+ >*■ A.. e4T£7_ ^ /'$-7 ^ BILL OF OHARGES. £ *;#- Tb« following bill of oharj cd re»olution, were adopted . eiety, at itt meeting in Octob< MltfUfaHoA* J^R-Shll1?-': ^Ifog, Foot.Arm, angora.■ :» and toes, from $3 to S 00 -**r''ln,nS* „ ■ 20 00 •ftrtirparinf Mamma, ,; 20 »» Excising Tonsils, each, w>"u ISirpaUngTumdh.fromltoSOO Operation tor Hare Lip w ' a H^lrocele from 5 to 10 Parafcntisi* Thoracis 85. .. Abdominis, first, *» subsequent, each, 3 00 atbuciNo luxations. '55 M^togethef with the iiibjoith t?the Lel^gnoD Medical So* ';1842. i 1M 21 50 sioS«Por elbow, MolOOO FrBCtareoftWneckpfFemor.OOO Thigh or£»j, . W-O" Arm or Gt%Hi 5 00| Compound or complicated accor- *taguMpireumstances. Practice of Medicine FoTfirst visit advica and medicine, (in ordinary cases) assp.Wi «. RESOLj Aeiotued, That every me;, —,*. tp^Pirfirif qJtaaggsia-yl^' mile jiise^uent medicine, advTc«r&*J. ..j 50 cents to linile, in addition to th« .first, j#A ■rescription and medicine for each additional case in a family For medicine exceeding an or. Einory prescription, additional triage' may be made. . ^ ^tendance during parturl- j '"tton, *,.common casea 5 00 ; ionsuiUtjon, exclusive ^[^S^ -lTt*r?vice in ttu«- country, \.S ia addition to the abovo, service in tiwfi-gLfa ijfineluding medH M e. All -setvice9 between 9 WUn-lt, .«. M.,and 8 A.M., ahatr be consul- .red as night ser.vlco. JTIOTSIV ibetof. this Society be requi- a ftoflfirdance **Vtn^«bove 9 ■6 NATIONAL LIBRARY OF MEDICINE Bethesda, Maryland f VALUABLE WORKS, Printed by J. tl J. Harper, New-York, and for sale by the Booksellers generally in the United States. THE HISTORICAL WORKS of the Rev. WIL- LIAM ROBERTSON, D.D.; comprising bis HIS- TORY of AMERICA; CHARLES V.; SCOTLAND, and INDIA. In 3 vols.8vo. 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F. dXvFdSON, CINCINNATI, rgjLrL£Lcd ^q-aiLtfc^ tLa gfculli. cLlcl Jll/est, In presenting this Ciucui.au, the undersigned feels a degree of con- fidence which arises, nut only from the merits, but from the increasing demand for this apparatus, from all parts of the world, The gratify- ing and satisfactory evidence of its peculiar and admirable adaptation to the purpose for which it is desigued, and the opinion so freely and confidently expressed by those who, a^re qualified by actual experiment to judge of its merits, that it is the" only apparatus which especially moots the wants of those Druggists a:ul others, where the sale of Soda Water is limited, or whose locations are remote from large cities, and who do not desire from 200 to 400 Dollars in an apparatus of the kind. It is so exceeding simple that an intelligent boy can readily under- stand its operations and management. A full supjjly is kept up at less than one cent per gallon, and the product more reliable and pure, and can not be contaminated as in some instances has been tho caso with the old complicated Gas Fountain. The Recent Improvements, with the new and elegant Draught Stan- dard, give to the fountain an additional advantage as an ornament, •while its careful-and perfect construction ensures its successful opera- tion for years. Orders for Fountains, or information concerning them will meet with prompt attention. W. TP. DAVIDSON, SOLD FOR CASH ONLY. SPuce $6o, = ^ndaditvj (goto. D/-..8.���B AVM. F. DAVIDSON, (SUCCESSOR TO GEO. M. DIXON,) WHOLESALE DRUGGIST, N. E. CORN Kit FIFTH AND MAIN STREETS, CINCINNATI, 0. The Proprietor, appreciating the position of the Physician, has directed his attention to supply what has long been a desideratum with the medical profession, a depot where medicines and chemicals can be always obtained in their purity, with cirtiu-.i uniiupnircd either by adulteration or "tricks'' too common in trade, and is pleased to say that the extensive patronage afforded him by medical men throughout the entire western country, is the reward of his efforts. His efforts will be unremitting, and having unsur- passed facilities for carrying on an extensive business, confi- dently promises satisfaction to all favoring him with their order*. Furnishing goods at as low figures as pure Drugs can be afforded. fl-A^A general assortment of Eclectic preparations, and active principles of reliable quality, always on hand. To Druggists, Apothecaries, and Dealers, a heavy stock is offered, complete in assortment, embracing the following goods of warranted quality: Drugs, .Medicines, and Medici- nal Preparations, Pare Chemicals, and Extracts, Apothecaries' Choice Goods. Shop Furniture, and Labels, Physicians' extra quality Powders, Medicinal and Perfumers' Pure Essential Oils. etc. (1) 2 WM. F. DAVIDSON'S dish Pries Current. Also,—Paints, Oils, Turpentine, Varnishes, Brushes, and Painter's Colors and Materials, Window and Apothecaries' Glass ware, Dye Stuffs, Dyers' and Hatters' Materials. The following staple goods of the most celebrated makers are offered to the trade AT FACTORY PRICES: White and Red Lead, ground and dry, Linseed, Lard, Castor, and Neat's Foot Oils. Alcohol, Glue, Star, Adamantine, and Tallow Candles, Starch, Alum, Salt-Peter, Potashes, Sand Paper, Matches, Patent Twine, f 25 II 50 (I 50 •L 00 5 00 35 ~J J*-*! ■* *Q/*«M VOL F. DAVIDSON'S Cash Prices C ARTICLES. k AMMONIA SPIRITS, Aromatic................ " A«SEN AT E....................... " HYDROSULPIIATE................ " IODIDE ........................... " MURIATE......................... " NITRATE, Crystals................ " " F'used.................. " OXALATE ........................ " PHOSPHATE ••••.................. '■ SULPHATE....................... AMYGDALIN................................ ANTIMONIALIS. Pulv. (James' Powder)....... ANTIMON Y, M ET A L ......................... " CROCUS .........'.............. « CHLORIDE, Crystals............. « " Solution (Butter of)- " SULPHURET.................... " SULPII. Golden................. ■w^ " TARTRATE, Crystals............ " " Powdered.......... ARSENIC, Powdered.......................... " Solution of (Fowler's).............. " IODIDE........................... « " Solution (Donovan's)....... ASPARAGIN................................. ATROPIA, in one drachm bottles.............. AQUA, CALCIS............................... " CAMPHORA .......................... " CINNA MON.......................... " MENTHA PIP......................... " ROSAR ............................... ARROW ROOT, BERM. Pure.................. " « FLORIDA...................... " « JAMAICA..................... BALM GILEAD BUDS......................... BALSAM APPLE TINCTURE.................. " CANADA............................ .—» « COPAIBA........................... " •' CAPSULES, No. 1.......... « « " No.2.......... « " " No. 3.......... « « SOLID.................... « PERU............................... " SULPHUR........................... «< TOLU............................... BANDAGES SUSPEN.SAKY, Cotton............. " " Silk................ BARK ANGUSTURA........................... " BLACK ALDEK ........................ « BAYBEKRY............................ " Powdered.................. « CINCHONA, Kol. True............•••■ •• Powdered............. » - Pale....................... dchrn. ft l or, 1 00 10 1 00 50 6 0(1 5 on 2(1 25 25 25 30 20 30 7") 4-0 50 1 2.1 0(1 2 (XI 2 25 1 05 I 50 4'l 1 25 2 50 0 00 35 25 35 40 1 25 1 50 65 •*■« *r WM. F. DAVIDSON'S Cash Prices Current. 5 ________ARTICLES.___ BARK CINCHONA, Pale, Powdered- " CANELLA................. " " Powdered....... " CASCARILLA.............. " '• Powdered--- " CASSIA.................... " " Powdered.......... « DOCV.'iViD................ •' " Powdered....... .„ " ELM....................... " " Powdered.............. " HEMLOCK, Ground......... « MEZEKKON................ " OAK, White Ground....... » PRICKLEY ASH........... " ■' '• Powdered-•• POPLAR. Ground........... " SASSAFRAS, of the Root • • • '< '• Puwdeed..... TAMRACK, Ground....... " WAIIOO. of the Root...... BARLEY, PEA ItL................ BARYTA, PUKE................. " ACETATE ............. " CARBONATE.......... » MURIATE............. » NITRATE............. " SULPHATE............ BAY RUM, Pure, in Bodies........ BEANS, TON K A......................................... VANILLA ...................................... BEBERIN E, PUKE....................................... « si; lpii ate......................•.......... BERRIES, .lUNIPEK..........................:......... LA UK EL..................................... " POKE........................................ " PKICKLEY ASH............................. " SUMAC ...................................... " FRENCH..................................... BITTER SWEET T\V UHiii............................... BISMUTH, M ET A L...................................... " OXYCHLORIDE.............................. " SUBMTU ATE................................ " VALERIANATE, in ± oz. vials................. BLACK DROP ........................................... ___BLISTER PLASTER..................................... " TISSUE, in Cans of 0 sliocts.......,............. BLUE PILL, AM., one-third Mercury. (Warranted equal to any Imported)....."....................... " " ENG., one-third Mercury-...*...............- BLUE VITRIOL........................................ BRAZIL WOOD, Ground................................. bott. ft i <** WM. F. DAVIDSON'S Cash Prices Current ARTICLES. CORKS, VIAL, Lar-o, Extra Fine...... " " Ordinarv.............. " '■ Assorted.............. CORK SCREWS, 15 to................. " PRESSERS, Iron............... COURT PLASTER, Black.............. " " Flesh.............. COWAGE DOWN...................... CREOSOTE ........................... . CREAM TARTAR, Pure, Powdered..... CROCUS METALORUM................ CUBEBS.............................. " Powdered.................... CUBEBINE........................... CURCUMA ........................... DELPHINIA ......................... DOVER'S POWDER................... DIAMONDS, GLAZIERS'.............. DIGITALIS Herb..................... " Powdered................. DRAGON'S BLOOD, in Reeds........... " " Common-■•....... DENTIFRICE, HAMLIN'S, Box 50 Cts.. " CRANE'S " 25 " • " HUNTER'S " 25 " • ELATERIUM......................... ELIXIR, OPII (McMunn's)............ PROPRIETAT1S............ " VITRIOL................... EMETINE, in £ oz. -vials.............. EMERY, Flour........................ " No. 0........................ " No?. 1 to4................... EPSOM SALTS, Refined, Pure......... -ERGOT- " Powdered.......................... ERGOTINE, in i oz. vials................... EXTRACT, ACONITE...................... " BARK PRECIP., with Directions- " BELL ADON NA................. " BLACK SNAKE R()OT.......... " BLESSED THISTLE............ " BITT ERSWEET................ " BONESET...................... " BUCHU, Fluid.................. " BUTTERNUT................... " CICUTA----.................... « CHAMOMILE.................. " CLOVER, Red.................. " COLOCYNTU. Comp............. " COPAIBA...................... " AND SARSAPARILLA (Thorn's)- CUBEBS, Fluid........................... DANDELION............................. Gross Each dchm ft dchm. ft Each lb dchm Doz ft Doz. ft • WM. F. DAVIDSON'S Cash Pr7 a Current. ______________ARTICLES.______________ EXTRACT, FOX GLOVE, CDiu'italis)............ ': G AUG ET. (Poke Ron;).............. " GENTIAN......................... " I1ARDI1 ACS...................... u lIiMRIIOUND..................... ,; HEMLOCK........................ H EN KANE, (ilvosciamus.) Shaker- ■ '* " English............... •' 11 «I-............................. 4 I Mi I AN HEMP, En-lisli........... " JALAP............................ " LiiJUORICE, Calabria.............. "• '; '•' Powdered •-• ■ " ■' Sicily................ "* " Refined............... LO-IUOlil).................. MAY APPLE, (Podophyllum)- MoM-SM....:.............. MULLEN...................... NUX VOMICA, Alcoholic....... OPIUM........................ PINK ROOT, Eliii-l............ ,; ' " ANU SENNA--- POPLAR BARK ............... POPPY....................... PARI ERA KRAVA, Fluid.....- QUASSIA. Sidid.............. KIIATIXV................... RHUBARB, Solid............. Fluid............. SARSAPARILLA .............. Fluid........- " " Shakers SAVIN........................ SENNA. American............. " Ale-:.. Fluid........... STRAMMoNIlM.............. SAPONAK1A.................. TOMATO..................... UVA L'KSI. Fluid.............. VALERIAN. Fluid............. Sol ill............. VANILLA..................... WATER PEPPER.............. Essential TJfctraCts, " Of very superior quality, for culinary purpc-efvof our own make ESSENTIAL EXTRACT, CTNN AM OX.......;................ " •' GINGER........................... " " i.l'MO:.....................;.-.'..... " ;' IvUTMIMS......................... u «* ORANli.:........................... 10 WM. F. DAVIDSON'S Cash Prices Current. ARTICLES. ESSENTIAL EXTRACT, I OSE..... '■ " VANILLA. FARINA .......................... FLAG ROOT. Candied.............. FLOWERS, ALTHAE............... " ARNICA...-............ " CHAMOMILE, En.-lisl,.. " German ■ " ELDER................ " LAVENDER............ " ROSE. Red............. " ROSEMARY............ FUNNELS, Glass. 1:, |.............. " Wcd-e Wood, 20 to..... GALLIPOTS, Strai -1,(.............. with covers, for ointments, &c, 1 oz. GALLS, ALEPPO........................ __'* " Powdered...........\... GELLATINE, French.............. Rose.....................'