wide—of straps secured at one end to the windlass, and at the other having hooks attached to corresponding eyes in the linen belts—of a head piece made of netting—of a piece of sheet iron twelve inches long, and hollowed out to fit and surround the thigh—of a bed-pan, box, and cushion to support it, and of some other minor parts. The patient lying on his mattress, and his limb surrounded by the apparatus of Desault, Hagedorn, or any other that may be preferred, the surgeon, or any common attendant, will only find it requisite to pass the linen belts be- neath his body, [attaching them to the hooks on the ends of the straps, and adjusting the whole at the proper distance and length, so as to balance the body exactly,] and raise it from the mattress by turning the handle of the windlass. While the pa- tient is thus suspended^ the bed can be made up, and the faeces and urine evacuated. To lower the patient again, and replace him on the mattress, the windlass must be reversed. The linen belts may then be removed, and the body brought in contact with the sheet. See Plate XIII.' • Most of the foregoing remarks, in relation to Hagedorn's apparatus, and the modification of it, were published by myself several years ago, in the fifth vo- lume of the Philadelphia Journal of Medical Sciences. They have now been transferred to these pages, with more or less alteration, in hopes that the impor- tance of the subject will form a sufficient apology for circulating them more ex- tensively than they could have been through their original medium. 302 Fracture of the Leg and Foot. Section XIV. Fracture of the Leg and Foot. The bones of the leg are susceptible of every variety of fracture; and may be broken at any place intermediate to the knee and ankle. Oblique and transverse fractures, how- ever, about the middle of the limb, are most common. When both bones are fractured at the same time, there is commonly an angular derangement together with evident crepitation, and by these signs the nature of the accident is rendered very plain. But a longitudinal displacement sometimes occurs, in which case the bones overlap and produce a shortening of the limb. If only one bone be broken, the other serves as a splint, and pre- vents, in a measure, deformity, though it cannot obviate the cre- pitation, and by this sign the character of the accident is evinced. Although the fibula is exceedingly weak and slender, and ap- parently contributes very little to the strength of the leg, yet when broken near its lower end, deformity and permanent lame- ness are extremely apt to follow, unless the case be well un- derstood and managed with adroitness. The lower part of the fibula, in fact, forms the external boundary to the ankle joint, and serves mainly to preserve the foot in its natural situation. As soon therefore as fracture of the bone takes place just above the ankle, the lower extremity of it is forced outwards by the abduction of the foot, while its upper portion, or that which is in contact with the upper fragment or shaft of the fibula, is di- rected inwards in an angular direction. Hence the. astragalus may be thrown from the tibia, the foot drawn to the outside of the leg, and great deformity ensue. Fractures of the middle, or of the upper extremity of the fibula, are comparatively unimpor- tant. Fracture of the Leg and Foot. 303 .The os calcis, from its great thickness and strength, is seldom fractured, except by great violence conjoined with inordinate ac- tion of the extensor muscle. A fall from a height, by which the patient lights on his heels, is the most common cause of it. Upon examination, the extremity of the bone will be found separated from its body and drawn upwards on the posterior surface of the leg, where it forms a distinct tumour. By this sign the na- ture of the case will be clearly manifested. The remaining bones of the foot may be comminuted by great violence directly applied to them, but are hardly suscep- tible of any other species of fracture. Like similar injuries of the hand, they are chiefly dangerous from the inflammation-that follows. Treatment of Fracture of the Leg and Foot. Simple fractures of one or both bones of the leg may all be treated upon the same principle—with the exception of fracture of the fibula immediately above the ankle. My own plan of managing these accidents is the following A mattress should first be prepared as directed for fracture of the thigh. Over the sheet which covers it five or six pieces of tape are laid; above the tapes a splint cloth, a yard and a half long and eighteen inches wide; next to the splint cloth a small firm pillow, covered by its case, and on the pillow the bandage of Scultetus, comprising a sufficient number of strips to reach from the ankle to the knee. Four or five assistants then take hold of the patient, and lifting him upon the mattress, place the limb on the pillow in the centre of the dressings. Extension and counter extension are next made from the foot and knee, the fragments properly replaced, and the bandage of Scultetus ap- plied. Two wooden splints, somewhat longer than the leg, half an inch thick and three inches wide, are then rolled in the splint cloth and folded closely against the pillow, so as to elevate its 304 Fracture of the Leg and Foot. sides and cause it to fit the limb with the utmost accuracy; af- ter which the tapes are tied over the edges of the splints, and the whole secured. To support the foot and keep it stea- dily fixed, the centre of a piece of roller about a yard long, should be placed on the sole, the ends crossed on the instep, and pinned above on each side to the splint cloth. Lastly, two segments of a common barrel hoop are crossed at the centre and tied, and their ends placed upon the mattress over the foot and dressings, to take off the weight of the bed clothes. See Plate XIV. When the bones pass each other and the limb is shortened, which very seldom occurs, it may become necessary to keep up extension and counter extension by some apparatus. That em- ployed by Dr. Hutchinson will be found the most convenient. It consists of two firm splints, long enough to extend from the knee several inches beyond the foot. The upper end of each splint has four small holes in it for the passage of tapes, and the lower a mortise, intended to receive a bar eight inches long. The bandage of Scultetus being applied and the leg laid on a pillow, two .tapes are placed on each side of the leg parallel with it immediately below the knee, and are secured by a roller passed several times around the limb. Through the holes in the splints the end of the tapes are next passed, and tied on the outside. Around the ankle, in the form of the figure 8, a silk handkerchief is placed, and the ends secured to the bar which is previously passed through the mortises at the lower end of the splint. By the tapes and roller counter extension is pro- duced, and by the handkerchief extension.* Should fracture of the fibula take place near its lower end, ac- companied by distortion of the foot outwards, the method pro- posed by Dupuytren will be found the most effectual. Two rollers, a cushion or pad and a splint constitute the means by which reduction is accomplished and maintained. The cushion, made of old linen or any similar material, must be two feet six inches long, five inches broad and four . thick; the splint two feet, and the rollers each five yards in length. The cushion, formed into the shape of a wedge, is laid * A representation of this apparatus may be seen in Dorsey's Surgery, vol. i. p 207, edit. 3d. \ Fracture of the Leg and Foot. 3().j along the internal surface of the leg, with its thick end down- wards, and should extend from the upper end of the tibia to the ankle. Over the cushion the splint is laid so as to project four or five inches beyond the foot; one of the rollers is then passed around the cushion and splint immediately below the knee, and extended down the leg as far as the ankle. A space of several inches will thus be left between the foot and splint, which must be filled up by drawing the one to the other with the remaining roller, passed over the instep and heel in the form of the figure 8. It must be obvious that, in proportion as the lower fragment of the fibula is drawn downwards and inwards along the foot, its upper end must be carried outwards, or re- cede from the tibia, and resume its natural situation. To replace the fractured os calcis, the surgeon bends the thigh on the pelvis, and extends the foot on the leg. The superior frag- ment is then drawn downwards, and by an assistant retained in contact with the inferior, while the surgeon lays one end of a compress or short roller on the instep, carries it over the toes, (which are well covered wi(h charpee, or lint) under the sole of the foot and heel, along the posterior surface of the whole limb, as high as the pelvis, where it is held tense by another assistant. He then takes a common roller eight or ten yards long, and pass- ing it around the foot by two or three circular turns, secures the end of the compress, after which the roller is carried about the os calcis and foot several times in form of the figure 8, thence passes up the leg and thigh by reversed and circular turns, and terminates at the hip, where it is fixed to the upper end of the compress. It only remains to preserve the limb in the position first given to it, and this is easily accomplished by placing three or four pillows under the ham, in the form of a double inclined plane. Sometimes it may be necessary to follow Desault's prac- tice and place a short splint over the instep—to keep the foot extended. i VrOL. I. 39 306 Compound Fracture. Section XV. Compound Fracture. * A wound communicating with the cavity of a broken bone, in which sense the term compound fracture is generally under- stood, may be produced by external violence, or by the protrusion of the bone itself. In the latter case, the bone is usually broken in a very oblique direction, though it sometimes happens that a very obtuse fragment will penetrate the integuments and pro- duce an extensive wound. The bones are all liable to compound fracture, but the long or cylindrical ones, especially those of the leg, are most apt to suffer. Unless combined with other injury, the mere protrusion of the bone does not necessarily increase the danger of the case, for it often happens that the wound heals by the first intention immediately after the fragments are re- placed. This was called, by Mr. Hunter, a simple compound fracture. A complicated fracture is not necessarily accompanied by an external wound or a protruded bone, and in this respect, among others, differs from a compound fracture. An open wound, however, conjoined with a luxation or with a lacerated artery, will generally exasperate all the symptoms, which at any rate are often liable to terminate most unfavourably. Compound Fracture. 307 Treatment of Compound Fracture. The treatment of compound fracture ^rnust be regulated by the extent of the injury, and by the age, constitution and habits of the patient. If the external wound is slight and the hemor- rhage inconsiderable, it will be sufficient to replace the bones and apply the dressings for simple fracture—merely covering the wound with a piece of lint or adhesive plaster. On the con- trary, when the bones have been extensively shattered and their ends project several inches beyond the wound, while the sur- rounding soft parts are lacerated and mangled, and blood is streaming from the limb, a very different course should be pur- sued. To replace the bones under these circumstances will sometimes be found very difficult; but the surgeon should al- ways make the attempt before he ventures to dilate the wound or saw off the bones. By well directed and gentle efforts in the way of extension and counter extension, the fragments may often be restored to their places; if these fail, then the soft parts which appear to bind the bones and prevent them from yielding may be slightly divided, and other trials by extension made. Should every endeavour of the kind prove fruitless, there can be no other resource than to cut off' the bone, though it must be ob- vious that such an operation can very seldom prove nece^jary, and must always be attended with disadvantage, .inasmuch as the limb will probably remain shortened or months elapse be- fore the bone is regenerated. After the bones are replaced, it generally happens that the hemorrhage stops; should the blood, however, continue to flow copiously, it may be necessary to di- late the wound and search for the vessels, which must be se- cured by the ligature or compress. Rather than make a very large opening, by dissecting among tendons, fasciae and nerves, it will sometimes be better to cut upon the main artery of the limb and secure it by a single ligature. This will have.the ef- fect of diverting the blood from its usual course, of diminishing the impetus of the circulation, and thereby of favouring the dis- position to coagulation in the mouths of the wounded vessels. 308 Compound Fracture. But it happens, occasionally, that this operation also fails, owing to the blood, by the enlargement of the collateral branches, finding its way circuitously to the original wound. Cases of the kind have been reported by Hodgson and others. Under such circumstances, compression in the manner formerly point- ed out may, perhaps, be the only remedy.* Instead of confining the limb by splints and rollers, it should be placed on a pillow and surrounded loosely with the bandage of Scultetus, and every care taken to obviate and remove inflammation. After this has subsided and the wound begun to heal, splints and the usual dressings may be applied. When old, debilitated, and intem- perate patients suffer from compound fractures, mortification may ensue. Such patients generally require a nutritive diet, bark, wine, &c. Complicated fractures not unfrequently terminate in death, or render amputation necessary. Under favourable circumstan- ces the treatment does not differ from that of compound frac- ture. *■ See ante, p. 63- Pseudo-Arthrosis. 309 Section XVI. Pseudo-Arthrosis, or Unnatural Joint. When the extremities of a fractured bone, instead of uniting through the medium of callus, remain loose and unconnected, a kind of false articulation is established and the limb rendered nearly useless. This disease may follow a fracture of any bone, though it has been most frequently observed in the humerus. It may arise from premature use of the limb, from the interpo- sition of a tendon, ligament, or muscle, from old age, certain peculiarities of constitution, disease in the osseous system, or from want of proper contact between the fragments. Reunion having been prevented by any of these means, the extremities of the bone generally become smooth and round, and are co- vered with a cellular or ligamentous substance. Sometimes a ball and socket are formed, and the ends of the bone roll upon each other. Two specimens of the kind are contained in my cabinet. Treatment of Unnatural Joint. In old subjects, and in peculiar constitutions, callus is some- times secreted very slowly, and months elapse before reunion is perfected. Aware of this, the surgeon should never despair of effecting a cure, but continue the dressings so long as any reasonable hope of success remains. Sometimes, however, it may be proper to deviate from this rule and permit the patient to use the limb, even although the fragments should continue 310 Pseudo-Arthrosis. moveable—a practice first suggested, I believe, by Mr. Hunter. By adopting this plan, the formation of callus will be promoted and unnatural joint often prevented. Indeed, in the early stage of this disease similar means have occasionally been used with success; at least friction, or rubbing of the fragments upon each other, has been found in a few instances to excite ossific action to a sufficient degree to effect a cure. In cases of long standing, however, there are two modes of procedure—the removal of the ends of the bone, or the introduction of a seton between them. The former has sometimes succeeded, but is difficult of execu- tion, and liable to be followed by severe symptoms and even death; the latter is extremely simple, and, when well managed, rarely fails. To the late Dr. Physick is exclusively due the merit of having first proposed and executed with success this ingenious operation. Upon my arrival in Edinburgh, in 1806, I communicated to the elder Monro, and afterwards to several distinguished surgeons of London, the result of two or three cases, in which Dr. Phy- sick had introduced the seton with complete success. The only one, however, who seemed to feel an interest in the operation was Sir Charles Bell, to whom, by particular request, I trans- mitted upon my return home, in 1810, an account of all the cases in which Dr. Physick had then operated. These were afterwards published in the second edition of his " Operative Surgery," and in answer to my communication, Sir Charles re- marks, " I have been reading your cases of the operation of the seton in artificial joint to my class. I continue to think it one of the most ingenious things in modern surgery. I have a pa- tient who I am in hopes will submit to the operation. He is a captain of an Indiaman. His thigh bone was broken by a spent cannon ball about eighteen months ago, and has not united." Upon showing the letter to Dr. Physick, he desired me to say, that he had twice tried the seton in the thigh, but without effect, and he was fearful it would not succeed in any case of the kind. Whether Sir Charles afterwards performed the opera- tion referred to, I have not ascertained; but that Dr. Phy- sick's apprehension was unfounded, has since been proved by Mr. Brodie and others who have succeeded upon the thigh as well as other bones. That the seton sometimes fails there Gan be no doubt, but that it generally succeeds is equally certain. Pseudo-Arthrosis. 311 A case occurred a few years ago at* the Aims-House, in which a seton was passed at different times, between the ends of a disunited humerus without effect. Dr. Hewson afterwards cut off the extremities of the bone with a saw, union took place and the patient recovered the use of his arm. On the other hand, a case is related by Mr. Samuel Cooper* " of a strong, robust man, whose chief peculiarity seemed to be his indifference to pain; the ends of his broken humerus were cut down to, turned out and sawn off by Mr. Long, in St. Bartholomew's Hospital, and the limb was afterwards put in splints, and taken the great- est care of; but no union followed." In general, when the seton fails to procure reunion, there is reason to believe that it has not been continued a sufficient length of time. In 1806, I was present at an operation per-, formed by the late Dr. Physick, upon the humerus of a woman residing in Baltimore; for some trivial reason, the physician un- der whose care the patient was left, removed the seton in two or three weeks, and no benefit of course resulted. Again—within the last seven years, Dr. Physick passed a seton between the ends of a disunited lower jaw, and the patient returned home. In a little time his attending physician became anxious to re- move the cord, under an idea that no union would take take place ; the patient, however, had promised Dr. Physick before his departure, that no one except himself should take it out. It was therefore continued a few weeks longer, and in the mean time perfect bony reunion was established. Sometimes, however, the seton effects its purpose in a very short time. In a case re- ported to me, in 1828, by Dr. George T. Kennon, a respectable practitioner of Norfolk, Virginia, the cure was accomplished in an uncommonly short period. " 1 have yet seen no case re- ported," says Dr. Kennon, " where the union went on as rapidly as in this case. On the fourteenth day after the seton was passed, the bending of the leg at the fracture was evidently more difficult, and believing that the degree of inflammation already ex- cited was sufficient for the purposes intended, the seton was with- drawn, the leg dressed with splints, and the patient discharged cured on the ninth week from the operation, and the seventh from the removal of the seton. The patient was twenty-five • See Dictionary of Surgery. 312 Pseudo-Arlhros is. years of age, of fine constitution, and withal obedient to his physicians, during the period of his confinement. The case had been of fourteen months' standing." To perform this operation, the surgeon should be provided with a skein of silk, and a long narrow seton needle, either round or flat. The limb should then be extended by assist- ants, in order to separate the extremities of the bones as much as possible from each other, while the surgeon passes the nee- dle, armed with the silk, through the integuments and mus- cles, and between the bones, taking care to avoid all the large vessels and nerves. Over each orifice made by the seton is placed a bit of lint and a pledget, and the limb supported by a roller and splints. Four or five, and sometimes twelve months, should elapse before the seton is removed; at the end of that time the fragments will generally be found perfectly consolidated. On Fractures, consult Desault on Fractures, Luxations, and other Affections of the Bones, translated by Caldwell, edit. 2d, 1811—Boyer s Lectures on Diseases of the Bones—Boyer's Treatise on Surgical Diseases, vol. 2d, by Stevens—Dor- sey's Elements of Surgery, vol. 1, p. 118, edit, by Randolph—Surgical Essays, by Cooper and Travers—Bell's Operative Surgery, vol. 2d.—J. Bell's Principles of Surgery, vol. l,p.S87—Pott on Fractures and Dislocations, vol. 1—A Treatise on Dislocations and on Fractures of the Joints, by Sir Astley Cooper, 4to. London 1822—Dupuytren sur la Fracture de VExtremitie lnferieure du Perone, &c. in Annuaire Medico-Chirurgicale, tom. 1—Roux's Narrative of a Journey to Lon- don in 1814, 2d edit. p. 159—Cross' Sketches of the Meaical Schools of Paris— Practical Observations in Surgery, by Henry Earle, p. 17, octavo, London, 1823 —Larrey's Surgical Memoirs—C. Bell's Observations on Injuries of the Spine and of the Thigh Bone, 4to. On Artificial Joint, consult Physick's " Case of Fracture of the os Humeri, in which the Broken ends of the Bone not uniting in the usual Manner, a Cure was effected by Means of a Seton," in the New York Medical Repository, vol. 1, p. 122—ilso, Caldwell's Appendix to Desault—Dorsey's Surgery, vol. 1, p. 130—Brodie, in Medico-Chirurgical Transactions, vol. 5, p. 377— Wardrop, in the same work, vol. 5, p. 365—Roux's Journey, p. 172—Hutchinson's Practical Observations in Surgery, p. 162—Inglis on Unnatural Articulations, in Edin- burgh'Medical and Surgical Journal, vol. 1,'p. 419—White's Cases in Surgery— On the Treatment of ununited Fractures with the Seton, by Isaac Hays, M. D., in American Journal of Medical Sciences, No. Xlll. November, 1830. fixations. 313 CHAPTER VIIL LUXATIONS, The term luxation, or dislocation, implies the removal of the ncad of a bone from its corresponding articulating cavity. To designate the varieties of the accident, other appellations have been usually employed—simple and compound, primitive and consecutive, recent and old, complete and incomplete luxation. By simple luxation is understood a mere removal of the head of a bone, accompanied by laceration of one or more ligaments —by compound, that variety of luxation in which an external wound communicates with the cavity of a joint. In primitive luxation, the head of the bone continues in the unnatural posi- tion it first assumed—in consecutive, it abandons the first situ- ation and becomes fixed in another. The terms recent and old refer merely to the duration of the injury, whilst complete and incomplete denote total and partial displacement. All the articulations, with few exceptions arc liable to luxa- tion; but (he orbicular, on many accounts, arc most exposed to such injuries. The ginglymoidal joints, on (he other hand, are so constructed as to render their displacement, in most instances, extremely difficult. External violence is the most common cause of luxation, though it is frequently produced by muscular action alone; in other instances the displacement is brought about bv a preternatural laxity of the ligaments, or a paralytic state of the muscles surrounding the joint. Sometimes the head of a bone is slowly removed from its socket by disease, or by the growth of a tumour within the capsule. Parts recently luxated, when examined by dissection, com- Vor.. 1. . 40 314 Luxations. monly exhibit the following appearances. Besides laceration of the capsule and ligaments, most recent luxations are accom- panied by an effusion of a greater or less quantity of blood in the neighbourhood of the joint, by rupture or extension of ten- dons and muscular fibres, and by injury of nerves. However, the inflammation that follows, seldom terminates in suppuration, but slowly subsides, the effused blood is absorbed, and the func- tions of the injured parts are afterwards in a measure restored. In the mean time the head of the displaced bone accommodates itself to its new situation, and forms a cup in the cellular mem- brane, muscle, or bone, against which it rests, whilst adventi- tious ligaments are created from the surrounding cellular tissue, and either unite with the remains of the torn capsule or become fixed to the bone and secure it firmly in its place. After a time some motion is acquired, and the use of the limb may be partially restored. Luxations are often confounded with other injuries, especially fractures; but from these they may be readily distinguished by want of crepitation; by the peculiar distortion and rigidity of the limb, which, according to the kind of displacement, is either lengthened or shortened, while the head of the bone is so fixed as to be nearly immoveable. Together with these signs an un- natural prominence or depression may be generally felt in the vicinity of the injured joint, but differing materially from that in- equality often observed in fracture. Treatment of Luxations. Constitutional as well as local means are generally necessary in the reduction of dislocated bones. The former, indeed, often exert greater influence over the action of muscles, (the chief impediment to reduction,) than any mechanical force, however powerful, that can be employed. The most efficient remedies of this description are blood-letting ad deliquium animi, the warm Luxations. 315 bath, nauseating emetics, intoxication, > at the shoulder joint, produced two months before, by the weight of a heavy chest, which fell upon him, from a cart, while he was driving it along the road. A physician was immediately sent for, who stated that the arm was fractured just above the elbow, and must be secured by splints and ban- dages. These were accordingly applied, and continued about two weeks, when the bone was declared so far united as to ren- der the dressings unnecessary. No notice, according to the pa- tient's account, was taken of the shoulder, although, from the first, the,swelling had been considerable, and the pain very severe. A short time afterwards the patient consulted Dr. Dutton, of Vil- lage Green, Delaware county, who, discovering that the os hu- meri had been luxated at the shoulder, and still remained dis- placed, determined to make an effort to restore it to its natural situation. With this view the patient's body was securely bound and rendered immoveable; three pints of blood were drawn from the right arm, whilst a strong sheet was twisted round the injured arm, above the elbow, and its ends given to five strong men, who were directed to keep up a constant and steady extension, which was continued for some time, and frequently repeated, but with- out any benefit. The patient suffered, as he remarked, a good deal, from this attempt to restore the bone to its place, and was debilitated by the loss of blood; still he was willing to undergo any torture, provided there was the slightest probability of his arm being again rendered useful. For this purpose he came to Philadelphia, and consulted Dr. Humphrey, by whom he was referred to me. It was evident, upon examination, that the head of the os humeri had been separated for a considerable time, from the glenoid cavity; for I found it so firmly lodged in the axilla, that the arm would scarcely admit of any motion, and the slightest movement occasioned pain. After explaining * See the Philadelphia Journal of the Medical and Physical Sciences, vol. vii. p. 81, 1823; and ditto, No. 3, May, 1828, p. 136. 326 Luxation of the Arm. to the patient the uncertainty of any benefit resulting from a further attempt to reduce the bone, and pointing out to him the suffering that must necessarily follow the efforts to restore it, I determined to make the trial, and for this purpose requested him to meet me on Monday the 12th of May, at the Almshouse Infirmary. Having arranged the necessary apparatus, I desired Mr. Gregg, one of the house pupils, to bleed the patient in the right arm. While the blood was flowing, a buckskin band, with an iron plate and ring secured to it, was fastened around the wrist. A large roller was then fixed in the arm-pit, and over this a sheet, folded diagonally, the ends of which were carried before and behind the chest, towards the opposite shoulder, and fastened to a hook. This sheet served for the counter extending band. Pulleys were next attached to the ring at the wrist, and every thing being prepared, I commenced the operation, (in presence of Drs. Humphrey, Horner, Jackson, the resident physicians, and students of the house, and several other spectators,) by setting the pulleys in motion, and keeping up, for several minutes, a continued but steady extension and counter extension. This fatigued the muscles of the arm con- siderably, and the patient was sensibly affected by the loss of nearly two pounds of blood, but did not faint. I then relaxed the pulleys, and taking hold of the arm, near the elbow, used it as a lever, and communicated a rotatory motion, in hopes of breaking up the adhesions and adventitious ligaments, connect- ing the head of the bone to its new socket. Additional attempts were made with the pulleys, apparently without the slightest ef- fect. Dr. Horner now proposed to change the direction of the force of the counter extending band, by fastening a hook in the floor, seating the patient on a chair, and passing the middle of a strap over the point of the acromion process, in order to secure the scapula. This was, also, tried but with no better success. 1 next disengaged the extending and counter extending bands, and laying the patient out upon the table, placed one of my heels in the axilla, while I produced extension, by pulling at the patient's wrist. The same was done by house pupil Strudwick. Finding these efforts unavailing, another attempt was made by means of sheets, fastened above the elbow and under the arm- pit. Five or six assistants took hold of the ends of each, and pulling steadily for some time, the head of the bone was per- Luxation of the Arm. 327 reived, gradually, to yield. It quickly returned, however, nearly to its former position, as soon as the efforts were discontinued. By this time the patient was greatly ex- hausted, and the muscles very much relaxed, when Dr. Hor- ner requested him to lay on the floor, and at the same time stretched himself down opposite to him, and taking hold of the wrist, made a continued but forcible extension, while counter extension was effected by his heel in the axilla. During these efforts the head of the bone gradually approached the gle- noid cavity, and at last entered it. The slightest movement, however, was sufficient to throw it out again, which led me to suppose that a portion of the capsule might be interposed be- tween it and the socket, and would require further laceration before the reduction could be entirely accomplished. But the patient was too much overcome to make any further attempt at that moment, and was therefore put to bed. On visiting him half an hour afterwards, with Dr. Humphrey, I found the head of the bone resting on the lower edge of the glenoid cavity, and a hollow under the acromion. I took hold of the arm, and made two or three slight rotatory motions, when it slipped suddenly into its place, and was completely reduced. There was a general swelling about the deltoid and pectoral muscles, which was noticed both by Dr. Humphrey and myself, but supposing it to be an approach to inflammation, a consequence to be ex- pected after the efforts made to restore the head of the bone, nothing was apprehended from it. The swelling increased, however, very slowly, for several hours, and although remarked by the house pupils and attendants, did not excite any alarm, inasmuch as the patient complained of little pain, and conversed cheerfully with some of his friends during the greater part of the afternoon. About six o'clock in the evening Dr. Brinton, one of the house pupils, visited him, and hearing that he had a short time before turned over in bed, in order to sleep, and struck with the unusually pallid appearance of his face, was induced to suspect that some unfavourable change had taken place. These suspicions were confirmed, for upon examination the pulse was found scarcely perceptible, and the whole system so much sunk as to render recovery impossible. Leaving Dr. Hopkinson in charge of the patient, Dr. Brinton immedi- ately repaired to my house, and informed me of his con- 328 Luxation of the Arm. dition. Before I could reach him, however, he expired. The appearance of the shoulder and adjacent parts soon explained, it seemed to me, the nature of the case; for the pectoral muscle was considerably elevated, and the skin, for some distance about the chest and shoulder, discoloured and ecchymosed, showing, in all probability, that some large artery or vein had been torn across, during the efforts to reduce the luxation. To determine this point with accuracy, I obtained the consent of the patient's friends to examine the body, and at ten o'clock next morning the dissection was made by Drs. Horner and Lawrance, in pre- sence of Drs. Humphrey, Jackson, the house pupils, several stu- dents and myself. Dissection. Three incisions were made—one from the acromion process, along the course of the clavicle, as far as the sternum—another perpendicular to the sternum, and about ten inches long—a third nearly at right angles with the lower extremity of the per- pendicular one, and running across the chest towards the arm- pit. The integuments and pectoral muscles being elevated along the edge of the sternum, and thrown backwards towards the shoulder, a considerable quantity of coagulated blood was found, filling the cellular membrane, and lying in masses be- tween the interstices of the muscles. In order to ascertain the condition of the large vessels beneath the clavicle, this bone was separated at its juncture with the sternum, and raised. The course of the subclavian artery and vein was then distinctly seen. A small opening was made in the vein, into which a bougie was introduced for several inches, towards the axilla, as a guide during the dissection; but the vessel was found perfectly sound throughout. Under the vein, as it passes near the glenoid ca- vity, a large mass of coagulated blood was observed, and upon clearing this away, the axillary artery was seen protruding, with its mouth open, having been torn directly across and se- parated from its connexions. Upon farther examination, it was discovered that the head of the bone, at the time of the luxa- tion, had been carried downwards into the axilla, about an inch and a half below the glenoid cavity, where it formed a while ligamentous cup-like socket, in the subcapularis muscle, and Luxation of the Arm. 329 pressing upon the axillary artery, produced such a degree of inflammation as gave rise to a copious effusion of coagulable lymph, which united the artery completely for some distance, to -he capsule of the joint, where it surrounded the neck of the bone. The lower part of the capsule was torn and separated from the neck of the humerus; the upper part remained en- tire, and was very much thickened. The head of the bone filled completely the old socket or glenoid cavity. Beneath the del- toid muscle there was a large hollow filled with blood, and the whole arm, as far as the elbow, had been extensively injected with the same fluid. The os humeri was carefully dissected from the condyles to its head, and the periosteum entirely scraped off, without showing the slightest vestige of a'fracture. The long tendon of the biceps was found considerably elongated, but not ruptured.* Remarks. The foregoing case must be considered, in every point of view, extremely interesting; it was mistaken, it appears, by the phy- sician who first saw it, for a fracture near the elbow, and treated accordingly; a few weeks afterwards the true nature of the dis- ease was discovered by another practitioner, and an attempt made, but without effect, to restore' the head of the bone to its natural situation. The patient finding his arm useless, and una- ble to follow his occupation, determined notwithstanding his pre- vious suffering, from one operation, to submit to another. The trial was made, under every disadvantage, the head of the bone restored to its socket, the axillary artery torn across, owing to an accidental adhesion between it and the capsule of the joint, which could not be foreseen, and the patient died. Persons acquainted with the difficulties often encountered, even in the most simple cases of luxation, will readily understand, without comment, the peculiar nature and the inevitable result of the case I have detailed. For those who possess little practical informa- tion on the subject, and who may, perhaps, be led to condemn • The diseased part being removed, was carefully prepared by Dr. Lawrance, and presented to the Wistar Museum, where it may at any time be inspected. Vol. I. 42 330 Luxation of the Ami. the efforts to relieve the unfortunate patient, as rash and unwar- rantable, the following observations are chiefly intended. The head "of (he humerus may be forced from the glenoid ca- vity of the scapula, and lodged in different situations. In nine out of ten cases, however, it rests in the hollow of the arm-pit, having previously ruptured the inferior portion of the capsular ligament. The tumour, formed by the head of the bone, in the axilla, and the unnatural hollow under the acromion process, are signs so decisive of4the nature of the accident as not to be overlooked, except.by the most careless or ignorant practi- tioners. To restore the bone to its original position, the surgeon makes extension and counter-extension, either by the hands of strong assistants, (some of whom take hold of the dislocated arm and pull steadily, but forcibly, whilst others resist, by se- curing the body or shoulder,) or by towels, or sheets, straps, or pulleys, as the case may require. If the force be well directed, and continued sufficiently long to fatigue the muscles, and there- by overcome their resistance, the head of the bone generally slips into its place without much difficulty. But the slit or rup- ture in the capsule remains open for a considerable lime, and in many instances never closes. Under these circumstances, the patient is continually liable to a recurrence of the accident, and the slightest effort will sometimes be sufficient to induce it. It not unfrequently happens that the surgeon finds it impossible, by the most powerful extension and counter-extension to restore the head of the bone, even in the most recent cases. This is owing generally, as is now well understood, to the rent in the capsule be- ing too small to admit the head of the os humeri to pass through and enter the glenoid cavity. When such difficulties exist, the surgeon discontinues the extending and counter extending forces, and taking hold of the arm, uses it as a lever, and communi- cates a rotatory motion to it, the chief object of which is to tear up and enlarge the opening in the capsule. This being done, a very slight effort in the way of extension, will probably be suf- ficient to reduce the bone. When the head of the bone, instead of being restored imme- diately to its proper cavity, is suffered-to remain in the arm- pit, for weeks or months, it will be found in a very different condition from that last described; inflammation takes place, Luxation of the Arm. 331 adhesions form between the bone and surrounding parts, adven- titious ligaments are created, a new socket is produced, the old one partially or entirely tilled up, and the bone after a short time almost as firmly fixed as it was in its original position. Previous to the time of the enlightened but adventurous De- sault, such a case was deemed hopeless and irremediable. This great surgeon conceived the possibility of restoring the use of the arm, under these almost desperate circumstances, and suc- ceeded in several cases of one, two, three and four months' standing, by the following means. " Previously to making ex- tension," s;iys ho, "it is necessary to move the bone very forcibly in every direction, in order first to break the adhesions, to tear the condensed cellular membrane, which serves as an accidental capsule, and to produce, so to speak, a second luxation, with a view to make way for a perfect reduction of the first. The straps being then applied; as in ordinary cases, serve the pur- pose of extension, for the accomplishment of which, the num- ber of assistants must be increased. Oftentimes the fii>t efforts are fruitless, and the luxated head remains stationary, amidst the most violent efforts. Let the extension then be discontinued: renew the forcible motions of the limb: carry the humerus up- wards, downwards, forward and backward ; force the resistances to give way; make the arm describe a large arch of a circle round the place which it occupies; let the rotatory motions on its own axis be impressed on it anew; and then recommence the extensions, and let them be made in every direction. By these, the head, already disengaged by means of the preceding violent motions, will be brought to a level with the glenoid cavity, and ultimately replaced."* From these extracts it will be seen, that Desault strongly inculcates the employment of forcible and even violent exertions in the reduction of all old luxations of the os hu- meri; the success, indeed, which he met with, almost invariably, and that too, in many instances, after other practitioners, who employed milder means, had failed, was such as seemed to justi- fy the practice completely, and induce other surgeons, both in Europe and in this country, to follow his example. The practice therefore, has long since become general and established, so much so, lhat the surgeon who should refuse to attempt to relieve hia • Desault's Works by Caldwell, p. 144. 332 Luxation of the Arm. patient because the head of the bone had remained out of the socket several months, would be considered culpable by all in- telligent members of the profession. Dr. Physick has, " in a va- riety of instances, succeeded after two and three months."* The late Dr. Dorsey, one of the best informed and most accomplished surgeons of this country, entirely approved of Desault's practice, and followed it successfully in several cases. Dr. M'Kenzic, of Baltimore, replaced a dislocated os humeri nearly six months af- ter its luxa(ion."t The same has subsequently been accomplished by Mr. Kirby,J of Dublin. For the last eighteen or nineteen years, I have repeatedly reduced luxations of the shoulder, and some other joints, from two to four months' standing, and al- though in several instances, the adhesions surrounding the head of the bone and the new socket were so considerable as to re- quire great force and extensive laceration, not the slightest ac- cident has ever occurred. The records of surgery, indeed, furnish very few examples, so far as I am acquainted, of injury, much less of death, resulting from attempts to restore the head of the bone even after it had been displaced for a very long pe- riod. Desault details the history of one case in which either a large emphysematous or bloody tumour formed under the pec- toral muscle immediately after the \ head of the os humeri had been restored to its glenoid cavity. " Scarcely was the reduc- tion accomplished, when a tumour rose suddenly under the pectoralis major, propagated itself towards the arm-pit and oc- cupied immediately its whole extent. All the assistants, asto- nished at the phenomenon, knew not to what circumstance to attribute it. Desault himself, a little embarrassed, thought first of an aneurism suddenly produced by the violence of the ex- tension. The pulse of the patient, being scarcely perceptible in 1he side affecteg\ and a syncope which supervened, appeared at first to favour this suspicion ; but immediately the absence of a fluctuation, of a pulsation and of a change in the colour of the skin, the return of the pulse the circumscription of the tu- mour, its resistance and the sound caused by striking on it, * Dorsey's Elements of Surgery. Vol. I. p. 237. f Ibid. * Kirby's Cases, with observations on Wryneck, the reduction of luxations of the shoulder, &c. p. 53. Luxation of the Arm. 333 produced a belief that it was owing, not to an effusion of blood, but to a disengagement of air that had been confined in the now lacerated cells of the cellular membrane. On the thirteenth day, the tumour was entirely gone. In the place which it had occupied a large ecchymosis appeared, produced, no doubt, by the rupture of the small vessels at the time of reduction."