." GLASSWARE, every variety, at Manufactur Long Vials, NARROW MOUTHS, J, I, and 2 drachms ... 8 oz.- 16 oz.- 20 oz ■ quarts- and 1 ounce • 2 ounce...... 3 and 4 ounce - 0 ounce....... Common Assorted Vials, V to 8 ou Prescription Vials. NARROW MOUTHS, *, 1, and 2 drachms- - „ ' i and 1 ounce....... „ 2 ounce............. „ " 3 and 4 ounce....... ,, . 6 ounce............. ft Doz. tb each Doz. ffrDE MOUTHS, if l^S^™^!?8™"- „ " iand 1 ounce...................... " 2 ounce........................]'... a " 3 and 4 ounce..................'..'..'........ ,, " 6 ounce.................. Gross WIDE MOUTHS, J, ^ffiK" *<™ i * 8 ounc^ i and 1 ounce.....,..... 15 1 00 40 1 GO 1 80 2 10 2 50 3 75 00 1 Oil 2 00 3 00 3 00 .'1 25 3 50 3 75 4 00 i 50 i 50 4 00 3 12 2 85 3 20 3 40 3 75 4 3S 3 75 3 75 3 20 VvAM. F. DAVIDSON'S Cash Prices Current. 11 ARTICLES._____________________ Prescription A As. WIDE MOUTHS, 2 ounce............................... " " 3 and 4 ounce........................ 11 '■ 0 ounce.............................. « " 8 " ..........................'■••■ " " Assorted Prescription from i to 8 ounce Druggists' Packing Bottles. GREEN, wide and narrow mouths, Pat. Lip. i pt........ •' *' " " " i- pt........ " " li " " 1 pt........ i« « « « <■■ l quart .... " i gal....... " " " " 1 gal....... Pickle and Preserve Jars. STRAIGHT or turn over tops, { pt...................... " " " 1 l't-..................... « " " " 1 (iuart................., II t< « « 1 ,.,] .................... " " " " 1 £lL.................... Acid Bottles, Ground Stoppers. | pint Acids, net..................................... i ': •' '• ..................................... 1 quart " " ..............-....................... I gal. " " ..................................... lgal. " " ..................................... Concave Castor Oil Bottles. 2 ounce Concaves..................................... 3 " '• ...................................>• i pint " ..................................... k " " ..................................... Octagon Castor Oil Bottles. 20 to gallon, or £ pint................................. 24 " ................................. 30 " i pint................................. Inks and Ink Stands. H and 2 ounce squat and cone Inkstands............... 4 " " " « ............... i ounce Inks, moulded................................ 2 " " " ................................ 8 " " " ................................ 4 « « «............................... 6 " " " ................................ g « « « ..................,........... Yv'M. F. UAVI DSON'S Cash Prices Current. \ AKI'Tl J-> _____________________ Moulded Castor Oil Eoitles, Bound, CASTOR OILS, (is to gallon................................. " " 10s and l'-'s to stall m......................... " '■' lfis to gallon................................. " « 20s " ................................. " " 2 Is and 30s to gallon......................... " " 40s and Si's " ....................... Specie Jars, with Tin Japanr.ed Cover3. 3 gallon................................................... 2 i: ...........................-....................... 6 quart.................................................. 1 gallon................................................. 3 quart................................................... \ gallon.................................................... 1 qunr!.................................................... 1 pint • • •.................................................. fr l>i»t..................................................... I, 2, and 4 ouui e........................................... Specie Jars, with Tin Japanned Covers, Squat Shape 2 gallon................................................... 1 " ................................................... 3 quart..................................................... i gallon.................................................... 1 quart...................................-................. 1 pint...................................-.................. Tinctures, with Ground Octagon or Crown Stoppers 2 gallon.................................................... 6 quart.................................................... 1 gallon.................................................... 3 quart..................................................... *r gallon.................................................... 1 quart.................................................... 1 pint......................•.............................. i pint arid 4 ounce.......................................... 1 and 2 ounce.............................................. Salt Mouth3, with Ground Octagon or Crown Stoppers 2 gallon.................................................... 6 quart.................................................... 1 gallon................................................ 3 quart..................................................... i gallon................................................... 1 quart.................................................... 1 pint..................................................... 4 ounce.................................................... 1 and 2 ounce.............................................. V/.M. F. DAVIDSON'S Cash Prices Current. ARTICLES. Flasks. Eagle i pt. and f.mcv \ pt. flasks---- " 1 pt. - " 1 pt. " ---- Quart fancy pattern................ Fluted Long Prescriptions. 1 and 1 ounce heavy moulded.................. Patent Medicine Vials, &c. I!a( eman's.................................... Turlington's.................................. Peppermint, (large and small)................. Harlem Oil'•••••'.............................. Iti-i i i-li '• ................................. Rai's " (Small).......................... End He's..................................... Oj-ndddi.c. (liin;e nnd small)- Li-jiiid i'] ' ileUloc........... Lemon Aeid................. Cal. i. e I Magnesia.......... I!ed Ink, (square or octagon). Ceinline Essence............ Dais-: in of Honey............ London Mustard............ Durable Ink............. Dalbj's Carminative...... Ni i ve and Hone Liniment. one ounce Vermifuge...... Varnish Bottles........... Lemon Syrup Bottles. Lemon Syrups, Gs and 7 s to trallon......................... Ss '• ......................... A full stock of Glassware, of every variety, constantly on hand at Manufacturer's Prkes. AN VTLLE'S LOTION.................. At VS PAHA DISK..................... YCl-.KiN E. Sweet, and Pure............ 1JE. No 1, Ilrown...................... While............................. ■• Extra. A No. 1.............. , \!'|.;:il SALT......................... d.lv CHLOK1DE, iii lf> er. bottles....... AM) SODIUM......... ' HYPOsn.i'HATE, in 15 gr. bottles- '- OS IDE. in ' oz. Lotties............. bott. dchm. bott. dchm 14 WM. F. DAVIDSONS Cash Prices Current. ARTICLES. GOLD, LE.U', AX Dee]...................... " " U.-ual........................ " •' Pale......................... GRADUATED MEASURES, Minimum....... '; '■ 1 tolboz., 40 to- 0UIACUM, Rasped......................... GUM, ALOES, Cape........................ '* '• " Powdered............... " " Soc,True.................... " " " '; Powdered.......... " AMRER............................. " AMMONIAC......................... " ARABIC, White...................... " " Select....................... " " Fair....................... - " " White, Powdered........... « ASAF(ETIDA........................- — " " Powdered................ " BENZOIN ........................... " CAMPHOR. Refined................... « CATECHU............................ " DAMAR............................. " ELASTIC............................ " ELEMI............................... " EUPHORBIUM....................... " " Powdered............. " GALBANUM.......................... ■— " GAMBOGE..................,......... " Powdered.................. " GU1AC............................... " " Powdered..................... " HEMLOCK...................'........ " KINO................................ " '•' Powdered....................... " MASTIC.............................. " MYRRH, India........................ " " Turkey..................... " " " Powdered.....■....... " OL1BANUM.......................... " OPIUM, Turkey....................... "** u " " Powdered, Pure........ " " Denarcotisod................. " SANDRAC........................... « SCAMMONY, Aleppo.................. " Powdered......... " SENEGAL............................ " SHELLAC, Orange.................... « SEEDLAC ............................ " STYRAX, Liquid...................... " TRAGACANTH, Sorts................. " " White................ " " " Powdered....... TOLU, in boxes, for chewing........... HEIFFER'S TEATS ............°........... WM. F. DAVIDSON S Cash Prices Current. 15 ARTICLES. HOFFMAN'S ANODYNE -- HONEY, Strained....... Herbs. SHAKER HEniiP, of the present yeirs growth, at the Society's prices. Particular attention is paid to these well-known arti- cles. Acting as their agent, a full assortment is kept. They are put up in neat packages of from one ounce to a pound, aud their qualilj can be relied on as entirely fresh. ACONITE LEAVES......................................... BELLADONNA ............................................ IIONESET.................................................. I! \L\loNY................................................. l'.l ITEKEEOLE............................................. BLESSED THISTLE......................................... CENT E A !' Y................................................ CATNEP ................................................... ClOETA.................................................... ELDER Fl.<>\VERS.......................................... I'l V K 1'IN'I Ell.............................................. FOX GLOVE................................................ FEVER FEW................................................ IIENBA N E................................................. HOI'S............."......................................... iioaiuioend.............................................. hyssop.................................................... liverwort............................................... -LOBELIA. (SeaieJ.......................................... LEMON BALM............................................. MARSH MALLOW LEAVES................................. MOTHERWORT............................................ MIILLI'N LEAVES.......................................... MARSH ROSEMARY........................................ PARSLEY LEAVES......................................... PENNYROYAL............................................. PRIVET LEAVES....... • •'•................................. PIPS! SEW A............................................... RASPBERRY LEAVES..................................... R( >SE LEAVES. Red........................................ RUE....................................................... SWEET MAK.IORAM....................................... « BA/.IL --■-.......................................... " BL'OLE............................................. SAGE...................................................... SAVIN............................••........................ 6CE LL 0 AP................................................ SPEARMINT............................................... SOAPWOKT...................................... ......... SI'MMEESAYOKY.......................................... TANSEY ................................................... STR A MMOM EM........................................... THYME..................................................... WATEKPEPPER............................................ 50 30 20 25 25 2a 50 25 2o 25 25 SO 25 50 50 25 30 00 35 25 30 26 35 30 25 1 00 25 40 25 £5 25 25 25 25 25 25 25 25 25 25 16 TYAM. F. DAVIDSON'S Cash Prices Current. Herbs. W1NTEKCREEN WORMWOOD.--- WITCH HAZEL • Instruments. BREAST PUMPS, G. Elastic....... PIPES. Glass............. BED PANS, White................ '• ■' Y'ellow................ CUPPING GLASSES .............. " CASES, with Pumps in C; LANCET -. Evau's Genuine........ " •• Imitation ...... " Gum........'......... '• Spring, German........ Am LACTEAL?, or Artificial Breasl, a desirable a-ti.-le for nursing POCKET CASES, VIALS, a neat article for Physicians to carry contain 20 vials................... GUM ELASTIC RINGS..................................... APOTUECARIES' SCALES, French No. 1..................... >; '• '• No. 2..................... " '• Small, with weights.............. " SCALE WEIGHTS, £ rr. to 2 drachms...... SPATULAS, 3 to 12 inch.................................... NURSING BOTTLES, Glass.................................. '■ '" G. E. covers............................ '■ BOTTLE TUBES, Metal........................... " '" '" Ivory........................... " " Silver........................... NIPPLE 'SHELLS, Glass..................................... " SHI ELDS, Metal................................... " " Class.................................... PESSARIES, G. Elast i •.......................•............... " Glass, Concave................................. " " Globe.................................... STOMACH PUMPS.......................................... TUBES.......................................... SCARIFICATORS, American, Superior....................... " German............................•...... STETHESCO PES, Plain...................................... Ivory ends................................. Each Doz. Each UP.INALS, Porcelain, Female............ " Male.............. NIPPLES. G. Elastic.................... li H< •;' r'....................... SPECiiLUMS, Ok --.=..................... ;' covered............... SYRI.VO- ;■■:. 24 oz., Self, in Case*-. •> tubes- ■ " 16 oz., " '• 2 ■' . ■ Doz. Set Inch Eael! Doz. Each Do/,. Each VOL F. DAVIDSON'S Cash Prices Current. 17 ARTICLES. Instruments. BYR1NGES, 12 oz., Self, in Cases. 2 tubes.......... " 8 " " ': 2 " .......... " 24 " Plain, not in Cases, single tube- tt |o t: a tt a « tt . ....... " ;- No. loo....... " Partridge's............. MECONINE....................... MENJ.M'ERMIN.................... MERCURY. Cure,.......................... Disiillcd........................ " cvanid::..................... " IODIDE, I'rolo.................. " " Drulo.......---....... " OXIDE, Black.............. ... " SIJBSULI'II. (Turpeth Mineral) ■ " SELPIUJRET. (Elheops Mineral)- " with CHALK. (Ilvd. C. Greta)--- MORPHIA, PURE ALOAI."il>, in | audi ■•■ " ACETATE, " '■-.. " MURIATE, " "■-. ----" SULPHATE, " ".-. " VALERIANATE " «... HONESIA, Ext............................... MORTARS, Wedge Wood, all sizes............ " Glass, 75 to...................... " Iron............................ MUSK, in Grain...................... ..... " Tincture of.......................... MUSTARD SEED, Eng....................... " " " Pul., Pure............ " " Am....................... " •' " Pul., for Plasters...... " Eng., for table use, in boxes...... NARCOTIN E............................... NAPTIIA, Mineral, for Pres. Potassa......... " Wood.................•.......... NICKLE........................... ....... NUTMEGS. Prime, Fresh.................... NUX VOMICA.............................. " " Powdered.................... OAT MEAL................................. WM. ~F. DAVIDSON'S Cash Prices Current. ARTICLES. lis- HLED SILK, Yellow and Green....... )IL, ALMONDS, Essential......... " ■< Sweet ............... " ALLSPICE, (Pimenta,) in 1 oz., vi " ANISE................................................ " BLACK fcEPPER..................................... " BERG A MOT ..........................'.............. " C AM PHORATED...................................... " CASTOR, Cold Drawn.................................. " " " " No. 24................. .......... " " " " No. 30............................ " " « " . No. 40............................ " CAJUPUT, True....................................... " CARAWAY........................................... " CEDAR............................................. " CHAMOMILE......................................... « CINNAMON........................................... " CLOVES ............................................. " COD LIVER, (Oleum Morrbua?,) a remedy in drscrvedD high repute for pulmonary and other diseases. Tin credit of this article is sometimes shamefully at.use- by the uuprincipled substitution of other oils for it and its being mixed to that extent which induces mud harm, rather than good, when the patient hanjts hi only hope on its use, as a last resort. A very good les is recommended, by adding to half an ounce of the su.- pected oil in a test glass, 25 or 30 drops of concentrate! Sulphuric Acid, which should instantly show a Leant: ful purple color in good samples, which peculiarity due not reside in any other adepose substance............ " COD LIVER, CAPSULES.............................. " COPAIBA ........................................... " CROTON, Pure, in 1 oz., vials....................... • " CUBEBS ............................................. « CUMMIN............................................. « ERGOT .............................................. " FENNEL....................m-....................... » HEMLOCK..................*&■.................... " HORSEMINT......................................... « JUNIPER ■■••....................................... " LAVENDER, Garden............................... " " Spike.........-......................... « LEMON...........................................•• " NEROLI. (Orana;e Flower)............................. « NUTMEGS, (Concrete) •••............................. « OLIVE, Draft........................................ " " Salad, in baskets.............................. ORANGE............. ORIGANUM, True-••■ PENNYROYAL......- PEPPERMINT, Pure RHODIUM......... ROSEMARY........ WM. F. DAVIDSON'S Cash Prices Current. 21 OIL ROSES, Pure " SAVIN...... SASSAERAS. SENECA " SI'EA RMI NT....................................... " SPRUCE......................................... " TAN'SEY........................................... " TAR............................................... " TOBACCO, in 1 oz. vials............................. " TURPENTINE..................................... " VALERIAN........................................ <• WINE............................................. " WINTERGREEN........................•.......... '■ WOKMSEED....................................... " WORMWOOD........;___....................___ ALSO, some rare varieties seldom met with in the shops, for perfumers' use. OINTMENT, CITRINE................................... " M ERCUEIAL, (blue)......................... " " Red Precipitate................ " STR AMMONIUM...........'.'................. ORANGE PEEL......................................... " " (.'round.................................. OXVMEL SQT'lLI.S..................................... PHOSPHORUS, cans, 1 to 11 lbs......................... PIPERINE............................................. PICROTOXIX .......................................... TLASTER, ADHESIVE, spread..........'.'............... " '■ roll................................. " Cantharides, roll............................. " Lead........................................ <: with G um............................... " Mercurial.................................... " " with Ammonia...................... " Galbanum, roll............................. " " spread, 75 to...................... " Burgundy Pitch........ „.................... " Poor Man's ....'........T..................... " Soap..................Y...................... " Belladonna.................................. PODOPHYLLIN E....................................... POPPY HEADS......................................... POTASSIUM, in -|- oz. vials............................... " Bromide.................................. • " Cyanide Fused............................. " " Granular.......................... " Iodide..................................... ** Iodo-Hydrarg.............................. POTASH, common...................................... " ACETATE................................... « BICARBONATE, crystals...................... « CARBONATE, (Sal. Tartar).................... « CAUSTIC............•........................ " " white.......................,........ •sea. 22 WM. F. DAVIDSON'S Cash Prices Current. ARTICLES. lb k POTASH, CHLORATE. • • •................. " CIIROMATE.................... " CITRATE....................... " PRUSSIATE.................... « NITRATE, Pure................. " SULPHATE, Crystals............ " " Powdered.......... *•* SULPIIURET, (Liver of Sulphur)- « TARTRATE, (Sol. Tartar)........ Faints, Oils, &c. BLACKS, BLACK, LAMP, English, h |, and 1...... " " Germantowu, j-, i, and 1. " " Extra, for Printing Ink-• DROP BLACK, Eng..................... " " Am.-.'.................. BLACK LEAD.......................... " IVORY ......................... BLUES. PARIS BLUE, Soft....... PRUSSIAN BLUE, Extra- '• " No. 1 • ULTRAMARINE......... " Extra- • ■ GREENS. CHROME, D., 6 ft boxes............ " No 1, D., 6 ft boxes..... BRUNSWICK..................... PARIS, Best......................, « No.l...................... EMERALD....................... VERDITER....................... OILS, VARNISHES, 40. LINSEED ................................ " Boiled.......................... COPAL VARNISH, No. 1.................. No.2.................. Extra.................. White................ COACH " DAMAR " JAPAN " LEATHER « Black.. Yellow YELLOWS. CHROME, 6 ft boxes................ " Extra, 6 B) boxes-•••...... DUTCH PINK...................... OCHRE, French..................... " Am....................... f ¥ "WM. F. DAVIDSON'S Cash Prices Current. 23 ARTICLES._____________ LEADS. PURE WHITE LEAD, in Oil. 25 ft kegs to 500- No. 1 " " " " " " " • PURE " " Dry................... RED " " " ................... LITHARGE.................................. MISCELLANEOUS. PUTTY, in Bladders......................... VENETIAN RED, Eng...................... CHROME " ........................... INDIAN " ........................... VERMILION, Chinese....................... " American.....•>.•............ tt Triest- •........•••........... TERRA DE SIENNA, Raw................-- " " " Burned............... UMBER, Raw............................. " Burned........................... VANDYKE BROWN....................... CARMINE................................. ZINC, WHITE, in kegs..................... " " Snow....................... BRONZE, a full assortment of every variety. Brushes. PAINT BRUSHES. 5...... 4...... 3...... 2...... 1...... 0...... 00..... ooo-... 0000- • • 00000-• oocooo- No. 1. WHITBWASH BRUSHES, WITH HEADS. "11. « 12. J5X5%vM£t 24 "WM. F. DAVIDSON'S Cash Prices Current. ARTICLES. No. 5.- « I.. " 3-. « 2-- OYAL VARNISH BRUSHES. 0--.- 00-" 000-. 0000- Sash Tools. In addition to the above, we have a full stock of brushes, co Bisting in part of Hat, Cloth, Hair, Shaving, Bathing, &c, &c. QUASSIA, Rasped......................••................. QUICKSILVER............................................ QUINIA, SULPHATE...................................... " PURE ALCALOID...............................* " AMORPHOUS.................................... - ACETATE........................................ « ARSENIATE ..................................... » CITRATE........................................ " " with Iron............................... " " " " syrup of-...................... •* PERROCYANIDE.....•........................... « IODIDE.......................................... ** " with Iron................................. » LACTATE........................................ « MURIATE........................................ •» TANNATE....................................... " VALERIANATE.................................. RED PRECIPITATE....................................... " LEAD................................................ «< SANDERS.............................,.............. " TARTAR............................................. RICE FLOUR.............................................. ROCHELLE-SALT-......................................... ROOT, ALKANET.......................................... " ALTHAE........................................... " ANGELICA...................................,..... " ASPARAGUS....................................... » BETH.............................................. * BJTT'.&...............,....... .................... * " Powdered................................... ■ BURDOCK.......................................... lehll to 2 00 2 50 3 00 4 00 5 00 n oo 00 00 10 00 1 00 1 25 1 ~Ai 2 00 5 00 ,- If' ■4 5 H YDRO*ULPH ATE............................... « NITRATE........................................ « PHOSPHATE...................................-. « POWDERS, in Tin............................... 20 1 40 30 50 50 25 12 p.; 20 25 1 75 I 00 40 It 50 it 25 t: 40 it eo it 30 c. 45 OZ. 1 75 tt 2 00 It 2 25 It . 1 30 I. 1 30 ■ t 1 00 ft ■l 0(1 ft 51) Doz. 2 (Kl ft 50 tt 00 « CO 4n " 50 it 40 tt ■ 00 tt 50 tt 35 tt 40 it 00 i- 40 bott. ft Doz. I 35 10 35 5 5(1 1 25 15 40 2 50 ism- -&£ :_.^„ Current. H ^ SODIUM, in i oz. bottles SOAP, CASTILE................. ....... t ERASIVE............................ i PALM ................................ ' WHITE, for Opodeldoc................... A " WINDSOR, Genuine................. ' BROWN " *' ................. SNUFF, CATARRH, (Dorland s)................. •< MACABOY- ........................... « SCOTCH................................. SPIRITS AMMONIA...........*," "A ''" 'A" ' u « ACETATE, (Mindeien)......... u « Aromatic.................. , « LAVENDER.............................. tt -. Comp.................... « ROSEMARY........................ « TURPENTINE........................... SPERMACETI...........................■*.■.■'' SPONGE, BATHING........................ " LIVERY, Common................. it Extra Fine.................. STRONTIA, MURIATE........................... NITRATE ............................ STRYCHNIA, Crystals..................... tt Powdered................... » ACETATE......................... t< NITRATE.......................... « SULPHATE......................... SUGAR LEAD, White...................... MILK................................... u " Powdered.................... SULPHUR,ROLL................................. « FLOUR................................ » MILK OF.............................. » IODIDE............................... TAMARINDS.................................. TANNIN................................ TAPIOCA, White..................'..'.'.'.'.'.'.'....... TTVPTrmvs nf everv variety contained in the Mate 1 toSS« wi?amauy non-omcinal, or domestic, preparations of various forms THE1NE............................ TIN, MURIATE, Crystals............. i.