* This patient recovered perfectly in le-.; than a month after the reduction, and no other similar case is mentioned, that I know of, either by Desault or any other writer. Although most writers on dislocations seem to think a rup- ture of the axillary artery, from attempts to restore the bone after it has been d;. placed a few weeks, a possible occurrence, yet I have not been able to find, after very diligent research, a single instance of this description except one, which is merely glanced at by Sir Charles Bell. " In this violent operation," says he, "one can imagine lhat if the axillary artery were at all diseased it might be torn; but I have not known of such an accident, though I have known such an ecchymosis succeed the operation of reduction, as would imply the rupture of some con- siderable vein. In employing the ambe in the New-castle In- firmary, both the axillary artery and the muscles have been torn, so that they were obliged to amputate on the instant."t Sir Charles Bell is silent as respects the event of the case; there is every reason to conclude, however, that it could not have been otherwise than fatal. A very remarkable instance has been re- corded by Loder of high inflammation, mortification and death, from an attempt to reduce a luxation of several months' duration. " When Loder was studying at the Hotel Dieu at Rouen, a man came to the hospital, on account of some trifling complaint. The celebrated M. David, then the principal surgeon of that establishment, perceived that the patient had also a dislocation of the left arm. The displacement had already existed several months, and the limb had acquired some degree of mobility. M. David recommended making a fresh trial to reduce the bone, and the patient's consent being obtained, the attempt was made with immense force, and the arm restored to its proper place * Desault's Works, p. 149. f Bell's Operative Surgery. Vol. U. p. 2-17. 331 Luxation of the Arm. again; but the event was most disastrous; for the whole limb was attacked with such violent pain and inflammation, that not- withstanding every means which surgery could suggest was im- mediately put in practice, mortification ensued, and the patient lost his life."* The foregoing observations are calculated to exhibit the treat- ment of luxations of the os humeri as sanctioned and pursued by the best surgical authorities, and to show that the practice thus established, if not uniformly successful, has, with the ex- ception of two or three cases, been unattended with danger. A question, however, may possibly arise—whether surgeons should be influenced by the event of the case I have detailed, and of those 1 have quoted, and deterred altogether from at- tempting reduction in dislocations of long standing, or whether the established practice should still be continued, unaffected by fortuitous circumstances or contingencies neither to be foreseen nor controlled? To the latter proposition I have no hesitation to give unqualified assent, and to declare, that should a case si- milar in external appearance to that of James Scofield again oc- cur, 1 shall feel justified in adopting a similar course. John Langton, aged thirty-five, a muscular athletic man, about six feet high, a labourer, accustomed whilst at work to the use of a pint of spirits daily, called upon me on the 8th of March, 1828, and presented a letter from Dr. Lewis Horning, dated Millers town, Pennsylvania, recommending him to my no- tice on account of a luxation of the left os humeri at the shoul- der-joint. From the patient I ascertained that the accident had occurred nine weeks before, from a violent fall upon the shoul- der ; that soon afterwards attempts had been made, four different times, to replace the bone, but without effect; that very con- siderable force had been employed each time, and that upon one occasion his body had been suspended upon the axilla over the top of a door. • First Lines of the Practice of Surgery, by S. Cooper. A'ol. II. p. 466. Luxation of the Arm. 335 On the 6th of March, the patient was admitted into the Alms- house Infirmary, and placed on low diet and the antiphlogistic system. This treatment was commenced about the fourth day after his admission. He was bled, regularly, to the extent of 5x. daily, kept on barley water, purged occasionally, had the shoulder carefully rubbed with oils, and the arm gently moved, several times a day, in various directions. This plan was pursued unremittingly until the 15th of March, on which day it was determined to attempt to restore the bone to its natural situation. Assisted by Drs. John R. Barton and R. Harlan, and by the house pupils, and in presence of Drs. Jackson and Mitchell, Dr. Canby of Indiana, and several medical students, I commenced the operation, by extending the patient upon a long narrow table, covered with blankets, placed a soft ball of old linen in the axilla, over this a coun- ter extending band which was fastened to a staple, then an ex- tending band, above the elbow, with its ends secured to a pulley, which pulley was also attached to a staple, and lastly secured the scapula by a band so contrived as to embrace the acromion process like a cap, and thence extending across the body, ob- liquely downwards, and held by two assistants, seated upon the floor. The apparatus being thus arranged, the fore-arm was bent upon the arm at a right angle, and used occasionally, by Dr. Barton and myself, as a lever, through the medium of which very slow and gentle rotatory motions were communi- cated to the head of the displaced bone, whilst at the same time, the pulley, under the management of Dr. Harlan, kept up a very moderate and continued extension, for at least half an hour. Not appearing to have the desired effect, this mode of pro- ceeding was laid aside, and the patient placed in the upright position on a stool, and extension and counter extension again employed by pulleys secured to staples in the floor. All our efforts Ihus made proving equally unavailing, we determined to lay the patient again on the table, and to renew our former at- tempts. Accordingly extension and counter extension were kept up in the horizontal direction for another half hour, but without much impression being made, apparently, upon the muscles of the arm. Under ihese circumstances, a pupil was directed to open a vein in the right arm; from this twenty 33G Luxation of the Arm. ounces of blood were drawn, without inducing syncope. To bring about, if possible, this state of the system, twelve grains of tartrite of antimony, dissolved in four ounces of water, were ordered, and gradually administered, without producing any other effect than slight nausea. Our efforts, notwithstanding, were continued in the most gentle and cautious way possible, sometimes by the pulleys, sometimes by the heel in the axilla, when we had the satisfaction, at last, to find the head of the bone gradually approach, and finally enter, with an audible snap, the glenoid cavity, but not until the lapse of one hour and three-quarters from the commencement of the operation. The patient, after being put to bed, complained chiefly of weak- ness, of numbness throughout the arm, of slight excoriation of the arm-pit, and bend of the arm, from the counter extending and extending bands, and was smartly purged by the tartar eme- tic given during the operation. In other respects, he said, he was comfortable, and slept during the night without an opiate. March 16th—I saw him at eight in the morning, and ob- served a general swelling over the deltoid and part of the pec- toralis major muscles, but not more than could have been ex- pected under similar circumstances. Upon pressing, however, upon the most prominent part of the swelling, I was surprised to find a distinct pulsation of an aneurismal character. During the day both the swelling and pulsation slowly increased, and satisfied me that an aneurism existed in the axillary artery. Dr. Barton saw the patient in the afternoon, and drew the same conclusion. March 17th.—At 10 o'clock, A. M., Drs. Barton, Harlan, and myself, saw the patient in consultation. The tumour and pulsation were somewhat greater than on the preceding day. At 3 o'clock, P. M., we saw him again, and the tumour appear- ing still to augment, though slowly, it was decided that, the sub- clavian artery should be tied without delay, lest the clavicle should be so raised by the aneurism as to render the operation afterwards very difficult, if not impossible. Accordingly I commenced the operation, almost immediately, in presence of Drs. Fearn, Pickering, Knox, Montgomery, Johnson, the house pupils, and several medical students, (assisted by Drs. Barton and Harlan,) by extending an incision from the acromial mar- gin of the sterno-masloid. muscle, for three inches and a half Luxation of the Arm. 337 along the course of the clavicle, through the integuments, pla- tysma myoides, &c., until the external jugular vein was exposed. This vessel being held aside, by a blunt hook, the incision was gradually, and very cautiously deepened, by the alternate use of the edge and handle of the knife, until the subclavian arte- ry was laid bare, just where it passes the edge of the anterior scalenus muscle, and lies on the first rib, and its pulsation dis- tinctly felt. 1 next attempted to pass a blunt steel needle, armed with a strong round ligature, made of saddler's silk, fixed in Physick's forceps, but the needle broke near its eye, in the act of pushing it beneath the vessel. The instrument employed by Wardrop for lying the carotid artery, (consisting of a flat silver cannula, containing a steel stilet,) was next tried, but without effect. At last, though not without some difficulty, the common silver aneurism needle was passed beneath the vessel, without disturbing its connexions, except in the slightest de- gree. The attending surgeons, and most of the spectators, having satisfied themselves that the ligature had been fairly de- posited beneath the vessel, without including any of the nerves or other parts in its vicinity, it was tied by three firm knots— at the depth of three inches below the clavicle, nearly in a per- pendicular direction—when the pulsation in the tumour ceased instancously.* The edges of the wound were brought together * Having experienced much greater difficulty than I expected, in passing the ligature between the subclavian, I called, soon after the operation, upon Mr. Schively, one of the most ingenious and eminent cutlers in the United States, and requested him to make for me an instrument, of the exact shape and size of the ordinary aneurism needle, calculated to hold a steel stilet, capable of being passed, without difficulty, beneath deep-seated vessels. His ingenuity soon removed the defects usually complained of, and produced an instrument, which, I do not hesi- tate to say, in point of simplicity and usefulness, is as yet unrivalled, if I may judge from an experiment I have since performed upon the subclavian arteiy of the dead subject, in presence of Messrs. Hall, Nott, and Levert. It consists of a silver cannula, fixed in a wooden handle, surrounded, (near the part where the cannula joins the handle,) with a silver collar, through which a steel stilet, made of a narrow watch-spring, the length of the instrument, passes, and immediately afterwards enters an opening just below the collar, in order to pass the whole cavity of the cannula and emerge at its point. This extremity of the stilet is covered with a flattened silver cap moderately blunt, whilst its other or upper extremity, passing upwards, from the collar above mentioned, lays parallel with the handle and has an eye near its end for holding a ligature. A small screw, for the purpose of fixing the stilct while the surgeon is in the act of passing the Vol. I. 43 338 Luxation of the Arm. with adhesive straps, supported by lint and a compress, the pa- tient put to bed, and forty-five drops of laudanum administered. In fifteen or twenty minutes after the operation, the tumour, which previously was tense and elastic, was found much dimi- nished, soft and flaccid to the touch. 6 o'clock in the evening—patient expressed himself easy and comfortable. Heat of the limb apparently somewhat greater than it was immediately after the operation. 10 o'clock at night—complains of thirst, and is restless—heat of the arm not perceptibly increased. Being unable to see the patient during the night, and only at particular intervals during the day, I requested house pupil Chew to keep an accurate ac- count of the symptoms and treatment—and the following b his statement. " March 18th, 9 o'clock, A. M.—Slept but little last night— having been disturbed by dreams and pain in the arm. He feels less pain, however, this morning, though the sensibility of the arm is somewhat increased. Temperature of each arm equal— 95°. Last evening the temperature of the left arm, was 94°, that of right, 96°. Pulse not yet felt in the arm operated upon. In the other it is 100, and rather tense. Tumour has subsided very much. Thirst not great. Barley water continued as drink and diet. 3 o?clock, P. M.—No material alteration. 9 o'clock, P. M.—Little or no pain in the arm, but complains of a disagreeable, tingling, sensation, which frequently begins at the shoulder, runs down the arm, and seems to pass out at the elbow, leaving a sensation in the fore-arm and hand, as if they were enlarged to the size of a foot in diameter. There is only a instrument beneath the artery, works through the silver collar, and may be used or not, as the surgeon pleases. It will be seen at once, that the great advantage which this instrument possesses over those in common use is, that the ligature being held by the upper instead of the lower end of the stilet, the surgeon can draw the stilet along with the li- gature, at once, through the cannula and under the vessel—whereas, in other in- struments, the ligature being passed through the lower end of the stilet must, after having been carried below the artery, be in part retracted again before the surgeon can tie it. An additional stilet, if necessary, with a sharp point, may ac- company the instrument. The use of the instrument, however, as well as its form and size, will be bet- ter understood by the drawing in plate XVI. fig. 2 and 3. Luxation of the Arm. 339 sense of soreness in the wound. Temperature of the arm unal- tered. No pulsation perceptible at the wrist. Pulse in the right arm one hundred and twelve, small and tense. March 19th, 9 o'clock, A. M.—Little sleep last night—owing to dreams and starting. No material change in pulse or tem- perature. 3 o'clock, P. M.—Pulse more frequent, (128,) quick, small and tense, but more irritable than febrile. Temperature of right arm, 96°; of left, 98°. Skin dry, but heat of it not in propor- tion to frequency of pulse. Bowels not moved since the copious purging produced by the tartrite of antimony, administered during the attempt at reduction. Ordered sulph. magnes. ^j. aq. pur. 5viij.—5ss. occasionally, until it operates. 9 o'clock, P. M.—Bowels have been gently opened twice. Pulse less tense, though still frequent, quick, and irritable. Skin moist. Complains only of some soreness about the wound. No pain in the arm. The tingling sensation, and sense of en- largement of fore-arm and hand, not so troublesome. Sensibility of arm slowly increasing, but the pulse at the wrist not yet dis- tinguishable. 12 o'clock at night.—Skin dry, with restlessness. No other important change. Ordered acetate of opium, gtt. xx. March 20th, 9 o'clock, A. M.—Slept tolerably well last night, after the opiate. Pulse 128, but not so quick and irritable as last night, though small and tense. Skin about the neck and face a little jaundiced and moist. No pain. Has a keen ap- petite, but allowed only barley water. 9 o'clock, P. M.—No material alteration during the day, ex- cept a reduction of temperature in both arms—being 94° in each. 11 o'clock, P. M.—Has not slept, nor inclined to sleep. Ordered acetate of opium, gtt. xx. March 21sl, 9 o'clock, A. M.—Slept about four hours during the latter part of the night. Occasionally disturbed by dreams, delirium, and starting. Pulse more frequent, (136,) has lost much of its quickness and tension, and is smaller and weaker. Skin moist. No pulsation in left arm. Temperature of it 98°— that of right arm 96°. Spots of erysipelatous inflammation about left shoulder, and whole limb considerably swollen. Dr. G. or- dered the wound to be dressed. Done in presence of himself* 340 Luxation of the Arm. Drs. Barton and Harlan. Sides found in contact, and a little pus formed. Surface of the skin around the wound carefully washed with warm water: adhesive straps and lint reapplied. Better diet ordered, consisting of oysters, soft eggs, and porter and water. 3 o'clock, P. M.—Has taken moderately of the diet last di- rected, pulse 128, somewhat quicker, more tense. 9 o'clock, P. M.—Some increase of pulse both in tension and volume. Skin not so moist. Bowels have been slightly opened. Continues the same diet. Is restless. Ordered acetate of opium, gtt. xx. March 22c/.—Sleep more disturbed last night than heretofore. Is now dull and inclined to sleep. Pulse 140, small and weak, with some fluttering. The capillary circulation of left arm ex- ceedingly languid. Its temperature 93°. That of the right arm, 94°. Ordered by Dr. G. carbonate of ammonia mixture and quinine, and the arm to be enveloped in wool. Same diet con- tinued, but has no appetite. The erysipelatous inflammation spoken of yesterday, has increased. The hand is covered with purple spots, and its temperature somewhat less than that of the fore-arm. 3 o'clock, P. M.—The pulse improved a little in strength; is more distinct, and not so fluttering. Has taken, since morning, carbonate of ammonia and quinine alternately, every hour. Diet continued, with wine whey. Discoloration of the hand increasing and extending to fore-arm, though the sensible heat about the same. Considerable determination of blood to the head, which is hot, attended by muttering, delirium and increased restless- ness. 9 o'clock, P. M.—Pulse improved, since morning, in distinct- ness and artificial strength—the result of the stimulating treat- ment. An increased determination to the head, and delirium. Has recently taken gtt. xx. of acetate of opium, and ten more will be given in an hour. Ordered wine whey, freely, through- out the night. Temperature of the arm and hand preserved by warm flannel. March 23d, 9 o'clock, A. M.—Has had a very restless night. Pulse more frequent, (160,) much smaller, thready, weak and fluttering, although the carbonate of ammonia, quinine, and whey have been continued. Heat of head and delirium aggra- Luxation of the Arm. 341 vated. Hand and fore-arm more swollen, with increase of li- vidity. Cutaneous vessels greatly distended, and apparently in a state of congestion. Patient cannot distinguish one attendant from another. 4 o'clock, P. M.—Died. (Signed) E. R. CHEW." March 24lh, 1 o'clock.—The parts having been previously injected, the dissection was commenced by Dr. Ashmead, in presence of Drs. Barton, Harlan, Jackson, Pennock, Temple, Hunt, Wragg, Bettner, Hall, Nott, Chew, Peace, Levert, Bar- ker, and myself. It was soon found, however, that, the injec- tion was not sufficiently firm to enable the dissector to proceed in a satisfactory manner, and, besides that, the parts were so changed from their natural relations, as to require more time to be consumed in the investigation, than could be spared by most of the gentlemen present at the examination. On these ac- counts the dissection was postponed, until the afternoon, and then resumed by Drs. Ashmead and Hall, in the presence of occasional visiters. Dr. Hall not having been present, (owing to indisposition,) during the reduction of the dislocation, I was anxious that the dissection should be made, and the account of it drawn up by himself; and he has obligingly furnished me with the following communication:— " Philadelphia Alms-House, March 24th, 1828. " Dissection of John Langton, sixteen hours after death.—The left hand and fore-ann exhibited marks of incipient gangrene, ex- tending only to the skin and subjacent cellular membrane, and ter- minated by a well-defined line at the elbow. The wound made by the operation was filled with an offensive sanies, and exhibited no tendency to healthy granulations. " We threw in the cold lead injection, by fixing a pipe in the mouth of the left subclavian, through the aorta: the shoulder and neck were minutely injected, but as the radial artery was not filled, the pipe was introduced into it, and the lead driven upwards until a por- tion of the first injection was made to recede through the divided thoracic vessels. " The arm, scapula, and clavicle, with a portion of the ribs, were separated from the body, and carefully dissected by Dr. Ashmead and myself, in the presence of the surgeons and house students. All the parts about the axilla were so blended by adhesions as to render their discrimination very difficult. The muscles were unaltered 342 Luxation of the Arm. except from extravasation and effusion to be hereafter noticed. The subclavian artery was healthy, the vertebral of its usual caliber, the internal mammary large; the inferior thyroideal, the posterior cervi- cal, and the superior scapular arose by a common trunk from the subclavian, together with an anomalous artery, about the size of a crow-quill, which descended, between the subclavian and carotid, along the trachea; its destination was not pursued. The posterior cervical was of the size of a large quill, having its branch to the base of the scapula, much enlarged. The superior scapular artery ran along the upper edge of the subclavius muscle, and had escaped the operator's knife, though it had been made visible by the incisions. It inosculated beneath the neck of the scapula with the inferior dor- salis scapulae, which was the size of a crow-quill. From the un- favourable state of the part for dissection, we could not demonstrate the channels through which the blood to the arm passed, but that these existed, and would, under auspicious circumstances, have be- come adequate to the circulation, the course of the injection and other circumstances fully prove. " As the injection from above had penetrated to the ligature, it is presumed that no coagulum had as yet formed. The ligature em- braced the artery just where it emerges from beneath the scalenus anticus, and included no other part. The artery was uninjured, in all the space between the ligature and the point where it became ad- herent to the head of the bone, at the internal margin of the lesser tubercle. It was firmly attached to the substance of the bone and the articular capsule by dense cellular or ligamentous substance, and such was the compactness of this juncture, and so short the portion of artery between this point and that of its attachment to the rib, that it seemed absolutely impossible to reduce the bone to its place and not cause the rupture of the vessel. This effect was here exhibited. Where the artery adhered to the bone, its internal coats had been ruptured, with the exception of a very narrow band immediately op- posite to its point of attachment. The extremities of the artery had separated, as far as the band above alluded to would allow,^which was about half an inch,) and the artery, by tending to straighten it- self, was only retained to the bone by the intervening portion of its external coat. The dilatation of the external coat had formed a sac, which was expanded by being stretched between the points of its at- tachment to the bone and the ruptured extremity of the artery. This true aneurismal sac extended beneath the artery towards the liga- ture, and beneath the pectoralis minor muscle, but was ruptured in its posterior portion, very near its adhesion to the bone, so as to have allowed the blood to escape and form a diffused aneurism. Luxation of the Arm. 343 The blood had penetrated beneath the pectoralis major and minor muscles, and along the edge of the latissimus dorsi as far as the seventh rib. It had extended beneath the humerus, to the space between the long head of the triceps and the teres minor, and had filled the axillary cavity, but had been prevented from extending downwards by the general agglutination of the parts, caused by the dislocation. Along the internal margin of the coraco brachialis and the deltoid, there was much extravasation, but we rather think it was caused by the means used to reduce the bone. " The walls of the true aneurismal sac, were of so compact a tex- ture, and its boundaries so well defined, that the conjecture of its having existed previously to the reduction of the bone, and that its rupture was a distant and subsequent event is rendered probable. " Upon exposing the articular cavity, the head of the bone was found to rest beneath its original socket upon a bed of dense liga- mentous substance. The capsule was much thickened, and had a rupture in its inferior anterior portion, through which the blood and injecting matter had entered. " About one-third of the lower portion of the glenoid cavity had been broken off, and remained attached to the superior part of the neck of the bone, by an adventitious adhesion. "The greater tubercle of the humerus was cracked through its base, with the exception of the portion beneath its anterior facet. From the thickening of the periosteum, and the deposite of osseous matter, we do not think that this fracture was recent. The extremi- ty of the acrdmion process was found fractured, but was*"still firmly embraced by the surrounding muscular and fibrous structure. " It is proper to mention that the left ventricle of the heart was enlarged, and its muscular substance unusually soft. The right ven- tricle and auricles did not exhibit these phenomena. Upon opening that part of the subclavian, embraced by the ligature, the internal coats of the vessel were found completely divided, but no traces of a coagulum could be observed above the ligature, nor was there any vestige of coagulable lymph, or any approach to adhesion—though the ligature held its place with great tenacity, and the parts em- braced by it seemed healthy. " No other part was examined. "JAMES C. HALL, M. D." Remarks.—A second time has it fallen to my lot to witness a rupture of the axillary artery, during the reduction of an old luxation of the humerus at the shoulder joint. The particulars of the first case, with remarks upon them, were formerly de- tailed in the seventh volume of the Philadelphia Journal of the 344 Luxation of the Arm. Medical and Physical Sciences. It was there slated that the practice advised by Desault, and followed by most European and American surgeons in cases of ancient luxations, was to employ extension and counter extension to an almost unlimited degree, to rotate the limb in every direction, break up the adhesions and adventitious ligaments, and, in fact, to set no limits to violence and force rather than fail to restore the head of the bone to its original socket. With a view of illustrating this practice, ema- nating from a surgeon of almost unrivalled skill and reputation, the following quotation was made, and may be repeated in this place. " Previously to making extension," says Desault, " it is necessary to move the bone, very forcibly, in every direction, in order first to break the adhesions, to tear the condensed cellular membrane which serves as an accidental capsule, and to produce, so to speak, a second luxation with a view to make way for a perfect reduction of the first. The straps being then applied as in ordinary cases, serve the purpose of extension, for the accomplishment of which the number of assistants must be increased. Oftentimes the first efforts are fruitless, and the luxated head remains stationary amidst the most violent efforts. Let the extension then be discontinued. Re- new the forcible motions of the limb; carry the humerus upwards, downwards, forwards, and backwards; force the resistances to give way; make the arm describe a large arch of a circle round the place which it occupies; let the rotatory motions on its own axis be impressed on it anew; and then recommence the extensions and let them be made in every direction. By these the head, already dis- engaged by means of the preceding violent motions, will be brought to a level with the glenoid cavity, and ultimately replaced."* In addition it was stated, in the paper referred to, that Dr. Physick had, " in a variety of instances, succeeded after two and three months;" that the late Dr. Dorsey approved of De- sault's practice, and followed it successfully in several cases— that Dr. M'Kenzie, of Baltimore, replaced a dislocated os hu- meri, nearly six months after its dislocation—lhat the same had since been accomplished by Mr. Kirby of Dublin—and that I myself had repeatedly reduced luxations at the shoulder, and some other joints, from two to four months' standing, and that though in several instances the adhesions surrounding the head * Desault's Works, by Caldwell, p. 144. Luxation of the Arm. 345 of the bone, and the new socket, were so considerable as to re- quire great force and extensive laceration, not the slightest ac- cident had ever occurred. I took the opportunity, at the same time, to remark, that there were very few cases on record, so far as could be ascertained, of injury, much less of death, re- sulting from the practice—that Desault had detailed the history of one case in which a large emphysematous, or bloody, tumour formed under the pectoral muscle immediately after the reduc- tion was accomplished—that Sir Charles Bell had mentioned an instance of rupture of the axillary artery and muscles, during the use of an ambe, and that in consequence the surgeons were obliged lo amputate on the spot—that David, surgeon of the Holel-Dieu, at Rouen, had reduced, after violent efforts, a dislo- cation of several months' standing, and that the patient lost his life from mortification of the whole arm. Since the publication of these statements, however, I have met with others, among writers, of a similar character. Pelletan, especially, in his Clinique Chirurgicale, alludes to several cases of the kind, and upon one of them makes the following remarks. "La tradition nous a conserve un fait de ce genre arrive" a 1'Hotel-Dieu il y a ti peu pres vingt ans. On voulut re'duire une luxation de l'humerus qui existait depuis quartre mois. Dans les violens efforts qui l'un fit pour y parvenir, il se fit un dechirement douloureux, et il s'eleva une tumeur volumineuse. On annonga que cette tumeur e'tait emphysemateuse; mais des tdmoins oculaires m'ont rapports que c'etait une crevasse de I'artere et un epanchemcnt de sang: on en fit 1'ouverture, et le malade mourut d'hemorragie."* In the eleventh volume of Johnson's Medico-Chirurgical Review,t there is a condensed ac- count of several cases, " illustrative of the ill consequences which sometimes follow the reduction of dislocation," from the French of M. Flaubert..!. The first case noticed is that of a stout sailor, of intemperate habits, and fifty-seven years of age, who entered the hospital of Rouen on the 13th of March, 1824; in consequence • Tom. 2d, p. 95. f Page 452. $ Memoires sur plusieurs cas de luxation, dans lesquel les efforts pour la reduc- tion ont etc" suives d'accidens graves. Par M. Flaubert, chirurgien en chief de I'Hotel Dieu de ltouen, in Repertoire General d'Anatomie et de Physiologie Pa- thologiques et de Clinique Chirurgicale, &c. &c, premier trimestre, cinquieme numdro, 1827. Vol. I. 44 346 Luxation of the Arm. of a forward luxation of the humerus which occurred eleven days before. On the same day the patient was admitted, an at- tempt was made by M. Leudet to replace the bone, in which, after two trials, he succeeded. "An enormous swelling followed almost immediately beneath the pectoral muscle. The face became pale and covered with sweat, the lips livid, and the pulsation in the radial artery ceased. 14th. The countenance was pale, the pulse small, hard and frequent. The swelling seemed to have subsided a little, but the limb was cold and of a purplish colour. In the axilla was a tumour, the pulsations of which were distinct to the eye, though not to the touch. It was now evident that the artery was ruptured, but the state of the parts around precluded any operation for tying the subclavian. On the 17th phlyctenae appeared, and on the succeeding days, gangrene be- came developed. 25th. The fingers, elbow, skin of the axilla, and inside of the arm, are in a state of sphacelus; the pulsations of the tumour are more marked. 27th. A good deal of hemorrhage from two openings situated a little below the arm-pit. Though the bleed- ing was arrested, the patient expired in the course of an hour. " Dissection.—H;md and inside of the arm in a state of gangrene. The pectoralis major was almost completely torn across, and its fibres were separated by clots of blood. The upper portion of the short head of the biceps was ruptured also. AH the muscles of the arm, shoulder, and outside of the chest, were infiltrated with blood. Between the pectoralis minor and latissimus dorsi, there was a large clot, on removing which, the axillary artery was found to be fairly torn across, a little above the origin of the subscapular. In order to discover the upper end of the vessel, it was necessary to dissect the subclavian, which was enlarged, as were the branches which arise from it. The axillary artery lay beneath the pectoralis minor upon the rib, to which it adhered by means of coagulable lymph. The end of the vessel was narrowed, and the thoracic nerves flattened. The second rib was depressed, its periosteum slightly absorbed, and the bone itself a little rough. The head of the humerus was some- what flattened at the part corresponding to the rib; the capsule was torn, the cartilage rough and ulcerated in parts. The inside margin of the glenoid cavity y/diS fractured/'' In the second case of dislocation into the axilla, reported by Flaubert, there was reason to believe that the axillary plexus of nerves was injured by the attempts at reduction. In the third Luxation of the Arm. 347 case, (also a dislocation into the axilla,) the axillary nerves were found upon dissection to have been torn from the spinal mar- row. Another case is related by the same writer, in which the reduction of a dislocation of the fore-arm backwards, was fol- lowed by great irritation, syncope, loss of pulse, enormous swelling, from which the patient narrowly escaped. A fourth case of luxation of the shoulder, attended by consequences nearly similar to those last mentioned, is also reported, and a fifth, (that of luxation of the hip,) in which it was doubtful whether the patient's death was caused by the accident or by the means em- ployed to reduce the bone. Flaubert concludes by remarking, that " surgeons either say less than they might about their mishaps, or that he alone had been unlucky enough to meet with all these unfortunate accidents." It is not my intention to comment, except in a very brief way, upon the case of Langlon. The particulars of it having been fairly and honestly stated, the profession will be able to draw its own conclusions. I may remark, however, that between the first accident of the kind I have detailed, and the second, (a period of five years,) I have reduced five luxations, each from two to four months' standing—one in a patient of Dr. D. T. Coxe, upwards of sixty years old—another of Dr. Manuel E. Robinson, about the same age, and three more in my own practice, besides several similar accidents of a recent kind—all of which termi- nated in the happiest manner. From these, and from many other cases of a similar character which I have treated within the last twenty-five years, 1 think I have good reason lo conclude, that where no adhesion exists be- tween the artery and surrounding parts, the operation may be done with safety; that on the contrary when adhesion does exist, (and of this we have no means lo judge,) rupture of the vessel must be an inevitable consequence, whether the reduction be effected by force, or by the most gentle means. To show, however, that neither my colleagues, nor myself, made use of unwarrantable force in the case of Langton, I shall present the following docu- ments, obligingly furnished by some of the gentlemen present at the reduction. 348 Luxation of the Arm. "My Dear Sir, " I was present when you reduced the luxated humerus of John Langton, assisted by Drs. John R. Barton and Harlan, on Saturday, the 15th inst. at the Alms-house Infirmary. " On that occasion, the force employed was much less than I have repeatedly witnessed in the reduction of ancient luxations, and less could not have been used with any probability of accomplishing the reduction. The force was gradually applied and long continued, with the intention, as you expressly remarked, to avoid the hazard of accident. "I believe it to be very probable that the rupture of the axillary artery in the reduction of long standing luxations of the humerus, has occurred in more instances than the small number on record. But unfortunately surgeons and physicians have seldom the candour or independence to acknowledge their failures or the unfavourable results of their practice, while the successful cases are sedulously blazoned forth to the world. This custom is analagous to the sup- pressio veritatis of a witness before a jury, and should be regarded as equally culpable, and leading to equally injurious consequences. A work exposing the hazards attendant on operations and the dangers of active medicines, illustrated with opposite cases, is a desideratum in the science, the execution of which would confer a most important obligation o» the profession. With great respect, yours, truly, Dr. Wm. Gibson. SAMUEL JACKSON. March 22d, 1828." "Professor Gibson, " Dear Sir—Having learned that you intend to publish the case of John Langton, I beg leave to express my pleasure at the disclosure of an event likely to be so salutary to the interest of surgery. The condition of the parts connected with the dislocation, was not evi- denced by any external signs, at the time when the reduction was attempted, nor could it be reasonably conjectured by any thing which appeared. The force applied was not irregular, ill-directed, or such as could have done any injury in that state of parts which usually follows a dislocation of the os humeri. The unexpected result arose out of circumstances beyond your control and insusceptible of detec- tion; had it been otherwise, I feel assured that your surgical tact and cultivated skill would have discerned the lurking evil, and provided against the consequences. Very respectfully, your obedient servant, J. K. MITCHELL. Philadelphia. March 28th, 1828." Luxation of the Arm. 349 "We, the resident students of the Philadelphia Alms-house In- firmary, certify, that as far as we are capable of judging, the utmost skill and prudence were exercised in the reduction of the above lux- ation. "The patient was bled, purged, and kept on barley water alone for four or five days previous to the operation. About one hour and three-quarters were taken up in the attempts at reduction: during this time he was bled copiously, took large doses of tartarized anti- mony—was placed in every position which could promote success— and extension and counter extension were made in the most gradual manner. The rotatory motions, necessary for breaking up the adhe- sions, were also made with the greatest caution. (Signed) HENRY S. LEVERT, M. D. J. C. NOTT, M. D. JOHN B. TUFT, M. D. E. R. CHEW. GEO. S. BETTNER, M. D. JOS. PEACE, M.D." WILLIAM ASHMEAD, M. D. My former paper on rupture of the axillary artery was con- cluded in these words:—"A question may possibly arise— whether surgeons should be influenced, by the event of the case I have detailed, and by those I have quoted, and deterred alto- gether from attempting reduction in dislocations of long stand- ing, or whether the established practice should still be continued, unaffected by fortuitous circumstances or contingencies neither to be foreseen nor controlled? To the latter proposition I have no hesitation to give unqualified assent, and to declare, that should a case similar in appearance to that of James Scofield again oc- cur, I shall feel justified in adopting a similar course." Such a case has occurred, but unfortunately, with a result that could scarcely have been anticipated, either by myself or coadjutors. If the question were again presented, I should answer it, I think, in the following way. If the patient is young, not very muscu- lar, the luxation not complicated with fracture—if no attempts have previously been made to accomplish the reduction, and the head of the bone has not been out of its natural situation beyond five or six weeks, I should advise the attempt to replace it. But, on the contrary, if the patient is very robust and vigorous, advanced in years, accustomed to labour and to the free use of ardent spirits, and the head of the bone has been long out, I should discountenance any attempt at reduction. In conclusion, I shall merely observe, that the fractures of the acromion pro- 350 Luxation of the Arm. cess, of the greater tubercle of the humerus, and of the lower portion of the glenoid cavity occurred, in all probability, either at the time of the accident, or during the attempts made in the country to reduce the bone—and that the snap so distinctly heard the moment before the head of the bone was restored to its socket, arose, beyond doubt, from thtf lower fragment of the glenoid cavity being but imperfectly united and broken up again by the extension and counter extension. EXPLANATION OF THE PLATES. PI. XV. 1. Scalenus anticus. 2. Scalenus medius. 3. Trapezius. 4. Pectoralis n^inor. 5. Pectoralis major drawn from beneath the biceps. 6. Coraco brachialis. 7. Biceps. 8. Deltoid. -*• 9. Tendon of the latissiinus dorsi. 10. Clavicle of a portion removed. 11. Acromion. 12. Head of the humerus out of its socket. 13. Glenoid cavity of the scapula. 14. Subclavian artery, coming from beneath the scalenus muscle with the ligature around it. 15. Inferior thyroid artery. 16. Posterior cervical. 17. Superior scapular. 18. External mammary. 19. Subscapular. 20. Band formed by remaining portion of the two internal coats of the artery, and connecting the divided ex- tremities of the vessel. 21. Cavity of the aneurism. 22. Anterior part of the aneurism. 23. Rupture of the sac. 24. Basilic vein and venae comites. 25. Brachial nerves. 26. Part of the sac turned upwards. PI. XVI. fig. I. a. Acromion process of scapula, with fissure through it. b. Glenoid cavity. I>Z3V. PL.2EC- JJrmmltEnf'l by Mrayt* Luxation of the Arm. 351 c. Inferior part of the glenoid cavity broken off, and attached by a ligament to the upper part of the neck of the humerus. d. Greater tubercle of humerus fractured through its base. e. Head of the humerus. /. New socket in which the head of the humerus rested. g. Part of Capsule of the articulation. Fig. 2. Improved cannula with its stilet—Perspective view. Fig. 3. Side view. a. Handle. b. Silver Cannula. c. Stilet, formed of watch-spring, with an eye at one end through which a ligature is passed, and with a silver head at the other made to fit accurately to the end of the silver cannula. The needle is pushed some distance through the blade so as to give a better view of it. d. Screw by which the stilet is retained firm in its place. The conclusions which I am now prepared lo draw (from the result of the cases of Scofield and Langton, from those reported by Flaubert, and from other communications to me within the last two years,) are directly the reverse of what I have slated in some of the foregoing pages; I am now disposed to condemn, in the most unqualified terms, all attempts at restoration of an- cient luxations of the humerus and other bones—except in cases where the patient is remarkably thin and debilitated, and where there has been little or no inflammation at the time or subsequent to the displacement. Two cases of old luxations of the shoulder, one in a mulatto woman thirty-five years of age, the other in a man of forty, presented themselves at the Blockley Hospital during the win- ter of 1835. The head of the humerus appeared in each case to have formed very close adhesions with the surrounding parts, and as the luxations had been of several months' duration, and had been followed originally by a good deal of inflammation, I declined attempting reduction, and should observe the same rule in all similar cases. 