- " Solution............. " Powdered....................... " Granulated.............■ • •'' •'"' « for Polishing, (Putty Powder,) En TRIPOLI.................• • •....... TWINE, Cotton, for Druggists use- ■ • " New Zealand, Genuine.....• tt t: " Imitation--- TURPENTINE. SPIRITS............. « VIRGIN............. ft Doz. ft Gall. ft Medica JO 25 40 1 00 2 HO 76 50 40 i;o 4 00 75 Doz. 1 00 ft 1 00 it. 1 00 tt 60 Gall. 4 00 ft 40 -w* WM. F. DAVIDSON'S Cash Prices Current. 29 ___A RTICLES.________ TURPE.NTI NE, VENICE.............. UVA L'ESI........................... VERATRIA, in 1 dracbm vials....... V1.RDEGRL-, Balls.................... " Distilled................. WAFERS. Red, Pea................... WAX, BAYBERRY.................... BEES, \ellow.................. '■ " White................... WHITING. Spanish................... " Pari<...................... WHITE. LILY........................ WINE, ANTIMONY................... '■ COLCHICUM SEED............ '• " ROOT............ " ERGOT........................ " IPECAC....................... " OPIUM........................ " CAT AW BA, Pure.............. " " •' pints......... " CLARET...................... " MADEIRA.................... " MALAGA............!.'.!...'.'.. *».« PORT, Pure Juice.............. " SHERRY..........'.'.'.'.'.'.'.'.'.'.'.'. WHISKEY, OLD RYE. Pure........... '• " MALT............... BRANDY, Fine Old Pale Mag-lory, Pure- " " Seignette " • HOLLAND GIN. Pure................. ST. CROIX REM, '•' .................. JAMAICA " " ................. NEW ENGLAND RUM, Pure........... ZINC, ACETATE...................... " CARBONATE, (Flowers Zinc)- - - - " CHLORIDE, in 1 oz. bottles..... " CYANIDE, 1 " " ....., " FERROCYANIDE, in 1 oz. bottles " IODIDE 1 « " " OXIDE. (Flowers)............... " SULPHATE .................... " VALERIANATE, in i oz. vials -. - dchlttv 50 25 GO 1 00 1 25 "«i0 40 5U Doz. 75 to 75 " 1 00 ff 1 CO if 1 0(1 ff 1 00 2 00 Gall. 2 50 Doz. 6 00 " 0 00 Gall. 4 00 Doz. 9 0(1 G.'lllr 2 00 li 4 (HI Doz. 8 00 Gall. -1 00 Doz. 9 0(1 Gall. 2 50 '; 1 00 " (i 00 Doz. ' 10 00 Gall. 5 00 Doz. S 00 Gall. 2 50 '■ 3 00 " 3 00 " 1 50 to 1 25 •2(1 2 00 *m. 30 WM. F. DAVIDSON S Cash Prices Current. EXTRA QUALITY DOUBLE REFINED SYRUPS. WM. F. DAVIDSON would respectfully invite the atten- tion of Druggists, Merchants, Shopkeepers, and business men, to his assortment of extra quality of Syrups, which he manufactures on an extensive scale, by a new and improved steam process, from the best quality of double refined, crushed, and powdered white sugars, warranted to keep in any climate unimpaired for years. The assortment consists in part of the following varieties, by the gallon or in bottles, packed in boxes of one doz. each: Names. Per Gal. Simple,___2.00 Lemon, .... 2.30 Strawberry,. 2.30 Sarsaparilla,. 2.30 Ginger,---2.30 Raspberry,.. 2.30 Per Doz. 5.00 5.50 5.50 5.50 5.50 Names. Per Gal. Pine Apple,. 2.25 Orange, .. , Vanilla,.., Sassafras,. - Rose, .... Orgeat,.. . , 2.25 2.25 2.25 2.25 2.35 Per Doz. 5.50 5.50 5.50 5 50 5.50 5.00 O* Syrups of the above varieties, acidulated for Swan's Soda Fountain, always on hand at 25 cents per gallon, in addition to the above prices. ICFTo avoid misconception, persons who use Swan's Fount- ain, and wish syrups ready prepared for it, are requested to state this fact in their orders. As much the largest consumption of Syrups is used for Soda water, they will be furnished in barrels, kegs, and jugs of vari- ous sizes, to meet the convenience of customers and dealers who ship to distant ports. The city and country trade can be sup- plied at any moment, and in any quantity, with the above, at prices far below what is commonly asked for an article twenty- five per cent, inferior in point of strength and excellence of flavor. All persons interested in the trade are respectfully solicited to make inquiry, as satisfaction in regard to price and quality is warranted. Packages, in all cases, will constitute an extra charge. Heavy iron bound half barrels and ten gallon kegs, $1 25; six gallon kegs, $1 00; three gallon kegs, 75 cents; jugs, 12 cents per gallon; dry kegs for packing jugs, 20 cents each. IT Sole Agents for the South and West, for SWAN'S PATENT ATMOSPHERIC SODA FOUNTAIN. WM. F. DAVIDSON'S Cash Prices Current. 31 DOUGHTY'S PURIFIED MEDICINAL OOID IL-XVESIFL oil. [Oleum Morrhuce.] Our Cod Liver Oil is carefully prepared, by an experienced and skillful operator, from the fresh Livers of the Cod Fish taken off the banks of New Foundland, and may be relied upon for purity and fkeshni-:ss at all times. The beneficial effects of pure Cod Liver Oil, in a variety of diseases, have, within a few years past, been confirmed by the most able medical testimony of the present age, and its thera- putic properties examined and faithfully tested by thousands of acute observers, fully establishing its former popularity as a remedial agent for the following diseases: PULMONARY CONSUMPTION. BRONCHITIS, DISEASES OF THE LUNLiS AND THROAT, CHRONIC RHEUMATISM, PLEURISY, LIVER COMPLAINT, SCROFULA, COUGHS, AND COMMON COLDS. The high merit which this article has justly acquired for the removal of disease, and the important demand for it, have led to very great improvements in its preparation, as well as care in the selection of the true species of fish affording this oil, giving to the article here offered the sure guarantee of a pre- paration upon which the patient can rely. This oil is manu- factured expressly for the undersigned, during the season supposed to be best adapted to taking the healthiest and fat- test fish ; the part from which it is obtained, undergoes the most rigid inspection as to its soundness and perfection, being kept entirely free from that of the Hake, Haddock, and other species of fish whose livers are destitute of medicinal oil. The person having charge of this important branch, manipulating only on the product of each day's catch, has thus far succeeded in producing the Pale Oil almost entirely deprived of the former re- pulsive attributes of the common kind. It is thus offered to the afflicted with entire confidence as to its purity and cleanliness. 1>'r,*!c1ti?n9--*v dessert spoonful may be taken three times a day by an adult, betore meals, and children in proportion to their age. For sale by the gallon, or in bottles, by WM. F. DAVIDSON, Druggist, North-east corner of Main and Fifth Streets, Cincinnati. a* 32 WM. Y. DAVIDSON'S Casl^^s^^ "^ustTublisiikd, by WM. XT'. DAVIDSON WHOLESALE DRUGGIST, The Cheapest Booh of EVER HUNTED. Compiled from the late revised edition of the WrdSl^ Pharmacopoeia; comprising 632 Labels. ^J ^ quality of yellow paper, for the low price of $1 00. alp the same/executed on black glazed paper, in gilt for o , y $^ 00- The largest size comprise 380, and the smallest s.ze ->-- Label,, together forming a complete set of 632. WHOLESALE DEALERS SUPPLIED ON LIBERAL TERMS. The undersigned, during his extensive i"tercou»e with medical men and apothecaries, has seriously felt he want of a suitable compilation of name,, whereby the profes- sion could complete the labeling of their furmture at a mode- Ttecost. Hence it was determined that he woud supply this Tsideratum by the present publication, which, it ,s hoped, will meet the emergency of existing wants. By mailing to us One Dollar, current money, and four cent in stamps we will send one set of the plain Labels lo any part 2 ttTited States, Post Paul; and for Two Dollars currency. and four cents in stamps, will send, yost paid, one set of the gttt* YM. F. DAVIDSON, (Successor to George M. Dixon,) N. E. cor. Fifth and "Main Streets. "•>->■ 692792 703996 SURGICAL DICTIONARY. ABD A BAPTISTON. (From a, priv. and PaitTlXta, im- **• mergo, to sink under.) Galen, Fabriciusab Aqua- pendente, and especially Scultetus, in his Armamenta- riam Chirurgicum, so denominate the crown of the trepan, because it formerly had a conical shape, which kept it from penetrating the cranium too rapidly, and plunging its teeth in the dura mater and brain. While, however, it is admitted by modern surgeons that mischief may be done by letting the saw penetrate too deeply, they do not find it necessary to obviate the possibility of such an accident, by using a conical tre- pan, with which it would be difficult to make any per- foration at all; but they guard against the danger, by observing particular rules and cautions laid down in another part of this book.—(See Trephine.) ABDOMEN. TheBKLLY. When a surgeon speaks of the cavity of the abdomen, he confines his meaning to the space included within the bag of the peritoneum. Hence, neither the kidneys nor the pelvis viscera are, strictly speaking, parts of the abdomen. Anatomists have divided the abdomen into different regions, the terms allotted to which are so frequent in the language of surgical books, that some account of them in this Dictionary seems indispensable. The middle of the upper part of the abdomen, from the ensifonn cartilage as low down as a hue drawn directly across the greatest convexity of the cartilages of the ribs, is called the epigastric region. The Bpaces at the sides of the epigastric region are termed the right and left hypochondria or hypochon- driac regions. The umbilical region extends from the navel up- wards to the line forming the lower boundary of the epigastric region, and downwards to a line drawn across from one anterior superior spinous process- to the ileum of the other. The middle space, below the last line, down to the os pubis, is named the hypogastric region. The parts of the abdomen situated on the outside of the umbilical region to the right and left, or externally with respect to two perpendicular lines drawn from the greatest convexities of the cartilages of the seventh true ribs, are named the ilia or Jlanks. On each side of the hypogastric region is situated the inguinal re- gion or groin. The whole of the back part of the ab- domen has only one technical appellation, viz. the lum- bar region or loins. As the abdomen is the frequent situation of several important surgical diseases; is much exposed to wounds; and various operations on different parts of it are often indispensable; it claims the particular no- tice of every practical surgeon. One of the most com- mon afflictions to which mankind are subject, is that in which some of the bowels protrude. This disease is called hernia, and ought to be well understood by every practitioner, who, however, can never acquire the ne- cessary knowledge without being minutely acquainted with the anatomy of the abdomen. In dropsical cases it is frequently proi>cr to tap the abdomen; and this operation, named paracentesis, simple as it may seem, requires more, consideration and attention to the ana- tomy of tbe parts than many surgeons bestow.—(See Hernia, Paracentesis, and Wounds.) Abdomen, Abscesses of the, may take place either within the cavity of the belly, or at some point of its cir- cumference, may be either of an acute or chronic nature. Women are generally considered more liable than men to abscesses in and about the abdomen; the abscesses named Iwnbar, being elsewhere treated of, are here ex- cluded from consideration. Collections of purulent matter, resembling turbid whey, and containing whi- t'Bh or yellowish flakes, are not unfrequently formed in ABD the cavity of the peritoneum, as one of the effects of inflammation accompanying puerperal fever.—(Stoll, Rat. Med. t. 4, p. 103; Lassus,Pathologie Chir. t. \,p 137, rumvelle idit. 8m Paris, 1809.) In lying-in women, abscesses frequently form be- tween the abdominal muscles and the peritoneum, es- pecially just above the groin. They are cases which have been very correctly described by Conradi. Be- fore the integuments project, the diagnosis is often attended with difficulty, and sometimes an obscurity prevails several weeks; for the patients seem as if affected with slight colic pains, which yield to com- mon treatment, particularly external applications, but soon return. Thus, unless the vicinity of Poupart's ligament be carefully examined, where some painful point, hardness, or elevdtion can be detected, the ab- scess may remain concealed until a large prominence, or the extension of the matter down the thigh, lame- ness, &c, makes the nature of the case completely ma nifeat. As the peritoneum adjoining the abscess is always thickened by the preceding inflammation, Con- radi assures us that there is no danger of the collection of matter bursting inwards. Some abscesses, indeed, have been so enormous, that the matter actually ' pushed the viscera out of their places, yet all this hap- pened without any inward bursting of the disease. The whole danger depends upon the duration of the complaint and the extent to which the matter spreads. A timely detection of the nature of the case, the use of emollient applications, and the making of an early open- ing, generally bring the disease to a speedy and favour- able termination.