352 Luxation of the Arm. To reduce a luxation of the shoulder forwards, the elbow should be directed backwards, and the arm drawn downwards as close to the side as possible. Counter extension may be made in the usual way or by the heel in the axilla. In luxation backwards, the arm must be elevated above the head; this will have a tendency to carry the ball of the humerus downwards and disengage it from the dorsum scapula?, from which it will slip into the axilla, and may afterwards be re- duced according to the directions already given for the manage- ment of dislocation in the axilla. This plan at least has been recommended by Sir Astley Cooper. From an interesting letter, however, which I received in September, 1831, from Dr. George Snider, a respectable practitioner of Jackson in Tennessee, detailing a case of disloca- tion on the dorsum scapulae, it appears that elevation of the arm above the head does not always succeed in reducing the bone. " On the 7th of June, says Dr. Snider, my colleague, Dr. James Young, was requested to visit Washington, aged twenty- five years, the slave of Mr. A. P., of this place, who was re- presented to have received a severe injury of the right shoulder by being precipitated from a cart, when at full speed. Dr. Y. on reaching the place where the accident happened, discovered that a dislocation had taken place—Washington was directed to be conveyed to his master's house, a distance of three or four hundred yards, when I saw him in conjunction with Dr. Y. Though the distance was but short, and a very few minutes had elapsed from the time of receiving the injury, until he was brought home, the swelling was found to have increased very much, and he complained of intense pain whenever the shoulder was moved. Upon an examination, a depression was observed beneath the acromion, and the head of the hone found resting on the dorsum of the scapula, below the spine, the arm approxi- mated to the chest, with the fore-arm thrown across it. "Reduction was attempted in the manner recommended by you, by elevating the arm above the head, with the view of disengaging the head of the bone from the dorsum scapulas, and throwing it into the axilla—we were unable after two trials to effect the reduction in this way. The bandages were then ap- plied in the usual way for dislocation into the axilla, and the Luxation of the Arm. 353 reduction accomplished (to our great satisfaction) with perfect ease. We are inclined to think that had we succeeded in throwing the head of the bone into the axilla, the difficulty of reduction would have been increased, on account of the rent in the capsular ligament not corresponding with the position of the head of the bone." Vol. I. 45 354 Luxation of the Fore-Arm- Section IV. Luxation of the Fore-Arm. From an examination of the structure of the elbow joint, v. might be supposed that luxation could scarcely happen in any direction. There is one direction, however, in which it is ex- ceedingly frequent—upwards and backwards of both bones of the fore-arm. * Laterally, luxation is very uncommon, and an- teriorly can hardly occur without a previous fracture of the ole- cranon process. The luxation upwards and backwards is generally produced by a fall, in which the patient extends his arm to save the body, and receives the whole shock upon the palm of the hand. A tumour, formed at the bend of the arm, by the condyles of the humerus, and covered by the brachialis internus and biceps muscles in a state of violent distention, by the contraction of which the fore-arm is kept in a state of semiflexion, and a large protuberance on the back of the elbow produced by the unna- tural projection of the olecranon, will be sufficient to point out the precise nature of the injury. Lateral luxations of the elbow may be known by the internal or external displacement of the bones composing the joint, or in other words by the peculiar deformity attending each variety of the accident. The luxation anteriorly, should it ever occur,* independently of fracture of the olecranon, may be easily recog- nised by the posterior projection of the condyles of the humerus, the extended position of the fore-arm, and the prominence of the coronoid process at the bend of the arm. Besides luxation of both bones of'the fore-arm from the hu- merus, the upper and lower extremities of the radius and ulna may be separated from each other. The direction of displace- * One case of the kind is recorded by Delpecli Luxation of the Fore-Arm. 355 ■ment of the upper extremity of the radius may be either back- wards or forwards. The former is (he most frequent, and is commonly produced by inordinate action of the pronator mus- cles, the effect of which is to dislodge the bone from the lesser sigmoid cavity of the ulna and place it on the outside of the olecranon, where it may be distinctly felt forming a considera- ble eminence; at the same time the hand is fixed in a state of pronation. In luxation of the radius forzoards, which is ex- tremely rare, the hand will be found in a state of supination, and the head of the radius may be felt projecting at the bend of the arm. According to Sir Astley Cooper, luxation of the upper ex- 'remity of the radius backwards is a very uncommon accident, and luxation forwards the most frequent of the two. This statement, I am very sure, however, is entirely unfounded; in- deed, I have always looked upon it either as a typographical error, or as introduced inadvertently by Sir Astley into his work. I myself have seen several examples of luxation of the radius backwards, and in particular I had an opportunity of exhibiting to the class, in the winter of 1S26, a case in which both radii were luxated at the same moment, from the patient being precipitated suddenly before a hogshead of sugar, whilst in the act of rolling it. Boyer says that " the upper extremity of the radius can only be luxated backward;" and Desault re- marks, on the other hand, that he himself had never met with the accident at all in either direction. The lower extremity of the ulna sometimes abandons the sig- moid cavity of the radius and projects posteriorly. At other limes, though rarely, it is pushed forwards. In the former case the hand is in a state of pronation, and the end of the ulna is felt be- hind the radius; in the latter the ulna projects on the front of the wrist, and the 1 and is fixed in a painful state of supination. 356 Luxation of the Fore-Arm Treatment of Luxation of the Fore-Arm. There are several modes of reducing the dislocation upwards and backwards of both bones of the fore-arm at the elbow joint, but I prefer the following. The patient should be seated on a chair, while the surgeon, placing his knee in the bend of the arm, makes counter extension and extension by grasping the fore- arm just above the rist; at the same time the fore-arm is bent nearly at a right angle upon the arm. This plan seldom fails, and the bones return to their places with an audible snap. The fore-arm should afterwards be carried across the chest and sus- tained by a sling, or, by way of additional security, may be sur- rounded by splints and kept still for a week or ten days. Old luxations of the elbow, or those which have existed beyond three or four months, can seldom be reduced. To reduce a lateral luxation of the elbow, Sir A. Cooper recommends forcible ex- tension of the arm in order to oblige the tendons of the brachia- lis internus and biceps muscles, which are stretched over the condyles of the humerus, to act upon the principle of the string of a pulley, and drag the bones into their places. To reduce a backward luxation of the upper end of the radius, nothing more is necessary than for the surgeon to force the pa- tient's fore-arm with one hand towards supination, and with the other to push the head of the radius from behind forwards. By these simultaneous efforts, the bone suddenly starts into its place, and the deformity and other symptoms instantly disappear. Luxation of the same bone forwards, must be treated upon the same principles, but the force should be exerted in an opposite direction. Luxation of the lower extremity of the ulna is commonly reduced without difficulty. When displaced in a backward di- rection, the hand should be gradually but forcibly extended and moved laterally until restored to its supine position. A slight pressure on the head of the bone will then be sufficient to re- place it. In luxation forwards the hand must be carried down- wards, or in the direction of the state of pronation. Luxation of the Hand. 357 Section- V. Luxation of the Hand. Under this division may be included dislocations of the wrist, of the carpal and metacarpal bones, and those of the fin- gers and thumb. None of these injuries are very common, and when they do occur, are generally accompanied with wounds and fractures, produced by heavy weights, or by the bursting of a gun. The radius may be merely dislocated, however, from the carpal bones, either in an anterior, posterior, or late- ral direction. In all these cases, the most common cause of the accident is a fall upon the palm, back, or edges of the hand. An anterior luxation may be known by the projection of the carpus in front of the wrist, by the tension of the flexor mus- cles, and the extended position of the hand. A posterior luxa- tion, on the contrary, will be characterized by the flexed posi- tion of the hand, by a protuberance on the back of the wrist, and by the tension of Ihe extensor muscles. Lateral luxations are easily distinguished by the projection or deformity at the radial or cubital edges of the wrist. The carpal bones are so firmly connected to each other by short ligaments and by a ball and socket joint, as to be scarcelv susceptible of luxation. Instances, however, are now and then met with, of displacement of the os magnum and os cuneiforme, either from violence or from extreme relaxation of their li^a- ments. The metacarpal bones are, perhaps, never luxated, ex- cept by a gun-shot wound or some similar violence. The fingir.v, from their mobility and the strength of the liga- ments and tendons surrounding them, are very seldom luxated. Indeed, except in a backward direction, owing to Ihe peculiar conformation of the articulating surfaces, a dislocation would 35S Luxation of the Hand. seem almost impossible. The thumb, however, is not unfre- quently luxated, either at the articulation of the metacarpal bone with the trapezium, or at the junction of the first or se- cond phalanx. Dislocation of the first phalanx from the meta- carpal bone is the most common, and may be known by the pro- jection of the latter inwards, or towards the palm of the hand, while the former is mounted upon the metacarpal bone, and forms a considerable eminence backwards. Treatment of Luxation of the Hand. Luxations of the lower extremity of the radius, whether in an anterior, posterior, or lateral direction, must be treated upon the same principles—by extension, counter extension, and pres- sure on the protruded bone, and by bandages and splints after the reduction is accomplished. To restore a displaced os magnum or cuneiformc, will often be found very difficult; and to retain them fixed in their natural situation still more so, especially when the luxation proceeds from relaxation of the ligaments. Well directed pressure, and an appropriate bandage, are the only remedies. Strange as it may seem, the dislocated thumb sometimes re- mains irreducible in spite of the most powerful efforts the sur- geon can make. Instances, indeed, are not wanting, of the thumb being dragged off' during violent efforts to reduce it. These difficulties may probably be traced to the common prac- tice of making the extension in a straight line, (by which the heads of the bones are wedged into each other,) instead of bend- ing the dislocated bone downwards in a semicircular sweep. Should the mere manual efforts of the surgeon prove insufficient, a piece of tape doubled into the form of " the clove hitch," or sailor's knot, may be secured to the thumb, previously covered Luxation of the Hand. 359 with a piece of buckskin, and a greater degree of force exerted, hut still in the direction recommended—downwards or towards the palm of the hand. If this treatment also fail, the surgeon must not, like Sir A. Cooper, despair of success, and under the idea that " the patient will have a very useful thumb after a time, even without reduction,"* abandon all other resources, but promptly execute the ingenious and efficient plan of Sir Charles Bellf—the division of one of the lateral ligaments by the oblique insertion of a couching needle. Luxation of the fingers should be managed in every respect like that of the thumb. One or more toes are sometimes dislo- cated by the relaxation of their tendons, and become very much deformed, and so inconvenient to the patient by impeding his walking, as frequently to require amputation. In three or four instances of the kind, I have performed the operation on this account, and with complete success. To relieve this deformity, Boyer,J instead of amputation, has proposed the removal of a portion of the extensor tendon belonging to the deformed toe, and relates two cases in which the operation proved effectual. * See Cooper on Dislocations, &c. 4to. p. 533. f See Operative Surgery, vol. ii. p. 261. t Treatise orr Surgical Diseases, vol. ii. p. 384. 360 Luxation of the Thigh, 6,i. Section VI. Luxation of the Thigh and Pelvis. The thigh bone is more subject to fracture than dislocation* though the latter is by no means uncommon. It may take place in four directions—upwards and outwards on the dorsum of the ilium, downwards and inwards into the foramen ovale, upwards and forwards on the pubes, and backwards into the ischiatic notch. The first two are the most frequent, and the latter ex- tremely rare. Luxation upwards and outwards, is generally produced by a fall upon the foot or knee, while the thigh is directed forwards and obliquely inwards. The round ligament and the upper por- tion of the capsular being torn, the head of the bone escapes, and lodges first upon the convex surface of the ilium, but soon changes its position, and sinks into the external iliac fossa, where it afterwards remains. A prominence near the superior spinous process of the ilium, formed by the great trochanter, together with a shortening of the limb and an inclination of the foot in- wards, are sufficiently characteristic of the nature of the ac- cident. Luxation of the femur downwards and inwards, differs ma- terially from the foregoing. The limb is lengthened by two or three inches, the foot turned outwards, the great trochanter removed from the superior spinous process of the ilium, and the head of the bone, especially in thin subjects, distinctly felt at the foramen ovale, or upper part of the thigh. This accident is produced by a forcible abduction of the thigh, or by violence applied while the thighs are extensively separated from each other. The round, as well as the capsular, ligament is general- ly torn, and the head of the bone rests upon the obturator ex- ternus muscle. Luxation of the Thigh, fyc. 361 Although luxation on the pubes is seldom met with, the ex- act situation of the head of the bone, and the manner in which the accident is produced, are well known. A hard tumour may be felt above Poupart's ligament, on the outside of the femoral vessels; the limb is shortened about an inch; the foot is turned outwards, and the trochanter major placed in front of the anterior superior spinous process of the ilium. This species of luxation must invariably happen from force ap* plied while the limb is carried backwards and fixed, and from the body being at the same time thrown off its balance and directed backwards. Dr. Physick* once met with a case of luxation of the femur on the pubes, in which the affected limb, instead of being shorter, was somewhat longer than the sound one. When the head of the os femoris is forced backwards and lodged in the ischiatic notch, the limb will be found shorter by half an inch or an inch than that of the opposite side, and the foot slightly inclined inwards. Owing to the depth of the notch, the head of the bone can seldom be felt. To produce this va- riety of luxation, the force should be applied while the thigh is bent upon the abdomen, or the body is thrown forward upon the thigh. Treatment of Luxation of the Thigh and Pelvis■; The muscles surrounding the hip and thigh bone are so large and powerful that the surgeon must expect to encounter very considerable resistance in his efforts towards reduction. What- ever may happen to be the direction of displacement, with lit- tle variation, the same means must be employed. In addition to the general treatment formerly recommended for all luxations, and which will be found particularly necessary in luxations of ♦ Dorsey's Surgery, vol. i. p. 271 Vol. I. 46 362 Luxation of the T/iigh, . Section IV. Exostosis. In health a balance exists between the absorbent and exha- lent vessels, which preserves each part of the animal frame with- in regular bounds. Deviations from this natural standard, in many instances, produce diseases, differing in situation, degree and character, from the slightest perceptible change of organiza- tion, to the most unlimited extent of morbid structure. Hence two opposite classes of disease result—according as the laws which regulate the decomposition or increment of the body pre- dominate. In one case the constituent particles are removed, and diminution is the consequence: in the other, an undue pro- portion of matter accumulates; giving rise to general enlargement or to excessive deposition, in some individual texture. In this way every tumour must form. A tumour, whether formed of cellular membrane, skin, muscle, or bone, is a vascular organized mass; receiving a supply of homogeneous particles from the tex- ture upon which it is reared, or with which it is assimilated. If this view be correct, we may perhaps conclude that such dis- eases, in their incipient state or original formation, do not differ in composition from the organ or part from which they are de- rived ; but acquire specific characters, as they increase, from pe- culiarities of constitution or from local causes, the operations of which are not always easily explained. That diseased super- structures, or " new productions which made no part of the original composition of the body,"* never exist, we cannot pre- tend to assert; but, we are inclined to consider such formations * See Abernethy's Surgical Works, vol. ii. Exostosis. 383 extremely rare.—The immediate foundation of every tumour, is probably laid in a bed of coagulable lymph: this lymph is rendered vascular, increases in every direction, in proportion to its supply, becomes smooth or irregular, soft or hard, fleshy, or bony, pa- renchymatous, or medullary, according to the original structure, from which it is derived. How it is enabled to assume specific, vitiated, or malignant characters, cannot satisfactorily be ex- plained, so long as our knowledge of the operations of nutrition and secretion are confined within narrow limits. Exostosis appears, generally, as a distinct tumour of a bone, is smooth on the surface, seldom painful, and may remain long with- out becoming very large. Occasionally, the whole surface of a bone is found rugged or scabrous; consisting of numerous plates laid over each other, and sometimes piled to a considerable height in thick'irregular masses. Again; the disease appears in the form of tuberculated knobs or irregular excrescences, close- ly connecled, or insulated. In a third variety, spinous pro- cesses or bony spires, are eked out several inches and termi- nate either in a sharp point or knob. After careful examination of diseased bones in the splendid cabinet of the late Dr. Wis- tar, and of numerous specimens in my own collection, I have met with no other forms of exostosis, than those mentioned. I conclude, therefore, that the disease seldom appears in any other shape, and under this impression shall denominate each variety according to its external characters. The first I shall call circumscribed exostosis, the second lamellated exostosis, the third tuberculated exostosis, and the fourth spinous exos- tosis. Under the term exostosis, authors comprehend several dis- eases, essentially different in symptoms, structure and appear- ances. Thus we have the "fungus exostosis," which accord- ing to the account given of it by Sir Astley Cooper,* must be the osteo-sarcoma or osteo-steatoma, complaints specific in their nature and in structure very remote from exostosis. The same may be said of spina ventoso. The divisions made by the French writers, founded upon supposed causes of the disease, such as the * Cooper and Travers' Surgical Essays, part 1st, p. 170. 384 Exostosis. scrofulous, darterous, syphilitic, scorbutic, and carcinomatous exostosis, are equally faulty, since they do not designate any variations of structure or form, but only imaginary shades of difference. Upon the whole, then, we are inclined to consider exostosis as a mere enlargement, from inordinate deposition of ossific matter transcending the natural limits of a bone, in the shape of a spherical tumour, a plaited covering, an irregular excrescence, or a pointed production; in each of which, however different the figure, the structure is the same. The bones are all subject to exostosis;—sometimes the dis- ease prevails universally. An instance is related by Mr. Aber- nethy " of a boy who was so excessively afflicted with an appa- rent predisposition to exostosis or an exuberant deposition of bony matter, that a very trifling blow would occasion a bony swelling on any bone of his body. His ligamentum nuchae was ossifidd, and prevented the motion of his neck; the margins of his axilla were also ossified, so that he was, as it were, com pletely pinioned. Besides all this, the subject in question had numerous other exostoses on various parts of his body."* Saucerottef has detailed the history of a man thirty-five years of age, in whom all the bones except the teeth, were increased to double their natural thickness, but remained of the ordinary length. The skull became so large as to present a hideous ap- pearance and the eyes were forced from the sockets. The ribs were approximated, and the sternum, clavicles and scapulae, un- commonly prominent. During the increase of the bones the patient could not move himself, breathed with great difficulty, and suffered from pain in every part. The pulse was scarcely perceptible, and the urine deposited a thick white sediment. After suffering for seven years he died, but permission could not. be obtained to examine the body.-—Such is sometimes the predisposition to exostosis, that even the muscles and tendons are completely ossified. A striking example of the kind is re- corded by Dr. Henry.J The patient was a labourer, nineteen years of age, and first perceived a painful swelling in his right wrist which gradually increased, involving all the muscles of * Cooper's Dictionary of Surgery, vol. i. p. 288. \ Medical and Physical Journal, vol. i. p. 491. i Philosophical Transactions, vol. xxi. p. 89. Exostosis. 385 the fore-arm and converting them into a solid bone, as high as the elbow. The left arm was attacked in a similar manner; then the right leg from the ankle to the knee, and finally the disease extended from the shoulder to the fingers of each arm. Of the individual bones, the cranium, lower jaw, ribs, sternum, and long bones of the extremities, are particularly liable to suf- fer from exostosis. The frontal, parietal and occipital bones, are sometimes ir- regularly thickened by ossific depositions; at other times they are changed into regular plates of uncommon thickness. There is a skull in the possession of Dr. Parrish, of this city, taken from a young negro, in which all these bones are upwards of an inch in thickness, and extremely compact and solid. Ex- amples nearly similar are given by Sandiforl.* The os frontis is more subject to exostosis than either the parietal or occipital bones. Frequently the external table is covered with bony excrescences, composed of spicula, resembling crystallizations.t Occasionally both tables are involved, and encroach upon the dura mater and brain. Every variety of exostosis has been found on the skull; but the lamellated is the most common. Exostosis may occupy the orbit, and become so large as to displace the eye. A few cases of the kind are recorded by writers. In the Edinburgh Medical and Surgical Journal^ an interesting history is furnished by Mr. Lucas, of a bony tu- mour an inch and a half in length, two inches five-eighths in circumference, and weighing an ounce and two drams; which grew from the orbit of a woman twenty-eight years old, and forced the eye forwards and outwards, causing it to hang be- yond the exterior edge of the socket. The disease was produced by a blow from a cow's horn, on the upper and inner an- gle of the orbit, nearly on the transverse suture. Mr. Lucas divided the upper eyelid and exposed the bone, which was so firmly fixed as to withstand every effort to extract it. The wound did not heal, and the bone continued to increase for some time. At length it became carious, and was finally drawn away, but not without difficulty. The eye was placed in its natural situation ; and the sight, although nearly destroyed by pressure, * Museum Anatomicum, vol. ii. p. 13. f Baillie's Engravings of Morbid Anatomy, p. 208. * Vol. i. p. 405. Vol. I. 40 386 Exostosis. was soon completely restored. Upon analysis, the tumour was found to consist of cartilage, phosphate of lime and carbonate of lime, was extremely irregular, resembled a wedge cut out of a sphere, and so hard as to admit of being polished like ivory.