—(See Arnemann's Magazin fur die Wundarzneiwissnischaft,b. l,p. 175,8uo. Gait. 1797.) Chronic tumours of the mesentery, which in scrofti- tous children sometimes terminate slowly in suppura- tion, and diseases of the ovary and other abdominal viscera, bringing on the formation of matter, are often the cause of purulent extravasation, great emaciation, hectic symptoms, and death. However, sometimes salutary adhesions are produced between the viscera, by which means an outlet is obtained for the matter through the bladder, anus, or vagina. Thus (says Lassus) in the case of a woman who had had for a long while pains in the right lumbar region, supposed to proceed from suppuration of the kidney, because pus was voided with the urine; the right kidney was found after death in the natural state; but there was an ab- scess in the right ova*ry, which was adherent to the bladder, into which the pus had passed through an ulcerated communication. In another patient, who had voided pus by the anus, the right kidney was sup- purated and adherent to the colon, with which it com- municated by a preternatural aperture. For many years a woman bad a hard tumour of considerable size in the abdomen: at length the pain of it became intolerable; and just at the moment when her death was apprehended, an immense quantity of pus was sud- denly discharged from the vagina. Tbe pain abated; the swelling of the belly subsided; merely tbe remains of the induration were now ferceptible; and the woman's health was perfectly re-established.—{Lassus, Patho- logie Chir. t. 1, p. 138.) The abscesses which sometimes form between the peritoneum and abdominal muscles, or between the layers of these muscles, or under the integuments of the abdomen, are attended with considerable variety, according as they happen to be chronic or acute, cir- cumscribed or diffused, small or extensive. Those of the acute or phlegmonous kind, sometimes following stabs and contusions, are particularly noticed in the article Wounds. They are cases which demand es- pecial care, because if not checked they may prove 10 ABDOMEN. fatal, many examples of which are upon record.—,See liiinuterc. J.itcrar. JjToric. 1741,p. 100; Kller, Medic. and Chir. Anmerkuvgen, p. 108, tes of the abdomen. Abdomen, pulsations in the. From the article Aneu- rism the reader will understand that, though it be the common nature of this disease to be attended with throbbing, it is not every pulsating tumour that is an aneurism. The cases usually called abdominal or epigastric pulsations often furnish a proof of the cor- rectness of the preceding remark. The authors who have treated of the latter affection with the greatest discrimination, are Dr. Albers, of Bremen, and Mr. Allan Burns, of Glasgow, two gentlemen whose high reputation and useful labours will long survive the re- cent termination of their meritorious lives. Some of the pulsations here referred to are the consequence of organic disease, and capable of demonstration by dissec- tion ; while the rest are not attended with any such appearance, and have therefore been regarded as ner- vous. The pulsation is not always produced by the impulse communicated to some solid tumour or sub- stance between the hand and the artery, but was con- ceived by Mr. Burns to be sometimes dependent on a nervous affection of the vessel itself.—(On Vie Dis- eases of the Heart, p. 263.) Hippocrates, in his book '• De Morbis Popularibus," makes mention of three patients affected with extraordinary pulsations in the abdomen. As one of these cases seemed to depend upon obstructed menses, it was probably not the re- sult of any organic disease.—{Hippocralis Opera Om- nia, ex. edit. Ftesii. Francof. 1621,lib.5,sect.7, p. 1144.) In order to remove a difficulty in believing how an artery, not affected with aneurismal enlargement, can communicate to the superincumbent parts such move- ments as are frequently remarked in cases of abdomi- nal pulsations, a fact pointed out by Mr. Hunter shouid be remembered: in speaking of the actual dilatation of an artery, he says, that when the vessel is " covered by the integuments, the apparent effect is much greater than it really is in the artery itself; for in laying such an artery bare, the nearer we come to it, the less visi- ble is its pulsation; and when laid bare, its motion is hardly to be either felt or seen."—(Treatise on the Blood, be. p. 175,4tu. Lond. 1794.) And this observation will apply to all tumours and indurations situated over a large artery. In the epigastric region of a certain pa- tient Taberranus felt not only a pulsation, but a tumour as large as the fist,-with all the other usual symptoms of an aneurism. On opening the body after death, he was therefore surprised to find, instead of this disease, a considerable scirrhous tumour in the middle of the mesentery, so closely connected to the .large vessels as to compress the aorta, by the pulsations of which it had been lifted up.—(04*. Anal. ed. 2, JV<>.'9.) Dr. Albers quotes an extraordir^ory case from Tul- pius: the patient, a laborious man, but subject to bi- lious attacks, was sometimes affected with violent throbbings of the spleen. These were not only very painful, but could be heard at a distance, and their number distinctly counted when the hand was applied to the part. What seems almost incredible, it is alleged that Tulpius could hear them at the distance of thirty feet! Their violence increased or diminished accord- ing ac the patient was more or less bilious, and some- times they entirely ceased, when his health improved; but always recurred as soon as the chylopoiclic organs became disordered again. After the patient's death, permission could not be obtained to open Ins body.— {Tulpii Obs. Medico-, Amst. l(i.r>2, lib. 2, cap. 28.) According to Bonetus, pulsations in the left hypo- chondrium are not unfrequent, and it was his belief that they were produced by the coeliac artery, lie cites several cases of this disorder from other writers, the tenour of which is to prove that the coMinc artery and mesenteric vessels must have been atlt-cted, as they were found after death dilated and filled with black blood.—(Sepulchretum Anatomicum, lib. 1, sect. 9. Obs. 9, 25, 27, 30,38, 42, 44, 45, and 40.; The conjec- ture of Bonetus and others, however, respecting the frequency of abdominal pulsations from dilatation of the cteliac and mesenteric arteries, by no means coincide* with the results of modem observations. Mr. Wilson, whose dissections were numerous, met with only one instance of true aneurism affecting any of the branches of the aorta, distributed to the abdominal viscera. This case was an aneurism of the left branch of the hepatic artery.—{Lectures on the Blood, and on the Anatomy, Physiology, and Surgical Pathology of the Vascular System, &-c. p. 37(5, 8vo. Lond. 1819.) Bontius was present at the opening of an inhabitant of Butaviu, who had been afflicted three years with a disease, the exact nature of which could never be made out during life. When the hand was applied above or below the navel, a pulsation was felt like that of the heart or an artery, and as Ibrcible as the motion of a child in the womb. It was synchronous to the pulsation of the heart and arteries. Hence Bontius concluded, that the case was owing to some affection of the heart. The vena cava, instead of containing blood, was filled with a medullary substance, which, pressing against the aorta, is supposed to have excited the extraordinary pulsations in that vessel. The heart was unusually dilated and flabby. Th« two ventricles were very- large, and filled with dark-coloured blood. The liver was of nearly twice its natural size. The gall-bladder resembled that of a bullock, and was filled with viscid bile nearly as thick as an extract.—(Jacobi Bontii de MedicinaIndorum, librii, Lugd. 1718, Obs. 8,p. 101.) Lewenhoek met with an instance of a similar pulsa- tion, which he imputed to irregular action of the dia- phragm, the pulse at the wrist not being affected. The disorder lasted three days, during which the functions of the alimentary canal were so much disordered that the-patient was expected to die.—(I'hdusoph. Trans. from 1719 to 1733, abr. by J. Eames, -s it as his belief, that " whenever any solid part of on» bodies undergoes a diminution, or is broken in upon, in consequence of any disease, it is the absorbing sys tcm which does it. • " When it becomes necessary, that some whole liv- ing part should be removed, it is evident that nature, in order to effect this, must not only confer a new ac- tivity on the absorbents, but must throw the part to be absorbed into such a state as to yield to this opera- tion."—(See Hunter on the Blood, Src. p. 439—442.) For an account of ulcerative absorption, vide Ulcera- tion. With regard to the difficulty which there may be in conceiving how such small tubes as the lymphatics can take up solid substances, Bichat points out that the distinction between the solids and the fluids can only be said to prevail when they form a mass; but that when reference is made to their separate particles, they do not differ from each other. This, he says, is so perfectly true, that the very same particle will alter- nately enter into the composition of a solid and a fluid, just as the elements of water are the same, whether it be in the liquid or frozen state. Now as the absorp- tion of solid substances takes place by the removal of these separate particles or atoms, no greater difficulty can present itself in understanding how this may be effected than in conceiving how fluids may be absorbed. —.See Anal. Gen. t. 2, p. 92.) I come now to a very difficult question, and one that has hitherto received no satisfactory answer; not be- cause the subject has not been earnestly, deeply, and ably considered, but because its difficulties and obscu- rity seem to defy all successful investigation: the ques- tion here referred to, is, On what principle and by what power are the lymphatics, supposing them to be ab- sorbent vessels, enabled not only to take up the old parti- cles of various organs and different fluids secreted in different textures and cavities, but to convey them frequently with considerable velocity and through a long tract, intercepted also by those complicated organs, the absorbent glands, into the venous system near the heart 1 In other words, what is their mode of action ? As Mr. Hunter has observed, the principle of capillary tubes was at first the most general idea, because it was familiar one; but this is too confined a principle; nor will it account for every kind of absorption. Capil- lar- 'ubes can only attract fluids; but as solids were often absorbed, such as firm tumours, coagulated blood, the earth of bones, &c, the advocates for tliis hypothesis were compelled to suppose the existence of a solvent. " TIUs may or may not be true; it is one of those hy- potheses that can never be proved or disproved, and may for ever rest upon opinion." But Mr. Hunter's conception of this matter was, that nature leaves as little as possible to chance, and that the. whole opera- tion of absorption is performed by an action in the mouths of the absorbents; but even under the idea of capillary tubes, physiologists were still obliged to have recourse to the action of those vessels to tarry the lymph along after it had been absorbed; and they might as well therefore have extended this action to the mouths of the vessels.—{On the Blood, Src. p. 443.) The question still continues without satisfactory answer, whether Hunter's language be adopted, and we say that absorption is effected by an action of the lymphatics and their orifices; or whether we employ the language of Bichat, and ascribe the performance of tho functions of these vessels, and the circulation of the fluid in them, to what he ingeniously (but not much to the edification of liis readers) calls organic sensibility and insensible organic contractility. This imagined kind of sensibility confers upon every ab- sorbent vessel a power of feeling quite unconnected with the brain, by which it is presumed.to be sensible of the presence of matter fit for removal, which is then imbibed and conveyed along the tube by the insensible organic contractility, by which is signified a power of contraction, not admitting of demonstration, not ex- citable by stimulation or irritation, but inferred to take place-in some inexplicable manner, chiefly because the fluid in«the absorbents is known to be constantly in motion, and always flowing towards the thoracic duct. In faot, Blchat's explanation is merely a reference to two principles, which are themselves hypothetical, and more calculate* to*ainuse a playful fancy «iian to satisfy a sound judgment. Organic sensibility, and insensible organic contractility, he observes, arc tha ABSORPTION. 15 more rrmarkable in the absorbent system, as they sur- vive for a certain time death itself. A fluid, injected while the animal retains some degree of heat, is ab- sorbed both on serous and mucous surfaces, and also in the cellular tissue, though with less freedom. This power of absorption after death, he says, may even be lengthened by keeping up artificial heat by means of a bath, though the plan Is less efficacious than he at first supposed, vital heat seeming to be essential.— (.'Inat. (itn. t. 2, p. 117.) All these observations, how- ever, merely amount to a Recital of the facts, that ab- sorption may proceed for a short time after death (never later than two hours from this event, p. Wit, and that It is promoted by artificial heat; but how, or by what exact mechanism it is accomplished, is not revealed to us. The lymphatics are not regarded by Bichat as endued either with what he terms animal sensibility, or with animal contractility. His proof of the first of these statements is, that when a lacteal vessel, full of chyle, a lymphatic filled with serosity on the surface of the liver, or even the thoracic duct, is punctured, the ani- mal betrays no mark of pain. But the little faith wUch he himself put in the doctrine, may be conceived froth the question to which it leads him, namely, what inference can be drawn from a circumstance where, in comequence of the belly being lafil open, the many agonies produced would comparatively annihilate any Blight sensation, even were it to exist 7 He alsg ad- ven s to the acute sensibility of the absorbent vessels in their inflnmed state.—(P. 115, I. 2.) Hunter admitted a vital contractile property in the lymphatica, or, as Bichat would express it, sensible organic (contractiIity. The former adopted this belief, because those vessels readily empty themselves of the chyle that is pervading them, and contract when Riilphuric acid is applied to them. On the other hand, Bichat argues, that sulphuric acid, like every other concentrated acid, and also heat, produce the same effect upon all animal substances, even after death, namely, a shrinking of them. When the absorbents, and particularly the thoracic duct, are touched with the point of a knife, they do not contract. If they are capable of con traction, Bichat maintains that it is when they cease to be distended, and not when they are irritated; consequently, it appears to him to be by virtue of their contractility of tissue. The opinions which he finally arrives is, that sensible organic con- tractility in them is at all events doubtful, and that, if it exist, it is very obscure, and at most not greater than that of the dartos.—(T. 2, p. 117.) This" last inference, and, indeed, the whole of Bichat's doctrine respecting the non-existence of sensible organic contractility in the absorbent ves- sels, are very difficult to reconcile with certain observations made by himself, in other parts of his work. Thus, he informs his readers (t. 2, p. 95), that he had frequently noticed In living animals, especially in dogs, manifest expansions in the coarse of a lym- phatic, and containing a limpid fluid. These appear- ances were mostly met with on the concave-surface of the liver, and on the gall-bladder. When the dilated portions of the vessel were pricked with a lancet, the fluid ran out, and they immediately disappeared. " On anuthcr occasion, I saw two or three of these small dilatations on the gall-bladder, and having then let the liner descend while I examined the bowels, I was much astonished the next instant at not being able to find them again; no doubt (says he) the contraction of the vessel had made them disappear." He adds, that the liver is the organ on which these vessels can be best seen in living animals; but 'its concave surface mutt be looked at the instant the belly is opened, for the contact of air, by making them contract, soon hinders them from being distinguished.—{See Anat. Gin. t. 2, p. 95, 90.) And in another place he says, "in drop- sies where the absorbents are full, if the skin be lifted up, they may easily be distinguished by their transpa- rency; but very soon, notwithstanding their valves, thnv empty themselves, and can no longer be discerned with the eye."—v P. 10S.) The foct of the absorbents expelling more* or less of their contents, when they have been punctured, might he very well ascribed to what Bichat calls con- tractility of tissue, or even to ^elasticity; but, the propulsion of the fliud from a 'dilated portion of an unwounded lymphatic into another portion of the same * vessel, certainly docs not admit of the same explana- tion. The valves may determine the direction which such fluid must follow, if it move at all; the anasto- moses may facilitate the passage of it; and contrac- tility of tissue, or elasticity, may have an auxiliary effect; but its first motion can only be accounted for by supposing either that there is an impelling power in the vessels themselves, or in some organ or organs with which they are connected ; or else that their con- tents are set in motion by external pressure, the swell of muscles in action, or the pulsation of neighbouring arteries. Now, in some of the cases mentioned by Bichat, no doubt can be entertained that the impelling power was in the lymphatics themselves, because he distinctly adverts to the contraction so speedily excited in them by exposure to the air, that the concave sur- face of the liver must be looked at immediately on the animal's belly being opened, or else they will not he distinguished. Dr. Bostock conceives, that "an attraction exists between the mouths of the lacteals and the chyle, which seems to be analogous to, or identical with, the elective attraction, which unites different chemical substances;" and " that the lacteals, as well at their extremities as through their whole extent, are pos- sessed of contractility, by which the fluids, when they have once entered, are propelled along them; an effect which is probably promoted by the pressure of the neighbouring parts, while the numerous valves with which they are furnished prevent the retrograde mo- tion of their contents."—{Elem. Syst. of Physiol, vol. 2, p. 580.) The principle on which the lacteals im- bibe the chyle can scarcely be referred to any thing so fixed and determinate as chemical attraction, or so independent of life. On the contrary, the absorption of chyle from the bowels may be looked upon as a pro- cess liable to be accelerated, or retarded, by various states of the constitution, habits of life, and different affections of the mind. If it were a chemical operation, and the abundance of chyle happened to exist on the villous coat of the small intestines, at the period of any sud- den death, the process would be expected to go on as long as that fluid and the villi remained in contact; yet we have no proof of this being the case: indeed 1 cannot comprehend any similarity between elective attraction and the absorption of chyle; the former being an operation in which the action of vessels or their orifices, and the influence of life, are considerations totally separated from the subject; whereas, in the latter, they form in reality the main topics of inquiry. Elective attraction, however, may only be intended as a comparison applicable to the disposition which the lacteals have to take up certain substances, but to reject others: though, even in this sense, the comparison would be very imperfect. Dr. Bostock's opinion is probably true, that an eluci- dation of the action of the lymphatics must be attended with even greater difficulty, than what presents itself to the inquiry into the principle on which the chyle is taken up and conveyed into the system. The increased difficulty chiefly proceeds from our having no positive information respecting the extremities of the lymphatic vessels, or the mode in which their contents are first received; "for there is reason to suppose that the transmission of the fluids themselves is conducted upon the same plan with that of the lacteals.** As the same author remarks, we do not know where the mouths of the lymphatics are situated; with what parts they are connected; how they are brought into contact with the substances which they receive; nor by what power they are enabled to take them up.—{Vol. 1, p. 582.) The source of tho lymph is also less certain than that of the chyle; for, even at the present day, M. Ma- gendie, influenced by the possibility of injecting the lymphatics from the arteries, and by the uniform nature of the lymph,'flnd its analogy to the blood, professes a belief, which was common many years ago„ that it is not formed by th^ decomposition of the old par- ticles of the body, nor by fluids absorbed from vari- ous* surfaces; but that it is composed of the thin ner parts of the blood, which, instead of returning by the veins to the heart, pass into the lymphatics, and are conveyed to that organ through the thoracic duct. The lacteals certaiidy have little disposition to take up any thing but chyle; but, as Dr. Bostock has explained, "the lymphatics are capable of absorbing a great va- riety of substances, differing from each other most 16 ABSORPTION. widely in their nature, so that it would almost appear as if, by a certain mode of application, any substance might be forced into them. Nor (says Dr. Bostock) is this conclusion affected by the hypothesis of M. Ma- gendie; for, although we might agree with him in sup- posing that in the ordinary operations of the system, the veins are the principal, or even the sole instru- ments in removing the materials of which the body is composed, yet we have unequivocal evidence, that when certain poisonous or medicinal agents are applied to their extremities, they may be received or forced into them, and conveyed into the circulation. The case of metallic or other medicinal substances that are taken up by the lymphatics, may appear to be less difficult to explain, because the absorption is generally produced by friction, sr some mechanical process, which may be supposed to force the substance into the mouths of the vessels, or to produce an erosion of the epidermis, which may enable the substances to come into more immediate contact with the mouths of the vessels. We may also imagine that when the component parts of the body are brought into close approximation with their capillary extremities, they are then taken up in the same way that the chyle is absorbed from the intestines."—(Elem. Syst. of Physiol. vol. 2, p. 583.) For my own part, I believe, that if the modern doctrine of absorption can be effectually de- fended and retained, the general presence of the orifices of the lymphatics at every point of the variously organ- ized textures of the body must be received as one of its leading principles. Many physiologists have little difficulty in conceiving how fluids can be taken up by the lymphatics, but rather stagger at the notion of this being also the case with the hardest solids. Others, however, accommodate their creed to both hypotheses, reconciling themselves to them by the argument that, if the minute capillary arteries can secrete this dense, hard matter, the small lymphatics can remove it. One example is not more difficult to comprehend than the other. Yet, such reasoning throws little light on the questions, how are the solids prepared for absorption, and in what manner are they taken up? These in fact remain completely unanswered. " What (inquires a judicious physiologist) are we to conceive of the intimate nature of this operation ? If solution of the substance be necessary, we are at a loss to find a proper solvent; many of the substances are insoluble in water, or in the serous fluid which is found in the vessels; while, on the other hand, it is perhaps not easy to conceive how the substances can be absorbed without being previously dissolved, and still more so, how the solids can have their texture broken down, and enter the vessels, particle by particle, as it were, and be suspended in the lymph in a state of extreme communition V As I have already men- tioned, these difficulties some physiologists, including Bichat, endeavour to diminish by arguing that the lym- /phatics must be supposed to act only upon the elements of every texture, and that, on this principle, the ab- sorption of solids is as readily intelligible as that of fluids, the same elements frequently contributing to the composition of both. However, it must be ac- knowledged, that all this kind of reasoning is entirely visionary. It is conjectured, that while parts retain the vital principle, they are capable of resisting the action of the absorbents. According to Dr. Bostock; dead mat- ter is more easily acted upon by the absorbents than living; and, in fact, " no part can be absorbed until its texture is destroyed, and, consequently, until it is de- prived of life. No substance can possibly enter the absorbents, while it retains its aggregation, so that it necessarily follows, that the preliminary step to the ibsorption of the body is its decomposition."—{Elem. Syst. of Physiol, vol. 2, p. 585.) He afterward explains, that by the death of a part preceding its abso/ption, is here signified only, " that it is no longer under the influ- ence of arterial action. It therefore ceases to receive the supply of matter which'is essential to the support of all vital (living?) parts, and the process of decom- position necessarily commences." To*me a better ac- count of the subject appears to be that which, dismiss- ing all metaphysical and chemical reflections upon the supposed death and decomposition of parts, previously to their absorption, represents the absorbents as acting directly upon the individual atoms, particles, or ele- ments of the various textures. We know nothing about the vitality of these atoms, or elements, In their separate capacity; supposing them to possess it, we know nothing of the moment when they part with it previously to their entrance into the absorbent system, just as we are completely ignorant both of the manner in which such elementary materials acquire the vital principle, and of the exact moment when they become thus endued. With regard to the lymphatic glands, their use is not precisely known, though various conjectures have been offered concerning it. As Dr. Bostock observes, we may presume that they serve an inqiortant purpose, from the circumstance of every absorbent vessel, in some part of its course, passing through one or more of these glands, as was first remarked by Nuck. Mr. Hewson in one subject injected the lymphatic vessels from the groin to the neck, without filling any lymphatic gland, so as to prove a fact which, he says, is contradictory to the received opinion, that such ves- sels always pass through glands in their way to the blood-vessels. He found, with regard to the abdomen, the observation not strictly true, as, besides the lym- phatic vessels which enter glands, there are others which escape them. He declares, that some of the lacteals in the mesentery do not pass into glands.