— A very striking example of inordinate deposition of bony matter, upon the orbits and adjacent parts, destructive of each eye, is recorded by Howship.* A man aged 50 took cold; inflammation supervened, and a tumour of the size of a hazel-nut formed be- low the inner angle of each eye. These continued to enlarge, and were attended with intolerable pain, which extended to the bones of the face and head. The eyes were constantly inflamed and pressed forward in proportion as they were encroached upon, until they were displaced and burst. When examined by Mr. Howship in 1815, the patient, independent of loss of sight, and occasional headach, enjoyed good health. The tumours of the maxillary bones were as hard as ivory and not in the least painful when pressed, filled the orbits and enclosed the nasal bones so as to obliterate the nostrils. A large exostosis of the consistence of ivory, and filling the left orbit, is represented in Dr. Baillie's plates of morbid anatomy. The facial bones are frequently the seat of exostosis. " We have," says Sir Astley Cooper, " in the collection .at St. Thomas' Hospital, a skull which I took from a fish woman who died in that hospital, who had long been remarkable (even at Billings- gate) for her hideous appearance. Two large swellings had been formed under the orbits in the fore-part of her cheeks, be- tween which the nose appeared wedged and the nostrils were closed; each eye projected considerably from its socket. This person was seized with a fit, which seemed to be of an apoplec- tic nature, and in that state was brought to St. Thomas' Hospi- tal, where she almost immediately died. Upon examination of the head an exostosis was found growing from each antrum, and forming the large swellings upon the cheeks: these also project- ed into the orbits so as to occasion the protrusion of the eyes. On the left side the exostosis entered the cranium, projected in- wards through the orbitar process of the os frontis,and occasion- ing such pressure upon the brain, as under a considerable excite- • Practical Observations in Surgery, p. 26. Exostosis. 387 ment of the vessels of that organ, to produce apoplexy, which proved fatal to her."* An exostosis sometimes arises from the cavity of the antrum maxillare. At other times the polypus or fungus which sprouts from the lining membrane of that sinus is converted into a hard and incompressible exostosis. Mr. Abernethyt has furnished a very curious case of this description. The patient suffered more than nine years with a fungus, which bled profusely, but finally sloughed during a fever. A bony mass, soon rose upon the edges of the walls of the antrum, projected in a sloping form, and resembled a large tea-cup, fastened upon the face. The tu- mour was irregular on the surface and became too large to ad- mit of extirpation. I am informed by Dr. Physick, that a case of fungus of the antrum, which terminated in a bony tumour, occurred to the late Dr. Jones of this city. BordenaveJ has cited two cases of exostosis of the antrum, of enormous magni- tude and of very solid texture. In one the patient was cured by the knife and cautery. The other was too large to admit of an operation, and after death, was found, upon dissection, smooth, polished, and extremely hard, on the surface, less com- pact internally and resembling very much the structure of pum- mice stone. Boyer§ relates the case of a soldier who suffered upwards of ten years with an exostosis of the left maxillary sinus, which produced epiphora, pushed the eye forward, dis- placed the nose and palate bones and rendered the visage truly hideous. The disease proceeded from syphilis, and was at last cured by the long continued use of corrosive sublimate and the liquor of Van Swieten. Many examples of supposed exos- tosis of the antrum have been furnished by authors; there is reason to believe, however, that most of the cases described as such, have really been fungous tumours mixed with bony par- ticles, or surrounded by bony coverings, as in osteo sarcoma and spina ventosa—diseases essentially different from exostosis. The monstrous tumour of the antrum contained in the Heavi- side Museum, and described by Howship and Fox,|| and the * Surgical Essays, part i. p. 171. f Transactions of a Society for the Improvement of Medical and Chirurgical Knowledge, vol. ii. p. 307. t Memoires dc L'Academie Royale de Chirurgie, tom. xiii. p. 408. § Traitfe des Maladies Chirurgicales, tom. vi. p. 168. B See Howship's Observations in Surgery, and Fox on the Teeth. 388 Exostosis. interesting specimen delineated by Sandifort,* in his account of the collections of Albinus, Rau, and Van Doveren, were un- doubtedly fleshy excrescences incorporated with considerable portions of bony matter. The alveolar processes of the upper jaw are subject to ex- ostosis. In several instances I have removed from the gums, tumours, partly sarcomatous and partly bony. In one case, I took from the alveolar processes of the left side of the upper jaw of a negro woman, forty years old, a very solid exostosis, which carried before it several of the teeth. The tumour equalled in size a walnut, and was so completely identified with the jaw, as only to be removed by Hey's saw and a strong bistoury. The complaint never returned. Culleriert gives the history of an exostosis seated on the right side of the upper jaw just above the canine teeth and the adjoining molares. Pelletan supposed the tumour to contain a fluid, while Dubois considered it a fungus from the gums. It turned out, however, a very solid exostosis, and was successfully removed by the chisel and mallet. In the lower jaw I have seen both the circumscribed and tuber- culated exostosis. The former is most common and generally seated between the angle and symphysis. In the splendid work on the bones, by Chesselden,J there is a fine representation of an enormous irregular exostosis, which originated from fracture, gradually increased for twenty years, and then caused the pa- tient's death. Gooch§ relates the case of a woman, whose lower jaw was enlarged in its whole substance from the angle to the chin, was very prominent, and measured fifteen inches in cir- cumference from those points: notwithstanding its magnitude the tumour occasioned very little impediment to the motion of the jaw; nor was it painful. It had been growing between two and three years, and arose without external injury. The pa- tient enjoyed perfect health. Several French writers, espe- cially Bordenave,|| have described, under the title of exostosis, very large bony tumours of the lower jaw; but in every instance, • Museum Anatomicum, vol. ii. f Dictionnaire des Sciences Medicales, tom. 14, p. 228. t Osteographia, or the Anatomy of the Bones, Tab. XLII. fig. 2. § Chirurgical Works, vol. II. p. 96. 11 Memoires de l'Academie, tom. XIV. p. 123. Exostosis. 389 so far as can be determined from their histories, they have ap- peared to me cases of spina ventosa or of osteo sarcoma, and as such shall be noticed hereafter. The humerus is subject to every variety of exostosis. The circumscribed and spinous are most common. Several speci- mens, in the Wistar Cabinet, have these varieties blended. In four examples the bone is uniformly enlarged, from near its head almost to the middle, and from this enlargement several spinous processes above an inch long project. The condyles and head of the bone are free from disease.—Sandifort* has de- scribed and delineated an exostosis which arises at the middle of the humerus by a narrow neck, forms an arch, and is then implanted by a bulbous extremity into the shaft of the bone— leaving a space between it and the tumour. In other examples, by the same writer, several spinous processes start in a cluster from the os humeri, immediately below its head. Again, sin- gle tuberculated exostoses spring from the neck of the humerus and resemble the great trochanter of the thigh. Several cir- cumscribed exostoses, also pf considerable magnitude, are de- scribed as occupying half of the humerus. Exostosis of the scapula is extremely rare. Sir Astley Cooperf never met with the disease. SandifortJ mentions an instance where bony depositions, in great profusion, covered the acro- mion and coracoid processes and surrounded the head of the hu- merus. The bones of the fore-arm are seldom affected by exostosis, I have three specimens in my collection—two of the ulna and one of the radius. The tumours are smooth, circumscribed, seated about the middle of the bones, and the size of a walnut. I have never met with genuine exostosis of the metacarpal bones or fingers, although spina ventosa of these bones frequent- ly occurs, as will be shown subsequently. Venereal exostosis of the clavicle is by no means unfrequent; but I have seen one instance only where it was independent of that complaint. The tumour was larger than an egg, circum- scribed and smooth, occupied the middle of the clavicle, and • Museum Anatomicum. | Surgical Essays, p. 174. $ Museum Anatomicum, vol. I. p. 222. 390 Exostosis. arose from external injury. The patient was a labourer, forty years of age, and sustained no inconvenience from the swell- ing. The ribs are sometimes studded over with small exostoses, and in some rare instances considerable bony masses are thrown out between the intercostal spaces. There is a specimen of this kind in my collection, which was found by the late Dr. Law- rance, on the battle ground near New Orleans. The late Dr. Godman, also, lecturer on anatomy in this city, had a very beautiful preparation, taken from one of the inferior animals, il- lustrative of the effect of external injury in the production of ossific deposition—bony plates being thrown out on the exter- nal and internal surface of the chest, forming a complete case and uniting several of the ribs closely together.—A very in- teresting case is related by Mr. Giffard,* of a patient who died from peripneumonia, occasioned by an osseous substance, the fourth of an inch thick, six inches long and three broad, extend- ing under, the third, fourth, fifth and sixth ribs of the right side. On the same side, towards the back, another bony substance was found connected to the bodies of the vertebras and ribs. The patient had been troubled, for many years, with cough and difficult respiration, arising from the exostoses, which finally caused so much irritation as to destroy him. Sir Astley Cooper mentions the case of a lady who had a very large and painful ex- ostosis seated oh the ribs, behind the right breast. The patient was almost exhausted when he saw her, and died soon after; but no opportunity of dissecting the tumour occurred. Very considerable ossified depositions are found, occasional- ly, upon different parts of the vertebral column. In some in- stances, bony flakes supply the place of the ligament covering the intervertebral substance; in others, the intervertebral sub- stance itself is converted into bone, rendering the spine a solid inflexible mass. I have seen a preparation, exhibiting the com- plete union of every vertebras of the body, and constituting a solid pillar of bone from the head to the sacrum. In my col- lection, there are two specimens of several dorsal and lumbar vertebras completely united by bone, instead of ligament; and the Wistar Museum contains a most beautiful preparation of ca- * Philosophical Transactions, vol. 8, p. 205. Exostosis. 391 ries in the bodies of ten dorsal vertebras, with destruction of the intervening cartilages, where a splint half an inch thick and twelve inches long, covered with protuberances, has been thrown out on the anterior and right side of the spongy bodies, uniting them closely to each other, preventing deformity and effecting a cure by firmly supporting the whole spine. Part of the spine of a horse belongs to the same collection, having the bodies of the dorsal vertebras strengthened in a similar manner, by a bony splint, still more extensive. Freke has recorded the case of a boy, whose back and ribs were covered with bony projections, from the neck to the sacrum. " April 14th, 1736," says he, " There came a boy of a healthy look and about fourteen years of age, to ask us at the hospital, what should be done to cure him of many large swellings on his back, which began about three years since and have continued to grow as large on many parts as a penny loaf, particularly on the left side. They arise from all the vertebrae of the neck and reach down to the os sa- crum ; they likewise arise from every rib of his body, and join- ing together in all parts of his back, as the ramifications of co- ral do, they make, as it were, a fixed bony pair of bodice."* All the bones of the pelvis are more or less subject to exos- tosis. The ilia, ischia, pubes and acetabula of a pelvis in the Wistar Museum, are studded with tuberculated exostoses. They are particularly large and conspicuous, at the superior and infe- rior spinous processes of the ilium, and on each sWe of Jhe outer surface of the pubes, over which thick bony masses, an inch long, project and unite with each other in a vaulted form, at the symphysis. Several bony plates, resembling the heads of large nails, are fixed upon each sacro-iliac junction, apparently serving the purpose of connecting the iliac bones firmly with the sa- crum.—An exostosis upon the inside of the pubes has occasioned 'death, by compressing the neck of the bladder and preventing the introduction of the catheter.t—The uterus, has been rup- tured by an exostosis, seated behind the pubes. A case of this kind occurred, several years ago, in the practice of Dr. Dewees.t The patient died, and upon examination by the late Dr. Physick and Dewees, " the pelvis was found faulty at the superior part • Philosophical Transactions, vol. ii. p. 252. ■j- See Boyer on the Bones, vol. 1st, p. 354. $ Coxe's Museum, vol. ii. p. 411. 392 Exostosis. by a projection of bone or an exostosis; it was situated a little to the left of the symphysis pubis, and looked towards the base of the sacrum; it diminished the superior cavity of the pel- vis in the direction of its small diameter about half an inch; it was sharpand pointed at its extremity. The projection of the bony process just mentioned, by diminishing the cavity of the pelvis, must be regarded as the remote cause of this accident. The child's head, enveloped in a portion of the uterus, rested against this point so long as inflammation and gangrene were the consequence. The efforts of the uterus continuing violent, and perhaps that violence increased by the difficulties which opposed them, eventually gave way, as its substance at this particular part was much weakened by the changes produced on it by in- flammation, nay, the bony tumour acted somewhat like a cutting instrument."—Although I am unacquainted with a case of the kind, it is easy to conceive that an exostosis occupying the ca- vity of the pelvis, even when it does not attain considerable bulk, may present great difficulties to the passage of the child during parturition. Portal seems to have entertained the same view when he says, " Independamment des vices du bas- sin provenant de sa conformation vicieuse, sa cavite en general et ses deux detroits en particulier pourroient etre retrecis par des exostoses plus ou moins grosses; il peut aussi se former des tumeurs de diverse nature dans le bassin meme, dans la matrice ou dans les parties molles adjacentes, qui empechent la sortie de l'enfant de cette -cavite."* Sarcomatous and encysted tu- mours within the pelvis are by no means uncommon, and have proved so injurious by interrupting delivery, that out of eigh- teen cases recorded by different writers, it appears, one half the patients died and the greater part of the rest recovered imper- fectly, t Exostosis may occupy any portion of the thigh bone, but is seldom found either at its head or condyles. Every variety of the disease is occasionally produced. A femur in my posses- sion is studded at different points, chiefly on the posterior sur- face, with numerous tuberculated exostoses of considerable size. There is, also, upon the same bone a circumscribed exostosis, • Cours d'Anatomie Medicale, tom. i. p. 374. f See Merriman's Cases of tumours within the pelvis, in Medico-Chirurg. Transact, vol. x. p. 50. Exostosis. 393 four inches long; commencing below the great trochanter and bulging an inch beyond the shaft of the bone.—A very fine specimen of lamella ted exostosis is contained in the Wistar mu- seum. The femur is of extraordinary thickness (measuring in circumference eleven inches) uncommonly heavy, and covered with immense scales or osseous incrustations folded across each other and irregularly plaited like the skin of a rhinoceros. These masses extend from the trochanter to the condyles, and in some places are upwards of two inches long. The head and neck of the femur and condyles are of the natural size and free from disease. Thirteen examples of exostosis of the femur are given by Daubenton,* in three of which the whole circumference of the bone is enlarged to the extent of nine and a half inches.— The work of Sandifort contains several tuberculated and cir- cumscribed exostoses. Upon one bone a smooth tumour, four inches long, two thick, and shaped like a kidney, rises by a broad base, from the inner side of the thigh bone, near the les- ser trochanter. In another specimen an exostosis of the same kind extends beyond seven inches; and in several others the tu- berculated variety is distinctly markcd.t Mr. Howship J men- tions an exostosis, belonging to the collection at St. Bartholo- mew's Hospital, of such astonishing magnitude as nearly to equal three feet in circumference and conceal the whole length of the femur. The spinous exostosis is rarely met with on the femur; at least I know of three examples only—two in the Wistar Cabinet, and one described and delineated by Cooper. In the former, each thigh bone, just above the condyles, is ir- regularly enlarged twice beyond its natural size; and from this protuberance several bony spires project. The longest grow from the inner side, run upwards and parallel with the shaft of the bone. In the case detailed by Cooper an exostosis, from one to three inches long, occupied the thigh bone above the in- ternal condyle, and was felt through the integuments and mus- cles about the size of the finger. When the patient walked he felt what he described as a snapping in the part like a cord slip- ping from a pulley, which probably arose from the extension of • Description du Cabinet du Roi, tom. 3d, p. 87. f Museum Anatomicum, vol. 2. t Mi (lico-Chirurg. Transact, vol. 8, p. 97. Vol. I. 50 394 Exostosis. the sartorius muscle and its sudden slipping over the swelling. When he placed the limb quite straight he found a difficulty in bending it; and when bent it was almost equally difficult to ex- tend it: each flexion and extension producing a snapping noise, which could be distinctly heard.* The tibia is extremely subject to exostosis. Among several specimens in the Wistar Cabinet, four, particularly, deserve notice. In the first the bone is enlarged irregularly from the tubercle to the middle of the leg, three times beyond its na- tural size. The fibula also is increased in the same proportion and anchylosed with the tibia.—In the second, a circumscribed exostosis, the size of an egg, springs both from the tibia and fibula, about two inches above the ankle, firmly uniting, and at ihe same time forcing these bones out of their natural position. —In the third, the superior and inferior extremities of the tibia and fibula are enlarged and anchylosed; the fibula,especially, in- cluding two-thirds of its superior extremity, is covered with very rough process.es, and the bone nearly equals in size the tibia it- self. In the fourth specimen, numerous spinous exostoses arise from each extremity of the tibia. Those attached to the upper end of the bone run downwards, while those seated near the ankle extend upwards nearly in a line with the tibia. Each extremity of the tibia is enlarged, as in the specimens of the same disease in the femur and humerus already described. Many examples of exostosis of the tibia are found in different authors. Chesseldenf has given a very fine engraving of a cir- cumscribed exostosis, seated on the upper end of the tibia,-— equal in size to a child's head. Sixteen specimens, varying in shape and size, are described by Daubenton.J The Museum of Sir Charles Bell of London, contains numerous specimens of the same kind.§ Several of the inferior animals are subject to exos- tosis of the tibia and metatarsal bones. The diseases called splent and spavin, so common among horses, are of this de- scription. In my collection are two very beautiful preparations of the knee joint, of the horse, affected with spavin, in which • Surgical Essays, p. 219. f Osteographia, Plate LIII. p. 53. * Histoire Naturelle du Cabinet du Rio, p. 93. § Description of the Anatomical Museum of the School of Great Windmill Street, 4to, p. 7. Exostosis. 395 bony matter has been thrown out profusely, so as to resemble the tuberculated exostosis in the human subject. The upper and lower extremities of the fibula are more sub- ject to exostosis than the intermediate portions. There is a fibula belonging to the Wistar Museum, upon the upper end of which an irregular exostosis, as large as an egg, is seated. Each end of the fibula, belonging to the opposite leg, terminates in a bulb of considerable magnitude. In two fibulas, in my posses- sion, irregular exostoses cover the greater part of the bone, ren- dering each nearly as large as the tibia. 