— {Exp. Inq. vol. 2, p. 44, vol. 3, p. 54.) On the other hand, Mascagni, in his numerous injections, never met with the circumstance {Vas. Lymph. Hist. pt. 1, sect. 4, p. 25i; and Dr. Bostock refers us to Gordon's Anat. p. 74, in confirmation of the rarity of such an arrange- ment.—{Elem. Syst. of Physiol, vol. 2, p. 548.) The fact of every lymphatic vessel commonly entering a gland in some part of its course, seems to Dr. Bostock to warrant the inference, that some important change is effected in the chyle and lymph by means of the lymphatic glands. " But {.says he) the same mode of reasoning might lead us to conclude, that although the absorbent glands are necessary to the existence of the higher orders of animals, they are not so for the pur- pose? of nutrition and growth generally, as it appears that there are large classes of animals, which resem- ble the mammalia in many of their nutritive functions, and in the vascular part of the absorbents, which are without any lymphatic glands, or are very sparingly furnished with them. It is not easy to point out any circumstances that belong exclusively to the mam- malia, which can assist us in explaining the necessity for these appendages to their lymphatic system."— {Vol. l,p. 554.) Malpighi fancied that the lymphatic glands had a muscular covering, which enabled them to act as or- gans for propelling the lymph from their cells into the vasa efferentia, and thence towards the thoracic duct, so that they were, according to his notions, like so many little hearts distributed through the system. This hypothesis, which is contradicted by anatomy, receives no confirmation from observation in the living animal. If it were true, we should expect to find the cells larger, and not so minute as to render even their exist- ence in the human absorbent glands a questionable point; some pulsating movement, gentle or strong, would be perceptible in the situation of every super- ficial gland; or, if the contraction were of a slower kind, the gland would sometimes be enlarged, and sometimes considerably reduced. Vet none of these circumstances prevail. It is likewise to be remembered, that no jet of fluid takes place from the vasa efferentia when they are cut, as they frequently are ill surgical operations. It is also te be taken into consideration that fishes are destitute of lymphatic glands (see Blumenbach's Comparative Anat. by Lawrence, p. 256); yet the fluid in their lymphatic vessels must be presumed to have its due degree of motion. In the mesentery of a turtle, no glands are observable; still, "in this animal, na- ture does her business as well, though the apparatus is differently constructed."—-(i/eic-aon's Exp. Inq. vol. 3, P-60.) Malpighi's hypothesis is, therefore, decidedly untena- ble ; and whatever difficulty we may feel in agreeing with Bichat, that the absorbent vessels are destitute of animal contractility, we can have no hesitation in adopting this conclusion with respect to the absorbent glands, considered as entire organs, without any refer- ence to the nature of the congeries of lymphatics within them. The existence of a white thick fluid in the lymphatic ABS ACE 1" (•lands wa.s noticed by Haller in the following terms: I " Succum glandulis ronglobatis inesse, album, serosum, larte tenuiorem, in juniori potissiuium animali con- spii'iiurn, id quidem cerium est. Eum creinon similem dixit Thomas Wliarton, cinerum Malpighius, diapha- num Nuckius, album Morgagnius, recte et ad naturam, ut puto omnes. —{Elem. Physiol, t. 1, p. 1*4.) Ai-i-onling to Hewson, the fluid formed in the lym- phatic glands, if diluted with a solution of Glauber's salts in water, or with the serum of the blood, and viewed with a lens of one twenty-third of an inch focus, presents numberless small white solid particles, resembling in size and sha)>e the central particles found in the vesicles of the blood.—{Exper. Inq. vol. 3, p. 67.) The supposition of iluysch and Nuck adopted also by Haller/ that one use of the lymphatic glands is to produce a fluid for the dilution of the lymph, is desti- tute of proof, inasmuch as the lymph is not known to be thinner after its egress from, than previously to its entrance into, a gland ; and one notion sometimes pro- mulgated is, that it is thicker. The investigations of Dr. Prout certainly show, that it contains a larger quantity of albumen and fibrme in proportion to its vicinity to the subclavian vein.— See Thomson's An- nals of Philosophy, 1819.) According to Mr. Wilson, the absorbent glands contain numerous arteries; and, in a horse, this vascularity gives to the inner lining of the cells the usual appearance of a secreting membrane; but whether it does actually secrete, or what it se- cretes, we have no means of thoroughly knowing.— {On. the Blood and Vascular System, p. 209.) The appearance of the lining of the cells of the lymphatic glands of the whale, is in favour of the opinion, that some secretion takes place from it, as an addition to the lymph.— See Abernethy's Obs. in Philos. Trans. 1790,/»'. 1.) Other speculators imagined, that the ab- sorbent glands were like so many filters, through which the lymph, or chyle, was strained. Another Idea was, that they drew some crude liquid from the nerves and returned it to the blood.—(Glisson, de He- pate, p. 439.) As to the conglobate glands, they were also sometimes contrasted with the conglomerate, and represented as organs for making good the loss pro- duced in the sanguiferous system by the secretions from the latter. Another suggestion was, that their office was to form the central particles of the globules of the blood. But, as .Mr. Wilson justly observed, all these opinions are merely suppositious, without a shadow of proof. Dr. Bostock considers it most probable either that these glands are proper secreting organs, and intended to prepare a peculiar substance, which is mixed with the chyle and lymph, or that they offer a mechanical obstruction to the progress of these fluids, by which means their elements are allowed to act upon each other, and thus some necessary change in the nature of the chyle and lymph may be produced.—(See Elem. System of Physiol, vol. 2, p. 554.) Richerand's opi- nion embraces both these views; for he says it was necessary that the lymph should be retarded in the glands, that it might undergo all the changes which these orsans bad to communicate to it. Although he confesses Ins ignorance of what these changes pre- cisely are, he represents the intention of them to be the production of a more intimate mixture, a more per- fect combination of the elements of the lymph, and to give it a certain degree of animalization, as, lie says, is proved by tbe greater tendency of the lymph to con- crete, taken from the vasa efferentia, or discharged from the glands. He also'supposes that another use of the glands is to deprive the lymph of its heteroge- neous parts, or, at least, to alter them so that they may do no harm by passing into the circulation. The yel- low colour of the glands, in which the lymphatics from the liver ramify; the black colour of the bron- chial glands; the redness of the mesenteric glands in animals fed with madder or beet-root; their whiteness at the period when the chyle is pervading them; are circumstances regarded by Hicherand as proving that the glands tend to separate the colouring matter from the I) mph, though their action in this respect may not always be completely efficient. Me adds that, from numerous arteries in the texture of conglobate Ainds, a serous secretion occurs, which dilutes the lunph, increases its quantitv, and at the same time annualizes it.—(.Vuurraax Eii'm. t. 1, p. 276,ed.5.) Thes.-obser- vations, however, are only conjectures, which absurdly Vol. I—B [ enough endeavour to blend together the doctrine of the glands rendering the lymph thinner, yet more disposed to concrete. Mr. Wilson, and some other anatomists prior to him, affirmed, that tbey had succeeded in tracing filaments of nerves into the substance of the absorbent glemN ; the possibility of which, however, is not generalh ad- mined. These contradictory statements are to be reconciled by the consideration, that one anatomist would set down as a minute nervous filament, appa- rently derived from a large unequivocal nerve, what another would doubt, or deny, to be a real continua- tion of such nerve; for anatomy, like most other pur- suits, cannot be prosecuted to extreme minuteness without leading to conjectures, difference of opinion, doubts, and obscurity. According to Bichat, when tho lymphatic glands are irritated in various ways, which is easily done, they do not appear to be endued with animal sensibility; but it may be developed in them, as well as in the absorbent vessels, by inflammation, which raises their organic sensibility to a great height.—(.Sec Aunt. Gin. t. 2, p. 116.) The changes in the structure and size of the lym- phatic glands, brought on by the progress of age, jus- tify the presumption, that tbe action of the lymphatic system undergoes modifications at different periods of life; but, on this ixrint, as M. Magcndie has remarked, no precise information exists.—i,.s be ascribed to them, it is natural to suppose, as Dr. Bostock remarks, that, during the growth of the body, a larger quantity of nutritive matter will be conveyed into the blood, and must pass through these organs.—(F.lcm. Syst. vol. 2, p. 554.) In the foregoing observations on the functions of the lymphatic system, its vessels have been presumed to be the true instruments of absorption ; by which is meant, not merely that they contain lymph, and transmit it .nto the venous system, a fact"of which no doubt is entertained by uny class of ph>siologisls; but, that sui;h lymph is really produced by the operation of these vessels upon the various kinds of matter presumed to be taken up by them, and to consist of all the old par- ticles of every texture of the body, the tin, the earth of the bones, and the superfluous quantity of many different secretions, naturally undergoing continual renovation, besides the chyle which is taken up by the lacteals, and conveyed to the thoracic duct, or common trunk of both descriptions of vessels. To this view of the subject, some physiologists of eminent talents do not accede, and even if it should hereafter be de- cidedly proved that the lymphatics possess the power of absorption, the tendency of numerous expciimcnts performed by M Magendie, Fodera, and others, is to show that, ut all evens, they are not the only ab- sorbents, and that the veins are very actively concerned in the function. As the doctrine of absorption is one that is insepara- bly interwoven with the theory of disease in general, and always has a powerful influence on practice, and the choice of remedies, I have considered the subject highly deserving of notice in this work; but my thanks are due to Professor M'Kenzie, of Glasgow, for his kind- ness in having suggested the want of such an article in the book. ACETIC ACID. Vinegar. Distilled Vinegar. Vine- gar is of considerable use in surgery ; mixed with fari- naceous substances it is frequently applied to sprained joints, and, in conjunction with alcohol and water, it makes an eligible lotion for many cases, in which it is desirable to keep up an evai>oration from the surface of inflamed parts. Vinegar was once considered useful in quickening exfoliations, which effect was ascribed to its property of dissolving phosphate of lime. Its application to this purpose, nowever, seems hardly ad- missible, for reasons which will be well understood from a perusal of what is said on the subject of AYcr»- sis. The good effects of vinegar, as an application to bums and scalds, were taken particular notice of by- Mr. Clegnorn, a brewer in Edinburgh, whose senti- ments were deemed by Mr. Hunter worthy of (tublica- tion.—'See Med. Facts and Obs. vol 2, and the art. Burnt.) 18 aci ALV Diluted vinegar is sometimes applied to the eye.— | (See Collyrium Aeidi Aceliei.) In the form of ac ol- lyrium it is alleged to be the best lotion for clearing the eye of any small particles of lime which happen to have fallen into and become adherent to it on the inside of the eyelids.—,See A. T. Thomson's Dispensatory, p. 8, ed 2.) Concentrated vinegar is sometimes employed for stopping violent hemorrhage from the nose. With this view it may be used either as an injection or a lotion, in wnich lint is to be dipped and introduced up the nostril. Vinegar is sometimes employed for obviating the smell of sick rooms. The strongest acetic acid which can be made is found also to be one of the most certain and convenient applications for the destruction of warts aud corns, care being taken not to injure the sur- rounding skin with it. Acetic acid has occasionally been recommended as an antidote to the narcotic poisons ; but the proofs of this are quite unsatisfactory, and the chemical history of opium and other narcotics by no means sanctions the practice.