1 have never seen true exostosis, either of the tarsal or meta- tarsal bones, and believe the disease to be equally uncommon in the toes. Two exostoses, projecting from under the nail of the great toe, arc mentioned by Cooper, who removed one with a saw, on account of the pain it occasioned the patient. The same writer states that he has known half the foot amputated, on ac- count of the exostosis, at the extremities of the metatarsal bones next the toes. Treatment of Exostosis. In every true exostosis or simple enlargement from inordinate deposition of ossific matter, much may be done both by consti- tutional and local means. General remedies, especially when combined with rigid abstinence, exert a more powerful influence over local diseases than is commonly imagined. There is scarcely a tumour, however large or extensively involved, whe- ther situated among vital parts or confined to the common tex- tures of the body, which may not by judicious management, be made to feel the operations of the absorbent system. By ab- stracting from the body its accustomed nutriment, the propor- tion to particular parts is diminished and regular demands ar& then made upon all those textures which act subserviently in 396 Exostosis. the animal economy. Superfluous fat is removed from its cells and made to contribute to the support of the general sys- tem. In like manner, unnatural enlargements and morbid su- perstructures are changed or extinguished and forced to renovate the waste which b perpetually taking place. A knowledge of these powers leads, in the hands of judicious practitioners, to very important results—such as are too often overlooked. The active aid of operative surgery, instead of being regarded with horror and as an exercise of skill often ostentatious and unneces- sary, is frequently employed before general remedies are even tried, and resorted to under circumstances where benefit cannot be expected to result. Whoever attends a European Infirmary will be struck with the diversity and multiplicity of operations, performed upon the most trivial occasions. Will it be credited when I say that the illustrious father of American surgery, during a practice, both hospital and private, of forty years, and more extended than that of any other individual of our country, has very seldom had occasion to resort to amputation? It may be asked what became of his patients? I answer, they have been cured by general and local means. " Doctor," said a late surgeon of the Pennsylvania Hospital, to a distinguished prac- titioner of a neighbouring city, " what would be done in your town with such a leg?" " We should cut it off," was the reply. " We can cure it here without," rejoined the other. " In a certain London Hospital," says Dr. Gregory, a patient was under the care of the physicians on account of a very bad leg, which baffled their skill and appeared to them almost hopeless; they therefore requested a consultation of the surgeons, to examine the leg and to decide what should be done with it. The sur- geons accordingly met, examined it, consulted about it, and re- solved nemine conlradicente, that the leg could not be saved and ought to be cut off. They cut it off without delay. But, strange to tell, the physicians, at their next visit, on examining the patient, found to their great astonishment, the supposed hopeless leg, as fast to his body as ever it had been. The puz- zle was soon explained. It happened that the man had two legs, both of them very bad; one of them the physicians thought they could save, the other they despaired of. There being but a right and a wrong* it was not very marvellous that the con- Exostosis. 397 sultation took the wrong. Both physicians and surgeons, 1 be- lieve, were a little disconcerted at that quid pro quo; and as it was thought rather a strong measure to cutoff both the man's legs, they exerted themselves to the utmost and saved the leg which should have been cut off: so that after all the poor man was but one leg out of pocket. As I was not an eye-witness of this edifying transaction, it is proper to give some notion of the genealogy of the story, which is very short and simple. I have it from a reverend clergyman, who had it from one of the physi- cians concerned, and who is now one of the most eminent of his profession in London. I know both the clergyman and the physician intimately; I know them both to be men of veracity and men of sense; and I have no doubt that the facts were just as I have staled them." These remarks may appear, perhaps, irrelative, but I am satisfied of their importance, and shall be gratified if they tend to check the disposition, so prevalent among young surgeons, to use the knife; or contribute in a single instance to alleviate pain, or remove disease by milder or more appropriate means. Wherever an exostosis may be situated, provided it be pain- ful, grows rapidly, presses on some important organ, impedes the motion of a joint or interferes with the flexion or extension of a limb, it will become expedient to interrupt its progress or re- move it entirely. For this purpose we commence by gradually abstracting from the patient his accustomed quantity of aliment, by prohibiting nutritive articles, whether solid or fluid; by obliging him to avoid spirituous, fermented, or stimulating li- quors of every description, and by restricting him to diet in every respect adapted to his age, constitution, and habits. It is impossible to lay down precise rules applicable to every case, since almost every individual is liable to have the natural actions of his body disturbed by causes which have no influence over the system of another. Many patients can live for weeks or months, on a little tea and a few crackers a-day, without being as much debilitated as others who are allowed animal food and more nutritive drinks. Much therefore will depend upon the peculiar constitution of the patient, and this may generally be ascertained in a short time. It is a great mistake to suppose that old peo- • Additional Memorial to the Managers of the lloyul Infirmary, p. 265. 398 Exostosis. pie cannot bear a system of abstinence, or that debility is ne- cessarily associated with age. There are many persons ex- tremely vigorous in advanced life, who can sustain with impu- nity, deprivations sufficient to destroy younger and more delicate patients. It is true, however, that the systems of most old people sooner and more suddenly suffer from diminution of ac- customed food, than those of younger ones. For this we should be prepared, and ready to substitute nourishment, so soon as we perceive the system suddenly yield. By pursuing this plan, steadily and for a length of time, we shall often succeed in re- moving exostosis and other tumours of considerable magnitude, without the employment of other means; but in general, it will be necessary to administer purgatives every third or fourth day, or at stated periods, and to draw blood either from the system or locally. Local blood-letting, if the tumour be inflamed or pain- ful, will prove extremely serviceable. Leeches should be pre- ferred to cupping, and twenty or thirty will be sufficient to de- tract several ounces of blood. They should not be applied over the most prominent or inflamed part of the tumour, lest ulcera- tion follow their bites.—Besides these remedies, pressure, gra- dually and steadily applied, will act powerfully, in promoting absorption. When the exostosis is seated upon the extremities, a firm compress supported by a roller will answer every pur- pose; but in certain situations, as on the cheek bones, it will be necessary to use a species of truss or an elastic spring, so con- structed as to keep up moderate but constant pressure. Some tumours, however, will not bear even the slightest pressure, and if the patient is resolute enough to endure the pain, ulceration will be apt to follow—with increase of the disease. Sometimes pressure with adhesive straps, covered with sheet lead and a roller, answers a useful purpose. Blisters kept open by savin cerate, have been extolled by some writers as efficacious in exostosis; but 1 have tried them in se- veral instances without effect. In venereal exostosis or node, they are sometimes beneficial. When these remedies fail, and the exostosis continues to in- crease, becomes more painful, interferes with some important organ, or endangers the patient's life, an operation may, per- haps, be necessary. It cannot, however, always be done. Ana- Ivxuttosis. 399 lomical considerations will sometimes prohibit it—at other times, owing to the duration and size of the tumour, so much irritation would be produced as either to destroy the patient or render the cure very tedious or doubtful. If the tumour is not very large, is of the circumscribed, tuberculated, or spinous va- rieties, and situated superficially, such incisions should be made as to expose its base to the action of Hey's saw, or the trephine. By the conjoint operation of these instruments I removed, se- veral years ago, from the tibia of a boy, a circumscribed exos- tosis of considerable magnitude, which had resisted every other remedy. About the same period, I removed with success, and by similar means, a large exostosis from the outer condyle of the humerus of a young gentleman. But often the exostosis is so situated, that neither the trephine nor Hey's saw can act without injuring, materially, the surrounding soft parts. To obviate this inconvenience, several cutting instruments, within a few years, have been invented. Mr. Machell,* an English surgeon, has constructed a circular saw calculated to work beyond its semi-diameter and at a considerable depth, without interfering with the muscles. The saw is actuated by several wheels, enclosed in a case or conveyance, which are propelled by a winch or windlass. A pair of forceps are at- tached to the instrument, in order lo fix it to the bone and keep it steady while the saw is in motion. Having never seen this instrument I cannot speak of it from experience ; but if a proper estimate can be formed from the drawing and description, it would appear exceedingly complicated and expensive, and not calculated to answer, without great trouble, the purposes for which it was designed. The teeth of the saw, moreover, being placed on wheel-teeth or cogs, which work upon each other, must necessarily be injured or broken after a few revolutions. Again—unless the forceps be screwed with great force so as to take a very firm hold of the bone, the saw cannot bo made to work steadily, and more or less resiliency or titter must follow every attempt to set it in motion. Both hands of the surgeon being employed, one in moving the handle, the other in holding the conveyance, it will appear evident that without the aid of the forceps the instrument, if it can operate at all, must do so ♦ Edinburgh Medical and Surgical Journal, vol. 11th, p. 273. 400 Exostosis. under every disadvantage. It was on this account, perhaps, that Sir Astley Cooper failed in removing an exostosis from the fe- mur with this machine, until he secured it by the forceps. " The saw was then attempted to be used," says he, " without the forceps, but it could not be well fixed: the forceps were, there- fore, added to it, and the bone was sawn through." But there are many situations where these forceps cannot be applied, or if applied, cannot render the saw steady.—The circular saw of Mr. Griffith,* although extremely simple in construction, pos- sesses so little power as to render it unfit for the most common purposes, and is decidedly inferior to that of Hey.—The chain saw of Dr. Jeffrayf of Glasgow appears to me calculated for no other purpose than that for which it was originally designed— the removal of carious joints; but under any circumstances it is extremely liable to twist or break; as I have several times proved in operations upon the dead subject. The cutting plyers of Griffith and Liston are fit only to detach small spicu- la of bone or to remove loose carious portions.^ Sir Astley Cooper has given the history of five operations for the removal of exostosis. The first was of large size and formed like an inverted pyramid, the apex of which was attached to the tibia; it had been growing forty-four years. An elliptic in- cision was made through the integuments, and the tumour re- moved by the amputating saw, without much difficulty. In the second case, a spinous exostosis was taken from near the inner condyle of the thigh bone of a young lady eleven years old. The limb had been painful as low as the heel, and when the patient " attempted to run, she felt a snap upon the swelling, as if a cord had slipped out of its pulley, which was owing to the tendon gliding over the projecting part of the bone." The tu- mour was separated by Machell's saw, and the irregularities that remained smoothed by the bone nippers.—The circum- stances of the third case were nearly similar to those just de- tailed.—In the fourth case, an exostosis of the fibula, involving the fibular nerve, thereby producing paralysis of the peroneal muscles, as well as the flexors of the foot and extensors of the * Surgical Essays, p. 218. f Jeffray's Observations on the Excision of Carious Joints, p. 175. 4 See Edinburgh Journal, No. LXVI. January, 1821, p. 155. Exostosis. 401 toes, was removed by Hey's saw. In the fifth case a large ex- ostosis, growing from the outer and left side of the pubes, at- tended with great pain in the hip, above and below the knee, and in the foot, was separated by Machell's and Hey's saws. These patients were all cured except the fourth, who was re- lieved of pain, but not of the paralysis. In 1815, a gentleman from the Eastern shore of Maryland, applied to me on account of a circumscribed exostosis which occupied the middle of the os frontis, had been growing for years, arose without evident cause, attained the size of a large egg and was solid and incompressible. Ulceration possessed the most prominent part of the tumour, which was supposed by the patient to be cancerous. As various remedies had long been tried, ineffectually, an operation appeared to furnish the only prospect of relief. An incision, traversing the whole swelling, was made, and the integuments turned aside, so as to ex- pose the base of the exostosis, which was then removed, with difficulty, by Hey's saw. The substance was reticulated and did not differ, apparently, from that of sound bone. The inter- nal table of the skull remained entire, the patient recovered in four weeks and the complaint has never returned. An exostosis may be removed from almost any bone in the body; provided it does not embrace the whole circumference, or extend throughout the length.— When a very large bony tumour surrounds the arm, fore-arm, thigh or leg, and an operation be- comes necessary, nothing less than amputation will probably answer. There are certain situations, where it would be dif- ficult, if not impossible, to remove even a circumscribed exos- tosis occupying part of a bone. Thus such a tumour growing from the inside of the pubes or sacrum, interrupting the flow of urine, or impeding the passage of the child in parturition, could not perhaps be reached or extracted. In the latter case, how- ever, so much dauber, probably, would not result; as an expe- rienced accoucheur would attempt to turn the child and avoid the projection.—The removal of an exostosis arising from the inner suffice of the ribs, as in the case related by Giffard, to which I have already referred, would be attended with great difficulties. The same may be said of the disease when seated on the spine, except the spinous processes alone should be in- Voi.. I. 51 402 Exostosis. volved; in which case an operation might be very beneficial; nf shall be shown hereafter, when I speak of an osteo-sarcomatous tumour, of monstrous size, which I removed, in October,.1818, from the spine of a young gentleman in Maryland.—An exosto- sis, growing from the inner table of the skull, and pressing upon the brain, might perhaps be removed ;—but not with much pros- pect of success. This would arise less from the difficulty of the operation itself, than from the exposure and subsequent in- flammation of. the brain and its membranes. Cases may possi- bly present, however, where the surgeon would be justified in re- sorting to an operation;—as in the examples recorded by How- ship* and Wadd,t of ossific matter deposited between the tables of the skull, distorting the bones and producing insanity by pres- sure on the brain. The successful issue of the interesting ope- ration, by KeateJ—the removal of a bony tumour involving the lamellae of the greater part of the os frontis and containing an enormous collection of hydatids, should form an additional in- ducement to saw away any bony mass encroaching upon or mterfering with the functions of the brain.—An exostosis of the lower jaw, involving its circumference, may be re- moved by cutting through the bone on each side of the tumour and completely insulating it. The void will afterwards be filled by callus, or the- cut extremities of the bone so firmly. united by ligamentous substance as to render the jaw nearly as useful as ever. Again; if the tumour should be situated at the symphysis, the jaw could readily be cut through on each side of it, and the ends of the bone pressed together and united, as in Dupuytren's celebrated operation for artificial chin.§ Great deformity, however, must necessarily result from such a proceeding, and in many instances I think the operation would be totally unnecessary, and should be supplied by the following mode, which I adopted, several years ago, in the following case. A poor woman had a tumour partly fun- gous, partly bony, the size of a large orange, which sprang from the symphysis of the lower jaw, on the inner side,. pushed before it several teeth, and so filled the mouth as • Medico-Chirurgical Transactions^ vol. 8th. f Malformation, and Diseases of the Head, by Wm. Wadd, 4to, 1819. * Med. Chir. Trans, vol. 10th. § See Diet, des Sciences Medicates, tom. xxix. p. 430. Exostosis. 403 nearly to prevent swallowing and render articulation almost unintelligible. I divided, with a strong curved knife, the al- veolar processes, (softened by caries) on each side of the sym- physis, nearly to the base of the jaw, separated the tumour from its attachments, and controlled the hemorrhage by ligatures and the actual cautery! Upon examining the cavity or bed occu- pied by the tumour, I was surprised to find how much of the jaw had been absorbed—a small portion only of its base re- maining on each side of the symphysis. Great as the vacuum was, however, it was soon filled by granulations and ossific de- positions, and in a few weeks the patient entirely recovered. Nothing could have been easier, in this case, than to have imi- tated Dupuytren, by cutting away the base of the jaw and bringing together its ends; but if I had done so the patient would not only have been horribly disfigured, but mastication and speech greatly injured by the teeth and tongue being thrown from their natural situation. Should an exostosis occupy the orbit and displace the eye, it may be removed, provided the base be not very large; not by following the practice of Lucas*—cutting down upon the tumour and then leaving it to drop off by caries—but by applying cau- tiously Hey's, or a small circular saw as near to its base as pos- sible. If the tumour cannot be reached by a saw, it may, per- haps, be made to exfoliate by the application of acids or caus- tics. An interesting case illustrative of the beneficial effects of caustic, is related by Louis.t A woman, thirty years of age, suffered from a fistula lacrymalis which resisted every remedy. The bones became enlarged, and an exostosis, the size of an egg, occupied the os planum and internal angular process of the os frontis. The eye was forced from its socket and hung over the cheek. Brassant, the surgeon who attended the patient, applied caustic to the exostosis; suppuration followed, and in three or four months the greater part of the tumour exfoliated, the eye resumed its position, and a cure was soon completed.—Neither the saw nor caustic, however, will often be required for exos- tosis of the orbit, as the disease must be considered rare. Tu- • See ante. f Memoires de 1'Acadcmie de Chirurgie, tome xiii. p. 277. 404 Exostosis. mours of a different description—steatomalous, encysted and sarcomatous, frequently occur, and become so large as to dis- place the eye. Several such cases I have seen. I know a gentleman at the present time, whose eye is pushed to one side and almost squeezed from the socket by an encysted tu- mour;—which could be removed with success, and with the utmost facility. In the year 1818,1 took from the orbit of a patient, under care of Dr. Coulter, of Baltimore, a sarcomatous tumour, which grew from the socket, compressed the eye, and in time would have destroyed it. Similar examples are re- lated by Trincavelli, Paau, Astruc, Bertrandi, Bonetus, Louis, Le Dran, St. Ives, Hope, Brocklesby, Rodman,* &c. There is another operation for the removal of exostosis, which deserves to be tried, whenever the situation of the disease will admit of it, before we resort to extirpation with the saw, or to amputation of a limb. This consists in the separation of the pe- riosteum from the tumour—thereby, in a measure, depriving the part of vascularity and promoting its absorption. The re- medy was proposed some years ago, by Sir Astley Cooper, and communicated to me in a letter, by Sir Charles Bell, of London. "Sir A. Cooper told me," says Sir Charles, "last night at the Anatomical Society, that he finds the largest tu- mours of exostosis, absorbed by simply cutting down upon them and separating the periosteum from the face of the bone by the handle of the knife." The older surgeons were in the habit of performing the same operation in cases of venereal exostosis or node, sometimes with success, but frequently without any bene- fit whatever. Consult Cooper and Travers' Surgical Essays, part 1—Wilson's Lectures on the Diseases of the Bones and Joints, p. 269— Boyer's Treatise on Surgical Dis- eases, by Stevens, vol. 2, p. 159. • See Schenkius—Memoires de PAcade'mie—Sepulchretum Anatomicum— Maladies des Yeux—Philosophical Transactions, 1744—Medical and Physical Journal—London Med. Obs. and Inq. Spina Ventosa. 405 Section V. Spina Ventosa. Sir Astley Cooper and some other writers have, improper- ly it appears to me, described this disease as a species of exos- tosis. It differs from it in many respects. The exostosis is firm, solid, and incompressible. Spina ventosa, on the con- trary, usually attains a much larger bulk than exostosis, in- volves the whole circumference of a bone, and, when dissected, is found to consist of a mere osseous shell perforated with nu- merous holes, and containing sometimes a thin sanies mixed with loose portions of lymph or of a substance resembling cheese. It is to this disease Mr. John Bell * alludes when he says, " The solid bone, whether radius or thigh bone, is annihi- lated, and a mere shell of osseous matter substituted in its place, and that in a manner so peculiar, that it must seem to the un- intelligent observer, as if the small and solid bone had been ex- panded into an extensive and flat plate of osseous substance, whereas the process is in truth .very simple and very intelligi- ble. The bone dies piecemeal of ulceration, or what, in techni- cal language, is termed caries, and is conveyed away by absorp- tion ; but the bone being dead, the surrounding membranes— namely, the periosteum and tendinous expansions, which once formed a part of its system of circulation, continue still alive, and ready to secrete new bone; and thus it happens, that while carious abcess preserves a large cavity full of foul matter, the surrounding membranes continue secreting bone, which, like a shell, thin and expanded, covers this cavity, and forms the walls of the tumour, of which some part is composed of thin expanded bone, resembling a cranium, some of cartilage, some • Principles of Surgery, vol.3, p. 59. 40G Spina Ventosa. of thickened membrane; and this shell is formed in proportion as the original fabric of the bone is destroyed." The cylindrical bones are commonly the seat of spina vento- sa ; though I have met with the disease, in two or three in- stances, among the flat bones. The finest specimen I have ever seen, was sent to me a few years ago by Professor Stevens of New York. It occupied the radius of the left arm, and the bone, nearly from the elbow to the wrist, was expanded into one or more irregular shells, the size of a cocoa-nut, and contained a thin steatomatous matter. (See Plate XVII.) Treatment of Spina Ventosa. When the smaller bones, such as the phalanges of the fingers and toes, are affected with spina ventosa, a cure may sometimes be produced by moderate long-continued pressure directly over the tumour; at other times, I have succeeded by making an opening into its cavity, and by stimulating injections, or by cutting instruments, exciting such a degree of irritation, as to cause it to fill up with granulations. In this way I once cured an obstinate spina ventosjst of the lower jaw, about the size of an egg. Should any of the large cylindrical bones be involved, and the tumour attain a large size, nothing less than amputation will be likely to answer. This was successfully resorted to in the case of Dr. Stevens' patient. See Boyer's Treatise on Surgical Diseases, vol. 2,p, 167—J. Bell on Tumours, vol. 3—Boyer's Lectures on the Diseases of the Bones, by Farrell, vol. 1, p. 364— B. Bell's System of Surgery, vol. 1, p. 305. =5; / Osteo-Sarcoma. 407 Section VI. Osteo-Sarcoma. The older surgeons employed the terms Osteosarcoma, Os- teo-Sarcosis and Osteo-S/earoma, to designate such tumours as were formed by the irregular admixture of bony, fleshy or fatty particles. By the moderns, osteosarcoma has been re- tained, as more expressive than the others. This disease may attack any of the bones, but the long bones of the extremities are commonly affected. According to Boy- er/ the os innominatum is more subject to the disease, than any other bone in the body. The progress of osteo-sarcoma varies in different cases. Sometimes, a long continued, deep- seated, lancinating pain, occupies some part of the bony system, long before any tumour or swelling is evident. At other times, a distinct tumour is perceptible from the first, gradually increases, and is not painful or inconvenient until it acquires considerable bulk and takes on inflammation. The pain is then extremely severe. The form of the tumour is either smooth and circum- scribed, or irregular: for the most part, the general swelling is studded over with knots or protuberances of various dimensions ; the apices of which, in the advanced stages of the disease, are apt to ulcerate and discharge a small quantity of thin, fetid mat- ter. Often, however, the whole tumour becomes enormous, and extremely ponderous, without the slightest ulceration of the integuments. When examined by the touch, the tumour feels solid and incompressible, or, if any evidence exist of fluctuation, it is only at particular spots, and is even then very indistinct. Old persons are seldom subject to osteo-sarcoma: I have met with two instances, however, in which the disease occurred • Traite des Maladies Chirurgicales, tom. iii. 408 Osteo-Sarcoma. in patients beyond the age of seventy. When young persons are attacked, a perceptible alteration is soon evinced in their general health and appearance. They become sallow, thin, and debilitated; and the bowels are alternately constipated and relaxed. Not unfrequently, a cough and tightness of res- piration, are constant and very troublesome attendants. In the advanced stages of the complaint, and especially when the tu- mour is large, ulcerated, and sloughy, hectic fever, and all its consequences, gradually undermine the strength of the patient, and finally destroy him. In several instances which have fallen under my notice, the patient has died from confirmed phthisis pulmonalis. When the structure of osteo-sarcoma is examined by dissec- tion, several interesting circumstances are developed. The in- teguments being raised, the muscles and tendons are found re- moved from their natural situation, and spread out and thinned to such an extent, as to cover a much larger surface than they usually occupy. The vessels and nerves of the part are also raised, and made to approach the surface of the tumour; to this surface the periosteum will be found closely to adhere, and to give a firm, dense, pearl-coloured covering, which is with great difficulty separated from the diseased bone. The bone itself in immediate contact with its investing membrane, will be found smooth on the surface, and either uniform and regular, or else disposed in lobulated masses of different forms and sizes. Some- times, these are extremely regular, of a rounded form, and re- semble very much a cluster of grapes. At other times, several large masses are joined together, and present the appearance of an artjchoke, or protuberant potato. When the bony texture of these tumours is cut, forcibly separated ,or crushed, a number of irregular cells are brought into view, containing either a thick, cheesy, Iardaceous, medullary matter, or else a gelatinous semi- transparent fluid, which oozes out of its own accord, or can be removed by mechanical means, or by maceration,—leaving the sides of the cavities lined by a very fine and delicate membrane. The morbid tissue of bone, will then be found to consist of in- numerable spicula, disposed in endless variety of ramifications, and shooting out into fantastic forms, resembling some species of coral, or assuming the shape of certain vegetable productions. Osteo-Sarcoma. 409 I have in my possession, a very fine specimen of osteo-sarcoma, of several pounds' weight, taken from the upper jaw of an ox, and presented to me by a very intelligent physician, Dr. Town- send of Maryland, to whom my cabinet is indebted for other valuable contributions. In this specimen, the cells which I have described, and the arrangement of the bony spicula, are uncommonly well displayed, owing to the magnitude of the tumour and the original texture of the bone upon which it is reared. The origin of osteo-sarcoma is enveloped in great obscurity. It appears, sometimes, as an hereditary disease, and as such,has been transmitted in succession to numerous individuals of the same family. A very remarkable case of the kind is recorded by Boyer, in which the father, brothers, sisters, nephews, and children of a woman thirty years of age, and who otherwise en- joyed good health, had from their earliest infancy, bony tumours on the tibia. The patient herself, had similar tumours on both tibias, on the left humerus, and on the middle of the left thigh. All remained stationary, and were of small size, except the one on the thigh, which gradually increased, became particularly large and painful after her marriage, and finally increased to such an extent, as to weigh twenty-one pounds, and render amputation necessary. Upon dissection, all the characters of osteo-sar- coma were distinctly marked. In many instances, this disease has been decidedly traced to a blow, to a jump from a height, to fracture and other external injury; but there is great reason to believe, in most instances, that it is connected with some constitutional affection, since we meet with many cases in which, after removal of the tumour or amputation of a limb, other parts of the body have been attacked in a similar man- ner, or else the patient has been carried off in a short time, by some disturbance of the vital organs. In several cases pre- sented to my notice, patients have undergone operations for osteosarcoma, and have so far recovered in a short time, as ap- parently to enjoy excellent health, when suddenly their strength has declined, hectic fever has supervened, a pain in the breast with cough and purulent expectoration, has taken place, and death has soon followed from phthisis pulmonalis. A case is recorded bv Dr. Bail lie, in his Morbid Anatomy, of a person who had a Vol.. I. ''- 410 Osteo-Sarcoma. very large bony tumour formed around one of his knees; this was removed at St. George Hospital by Mr. Walker, by ampu- tation of the limb: very soon after, a difficulty of breathing be- gan, occasioned by part of the lungs being converted into bone, and by a very considerable deposition of bony matter on the inside of several of the ribs, which caused the patient's death.* These circumstances would seem to favour the idea suggested by Boyer.t Richerand,J Callisen,§ and some other writers, that osteo-sarcoma is, in reality, a cancerous affection of the bony tissue, and as such, may give rise to all the consequences which are liable to result from a similar disease of the soft parts. It is to be hoped, however, admitting this view of the subject to be correct, that the disease is not always so deeply engraft- ed upon the constitution, as necessarily to give rise, after ex- tirpation or amputation, to a similar affection of the pulmonary system, or any other of the vital organs. How far scrofula can be considered as giving rise to, or as connected with osteo-sar- coma, as it is known to be with some other affections of the bones, remains yet to be determined. • Wilson's Lectures on the Bones and Joints, p. 274. ■j- Maladies Chirurgicales, tom. iii. p. 587. * Nosographie Chirurgicale, tom. iii. p. 121. § Systema Chirurgise Hodierns, vol. ii. p. 20£.. Osteo-Sarcoma. 411 Treatment of Osteo-Sarcoma. Before an osteo-sarcomatous tumour has attained a large size, it may be removed, possibly, by local and constitutional remedies, without the aid of an operation. Leeches applied to the part itself, or its vicinity, will be found useful. Blisters, also, often repeated, and kept open by savin cerate, will prove still more beneficial. As a constitutional remedy, Sir Astley Cooper * has extolled the exhibition of oxymuriate of mercury, combined with the compound decoction of sarsaparilla, a medi- cine which has long been used in France, and in this country, with the happiest effects, in the treatment of various diseases, especially chronic ulcerations, and tumours of different kinds. Low diet, conjoined with purgatives, must likewise be had re- course to, and perhaps moderate pressure, steadily applied to the tumour, may prove useful. When these remedies fail, an operation will become necessary. In many instances, nothing less than amputation will answer, inasmuch as the whole cir- cumference of a bone is involved in the disease. Great care should be taken, therefore, to ascertain the extent and connexions of the tumour, as without just views in this respect much mis- chief and unnecessary pain and hazard to the patient may result. Mr. John Bell has related the case of a labourer, forty years of a^e who had a tumour of enormous size, and of anomalous cha- racter, partly cartilaginous and partly solid, occupying two- thirds of the fore-arm from the wrist upwards. The hand was sound; the fingers and wrist could be easily bent; and the tu- mour seemed to move so freely, that a surgeon of skill and learning was induced to undertake its extirpation, in hopes of saving the hand and joint. "The poor man having willingly assented to any operation, however lingering or painful, which mi"ht save his hand, the dissection was carried all round the tu- mour, and into its central parts, before the surgeons present were * Surgical Essays, p. 183. 41^ Osteo-Sarcoma. undeceived. As the radius turns vertically like a spoke or spindle, it turns without any apparent motion, except in the parts connected with its lower end; the hand turns freely along with the radius, so that we never suspect, till we become ac- quainted with anatomy, that it is by the spoke-like motions of the radius that the hand moves; it seems moveable in itself, by its own immediate joints. This tumour, in like manner, moved easily; could be turned upwards and downwards; so that the surgeon never once suspected that the motion was in'the radius, or that the tumour was fixed, and made a part of the bone. It seemed moveable, and, doubting, he began to extirpate it, by drawing a long incision round its root, on the side of the ulna: but finding it difficult, with this limited incision, to dissect the tumour, he prolonged the incision, continuing it over the back of the hand to the knuckles, in the direction of the extensor tendons. He then dissected more freely, and continued sepa- rating the skin from the tumour, till he came to a thick and solid sac, which seemed to consist of the muscular fibres and aponeurosis of the pronator quadratus muscle. He continued this dissection, separating this thick and solid sac from the in- terosseous ligament, till he could go no further. Finding that it terminated in a solid and osseous basis, he now plunged in- trepidly into the heart of the tumour. In cutting into the heart of the tumour, he found that he had opened a very large sac, not firm only, but osseous; but still as he was penetrating into the tumour at one side, he continued still unsuspicious, and per- severed in dissecting away what he imagined to be a common tendinous sac, ossified only at certain points; he made thus a large opening into the tumour, felt its cavity full of loose and fatty bodies, pushed his finger under the extensor tendons into the deepest part of the sac, began to hook out the fatty tubercles with his fingers, and at last baling it out with his hand, hooking with his finger, and catching the fatty masses in his palm, he so far emptied the cavity as to be able to search with his fingers in every direction, and then he found, to his utter confusion, the ball of the carpus formed by the scaphoid and lunated bones, at the bottom of the cavity bare. He was now, for the first time, undeceived, and knew what sort of disease he had to contend with; he was now conscious that the radius was diseased; the joint destroyed; the original bone ulcerated. He felt distinctly Os teo-Sa rcoma. 413 that the ball of the carpal bones originally opposed to the lower end of the radius, was now, by the destruction of the radius left naked; and, in fine, that the wrist was irrecoverably ruined. There was no going on with the operation, and no stopping here; he therefore explained to the patient, who had borne this severe and long-protracted dissection with great composure, the necessity of amputating his hand, which he submitted to with equal resignation."" The above case is calculated to show7, in a striking manner, with how little prospect of success we can undertake to remove an osteo-sarcoma of any magnitude, involving the whole cir- cumference of a bone; but it still remains a question, whether such a tumour, while in its incipient state, of small size, and seated on one of the bones of the fore-arm or Ipls might not be successfully extirpated by sawing through the sound bone above and below its margins. The extremities of the diseased bone, would eventually, perhaps, be filled up or connected by adven- titious ligaments, and so much support afterwards given by the sound bone, which would act as a splint, as to render the limb sufficiently useful for most purposes. Much, however, must necessarily depend, in such a case, upon the precise situation of the tumour; if closely connected with a joint, the operation would be attended with risk, and in the end would, perhaps, prove unsuccessful, or give rise to subsequent amputation. It will appear from what has been said, that the treatment of osteo- sarcoma must be different in many respects from that of exos- tosis; that we cannot extirpate the former, with the same suc- cess as the latter; and that, in many instances, owing to consti- tutional disturbance, all our operations will prove unavailing. This remark will even apply to amputation, for it has been de- cidedly ascertained, that the lungs and other important internal organs, have been attacked, in a very short time after the re- moval of a limb affected with the disease. To guard against such unpleasant consequences, our only resource is to continue the constitutional treatment recommended, after the opera/ion, and to substitute an issue in the vicinity of the part from which the tumour has been removed. Experience has long ago taught me, that, without precautions * Principles of Surgery, vol. iii. p. 64. 414 Osteo-Sarcona. of this kind the patient's chance of recovery will be very much lessened. It appears too, that the very ample and extended ob- servations of Sir Astley Cooper have taught him the same lesson, if we may judge from the hint contained in his essay on " Fun- gous Exostosis," a term apparently employed by him to de- signate osteo-sarcoma. "The operation of amputation," says he, "after constitutional means have been employed, and the continuance of these constitutional means after the operation, hold out the chief hope of safety; for amputation without these will do no more than to avert the blow for a season."* As a local remedy for osteo-sarcoma, Sir Astley was induced to try the effect of cutting off the supply of blood from the tumour by tying the arteries which supplied it. The operation was ac- cordingly performed in two cases, but without success; the cur- rent of blood being temporarily diminished, but returning in a short time with its accustomed force. Many of the foregoing remarks will be illustrated by the fol- lowing cases, which have occurred, at different periods, in my practice. Case I. On the 28th of January, 1816, I was called| to Washington, to visit Master W. M., aged sixteen, in consultation with Drs. Shaafe and Worthington, two distinguished physicians of that place. I found the right leg of the patient occupied by a large elastic tumour, which extended from the outer ankle along the course of the fibula, to within three inches of the knee. To the touch it was firm and incompressible, but at the same time slight- ly elastic, somewhat irregular, inflamed on the surface, and di- vided into two considerable lobes about equal in size. When handled, a distinct crepitation could be perceived near the an- kle, and the whole tumour admitted of so much motion as to convey the idea that it was seated on the fibula, not identified with it. A deep-seated, severe lancinating pain was constantly present, and not only pervaded the whole diseased mass, but extended up the thigh, and rendered locomotion very dif- ficult. The complexion of the patient was of a pale, yellow, cadaverous hue, and his skin studded with small, irregular, tu- * Surgical Essays, p. 186. Osleo" Sarcoma. 115 berculated bumps. The lymphatic glands of the neck were slightly enlarged, and those of the groin of the diseased limb thickened and painful. For several weeks he had laboured un- der hectic, and was much reduced. Upon inquiry, I ascertained that a hard swelling, the size of a marble, had occupied the middle of the fibula from early in- fancy; that in July, 1815, while indulging with his Companions in vehement exercise in leaping, the patient experienced for the first time an acute and sudden pain in the small lump; with great difficulty he was able to walk home, and then discovered that the lump was larger than usual, and inflamed. The in- flammation increased from that period, the tumour augmented slowly, was never entirely free from pain, and in a few months presented the appearance described. To save the limb was altogether hopeless; amputation was therefore determined on; and 1 performed the operation without delay. The patient recovered in a few weeks, grew fat and ro- bust, and apparently soon enjoyed excellent health. This con- tinued for eight months without intermission. About this period he made a visit to his friends at Baltimore, and while walking in the streets was suddenly seized with difficulty of breathing, and was so overcome by debility as with difficulty to reach home. From that moment he was confined to his bed, suffered from continual cough and hectic, and died in a few weeks with all the symptoms of confirmed phthisis pulmonalis. Immediately after the amputation, the diseased leg was ex- amined, in presence of the consulting physicians. Upon re- moving the integuments the muscles were found spread out on the surface of the tumour, and considerably extenuated and al- tered in texture. Under the muscles the* two chief lobes of the tumour were very conspicuous, and covered by a dense com- pact shining membrane, which was with difficulty separated from the bone. The bony tumour was found to consist of the greater part of the fibula, expanded into a large, porous, spongy mass, filled with an infinite number of cells of different dimen- sions, and separated from each other by ridges or partitions. These cells contained a fleshy, and in some instances, a steato- matous-looking matter. That portion of the fibula naturally at- tached to the ankle was carious and disjointed, had lost all traces of its original appearance, and was so loosely connected with 416 Osteo-Sarcoma. the surrounding parts as to give considerable latitude of mo- tion lo the lower tumour, and produce that- crepitation which had been observed antecedent to the operation. The upper end of the fibula, to the extent of two inches and a half, was free from disease; the rest was totally disorganized and ruined. The tibia was perfectly sound. The whole tumour, including the leg, measured at the most prominent point twenty-four inches in circumference. The fibula, when prepared and dried, lost a great part of its bulk and weight, and now resembles a vegetable production. A model in wax was taken from the preparation, while recent, from which a drawing has been made, as repre- sented in Plate XVIII. A view of the dried bone is also given in Plate XIX. Case II. A man upwards of 60 years of age, in the employment of the late Honourable Charles Carroll, of Carrollton, had, for several years, a tumour as large as a child's head, seated on the ribs, about the middle of the left side of the chest. At the request of Mr. Carroll, I examined the tumour in consultation with his at- tending physician, Dr. Matthews. The patient stated, that fifteen years before, he had received a kick on the chest from a mule; that soon after a small lump arose upon the injured part, which slowly increased, unattended with much pain, and so little incon- venience as to enable him to attend constantly to his occupation —that of a gardener. For several months, however, before I saw him, the pain, together with the magnitude of the tumour, prevented him from engaging in any business, and rendered him anxious to obtain reliefU To the touch, the tumour was firm and unyielding, except at particular spots, where it was soft, and seemed to contain a fluid. The whole mass could be readily moved for some distance un- der the skin, so as to convey the idea of a sarcomatous excres- cence, loosely attached to the surface of the ribs. Under this impression it was determined that it should be removed. On the first of March, 1817, I commenced the operation in pre- sence of Drs. Matthews, Denny, and Richardson, by dividing the integuments and muscles on the chest, so as to expose the tumour completely to view. This I found covered with a < rf . ;-'" lJl-"** -, *'■*'-.• »T-/ *■ ' -"**• * >»* -■ ■ • ',■-: ■ :■'* '•.' "'■■' .:■ ■:•>>;.- ' .. •■"■■■- ■-• ■ •* . ■ "■■■• ^'v 'c- • .'• 'I''•' <» • ■ ,'-r '• -»•■, •-;• t -.%/■:,>