—{Brande's Manual of Pharmacy, p. 9, 8oo. Lond. 1825. i The pyroligneous acid, which is merely strong acetic acid impregnated with empyreumatic oil and bitumen, is much used by Mr. Buchanan, of Hull, as an ingre- dient in applications to the ear in certain cases of deaf- ness.— See Illustrations of Acoustic Surgery, 8vo. Ldnd. 1825.) ACHILLES, Tendon of. See Tendons. ACID. See Acetic Acid; Muriatic Acid; and JVi- trous and JVitnc Acids. ACTUAL CAUTERY. A heated iron, formerly much used in surgery for the extirpation and cure of diseases. Its shape was adapted to different cases, and the instrument was of tenapplied through a cannula, in order that no injury might be done to the surround- ing parts. Actual cauteries were so called in opposi- tion to other applications, which, though they were not really hot, produced the same effect as fire, and conse- quently were named virtual or potential cauteries. The actual cautery is still in use upon the continent; and by foreign surgeons we are not unfrequently criti- cised for our general aversion to what they distinguish by the appellation of an heroic remedy. Pouteau, Percy, Dupuytren, Larrey, Roux, Delpech, and Mau- noir are all advocates for the practice; and the latter gentleman, when he was in England, took the opportu- nity of reminding British surgeons of their error, in totally abandoning, as they rfow do, the employment of heated irons in the business of their profession.— (See Obs. on the Use of the Actual Cautery, Med. Chir. Trans, vol. 13, /<. 364, &c.) ACUPUNCTURE. (From acus, a needle, and pungo, to prick.) The operation of making small punctures hi certain parts of the body with a needle, for the pur- pose of relieving diseases, as is practised in Siam, Ja- pan, and other oriental countries, for the cure of head- aches, lethargies, convulsions, colics, &c.— See Phil. Trans. JVo. 148; and Wlh. Ten. Rhyne, de Arlhri- tide Mannssa Schcmatica, c$-e. Bno. Lond. 1083.) Dr. Elliotson has tried acupuncture very extensively, and his experience coincides with that of Mr. Churchill, con- firming the fact, that as a remedy for chronic rheuma- tism it answers best where the disorder is seated in fleshy parts. He also finds that one needle, allowed to remain an hour or two in the part, is more efficient than several, used but for a few minutes.— See Med. Chir. Trans, vol. 13, p. 467.) Neuralgia is a disease in which the practice may deserve trial. Local paralysis is another. In a modern French work it has been highly commended; but the author sets so rash an example, and is so wild in his expectations of what may be done by the thrust of a needle, that the tenour of his observations will not meet with many approvers. For instance, in one case, he ventured to pierce the epigastric region so deeply, that the coats of the sto- mach were supposed to have been perforated : this was done for the cure of anobitinute cough, and is alleged to have effected a cure! But if this be not enough to excite wonder, I am sure.the author's suggestion to run a long needle into the right ventricle of the heart, in cases of asphyxia, must create that sensation.— [See Berlioz, Mim. snr Us Maladies Chroniques, et sur V Acupuncture, p. 305—309, 8iw. Paris, 1816. Churchill on Acupuncture, 1824; Dantu, Traite de VAcupunc- ture, 1828.) ADHESIVE INFLAMMATION. That kind of in- flammation which makes parts of the body adhere or grow together. The process by which recent inrised wounds are united without any suppuration, and fre- quently synonymous with union by the first intention. — See Union by the First Intention.) ..EGYLOrs. (From a if,, a goat, and JiuV, an eye.) A disease so named from the supposition that goats were very subject to it. The term means a sore just under the inner angle of the eye. The best modern surgeons seem to consider the segy- lops only as a stage of the fistula lacbrymalis. Mr. Pott remarks, when the skin covering the lachrymal sac has been for some time inflamed, of subject to fre- quently returning inflammations, it most commonly happens that the puncta lachrymalia are affected by itj and the fluid, not having an opportunity of passing off by them, distends the inflamed skin, so that at last it becomes sloughy, and bursts externally. This is the state of the disease which is called perfect aigylops or tegylcps. .« Aigylops was a common term among the old surgi- cal writers, who certainly did not suspect that obstruc- tion in the lachrymal parts of the eye is so frequently the cause of tbe sore as it really is. The skin over the lachrymal sac must undoubtedly be, like that in every other situation, subject to inflammation and abscesses; but we do not find that sores unconnected with disease of the lachrymal sac are here so frequent as to merit a . distinct appellation. AGARIC. A species of fungus growing on the oak, and formerly much celebrated for its efficacy in stop- ping bleeding.— See Hemorrhage.) ALBUGO. (From albus, white.) A white opa- city of the cornea, not of a superficial kind, but affect- ing the very substance of this membrane. The disease is similar to the leucoma, with which it will be consi- dered.— See Leucoma.) ALPHONSIN. The name of an instrument for ex- tracting balls. It is so called from the name of its in- ventor, Alphonso Ferricr, a Neapolitan physician. It consists of three branches, which separate from each other by their elasticity, but are capable of being closed by means of a tube in which they are included. ALUM. (An Arabic word.) Alum either in its sim- ple state, or deprived of its water of crystallization by being burnt, has long been used in surgery. The in- genious author of the Pharmacopoeia Chirurgica re- marks that, except for external use as a dry powder, the virtues of alum are not improved by exposure to fire. Ten grains of alum made into a bolus with con- serves of roses are given thrice a day at Guy's Hospi- tal in internal hemorrhages, gleets, and other cases demanding powerful astringent remedies. In a relaxed state of the urinary passages, or want of power of the sphincter vesica, small doses of alum have been found of service. Alum is employed as an ingredient in several astringent lotions, gargles, injections, and col- lyria. Dr. Groshuis, a Dutch physician, first recom- mended its use in colica pictonum, and Dr. Perceval subsequently joined in the advice. The principle on which it acts is that of decomposing the common pre- parations of lead, and converting them into sulphates, which are comparatively innoxious. "Burnt alum, which is a mild caustic, is a principal ingredient in many styptic powders. ALVINE CONCRETIONS. Comprehending under this head both gall-stones and intestinal concretions, an interesting subject presents itself, certain parts of which have been chiefly elucidated in modern times, as wUl be hereafter explained. When the concretions voided are very numerous they are generally gall- stones. Thus Dr. Coe relates an instance in which seventy were discharged in one day. In the same short time Petermann knew of seventy-two being voided from one individual; Birch, one hundred; Bar- bette, Sloane, and Vogel, two hundred; and Russell, four hundred. A patient under the care of Van Swie- ten had voided two hundred, and was stillcontinuing to expel others. Riverius speaks of another patient who had voided calculi from the bowels for several years whenever he went to stool.— Observ. Commun.) FerneUus likewise adverts to cases in which the con- cretions evacuated were innumerable.— Pathol, lib-6, cap. 9., If we take a view ofalvine concretions gene- rally, and include all their different kinds, v Moreali, Dell' Uscita di una Pietra, per la Via del I'.sophago, Modena, 1781); by Borsieri; and by a long list of other writers, whose names and publications are specified by Plouquet.—J.it. Med. Dig. art. Calcu- lus, Vomitus, Slc.)—With this class of substances, says Rubini, may also be arranged those concretions which are found upon dissection either in the intes- tines or stomach, whence probably in time they might have been expelled. Facts of this description are re- corded by Portal, Vicq d'Azyr, Jacquinelle, Chandron, Ac. The cases recited by White and Hey, in which the colon was completely obstructed, I have already mentioned; and to these may be added the instance quoted by Rubini, in which Meckel found the jejunum entirely blocked up by a similar substunce.— See Pen- sion sulla varia origine e nature de corpi calcolosi, che vengono talvolta espulsi dal tubo gaslrico, Meino- ria, p. 5 and 6, 4to. Verona, 1808.) Rubini observes that, with respect to the origin of alvine concretions, whether discharged from the ali- mentary canal upwards or downwards, some of them appear to be formed in that canal itself, while others pass into it flrom other situations; and they all admit of being distinguished according to the place of their origin and formation into three kinds. 1. hepatic, or biliary; 2. gastric, or intestinal; and 3. iwhat this author tenns i mixed, or heputico-gastric. Hepatic al- vine concretions, as the name implies, are derived from some point of the hepatic system; the gastric, or intestinal, are formed within the alimentary canal; and tho nnxed commence in the hepatic organs, but afterward get into the bowels, where they acquire an increased size. On the subject of hepatic concretions, or biliary cal- culi, or gall-stones as they are usually named , there is no point of the system where thev do not occasion- ally form. Riedlin found iliem in the surfkee of the liver. Sorbait met with a biliary calculus as large as B2 a goose's egg, adhering to the peritoneal covering of the liver, and a similar case is recorded by Bemvenio. Tallon, Pomme, Saurau, and Heberden have seen cal- culi within the substance of the liver; while Blasius, Fallopius, Columbus, Ruysch, Henricus ab Heers, and Morgagni record examples, in which the concretions were in the parenchyma of that organ. Plater, Revcr- horst, Glisson, Morgagni, and Walter have seen them in the biliary ducts, as probably were those which Co- lumbus and Cainenicus say they found in the vena porta. Walther and Dietrick found calculi in the ductus hepaticus; Ruysch and Soemmenng in the ductus cysticus; and Dietrick, Galeazzi, and Richter, in the ductus choledocus. Greisel, Benivenio, Eller, Morgagni, Dargeat, and D'Henrillay have seen calculi included in morbid cysts, attached either to the liver or the gall-bladder. The place, however, where calculi are found in the greatest number, and with most fre- quency, is the cavity of the gall-bladder itself. Here they are sometimes single, their size varying up to a magnitude completely filling ihat cavity, as Saye i Journ. des Savans, Sept. 1697j, Halle, and Isenilamm have noticed: while sometimes their number amounts to a hundred, or even a thousand, of different sizes. Rubini possesses a gall-bladder, which contains above a hun- dred small calculi, and fonnerly 1 had a similar num- ber, which I found in tbe body of a female. Van Swieten met with a hundred ; Haller, a hundred and forty; Stieber, two hundred; F. Plater, three hun- dred ; Walther, five hundred; Mentski, seven hundred j Baillie, a thousand; Hunter, eleven hundred ; Pari, six- teen hundred; Stork, two thousand; and Meckel, several thousands.— Handb. der Pathol. Anat. b. 2, p. 460., All hepatic concretions, however, are not calculated to pass from the place of their origin into the intes- tines, but only such as are situated in the ductus hepa- ticus, or its main branches, in the gall-bladder, the ductus cysticus, or the ductus choledocus. When their size is not disproportionate to the diameter of the ducts, they pass with facility; but, when their dimen- sions are larger than those ducts can naturally admit, the latter becomes stretched and dilated, whence arise the sharp pains and colic which attend the disorder, analogous to the sufferings produced by the descent of large calculi from the kidneys to the bladder. The reality of these dilatations of the hepatic ducts is proved by dissection. Heister found the orifice of the ductus choledocus, which is usually very small, so much enlarged that it could receive a finger; and Vieq d'Azyr saw this duct enlarged through its whole ex- tent in a similar degree.— Hist, de la Socitte Royale de Medec.ine, an. 1779, p. 220. i Galeazzi, in dissecting a body, found the ductus choledocus so dilated, that it resembled a kind of bag, in which several calculi were included. Mr. Thomas has likewise seen two cases, in which the point of the fore-finger readily passed from the duodenum into the gall-bladder.— See Med. Chir. Trans, vol. 6, p. 115. Morgagni saw this duct in one instance large enough to hold a couple of fingers, and he quotes many similar instances from Bezold, Trew, Vemey, and others. We may conceive how dilated this tube must have been in a case recorded by Rich- ter, where, though it was not completely obstructed, a calculus weighing three ounces and a half was lodged within it.—(Rubini, op. cit. p. 7—19.) With regard to those concretions which are distin- guished by the epithet gastric, or intestinal, some are formed in the cavity of the stomach; the rest in one or other of the intestines. They remain for a greater or less period in the place of their formation, according as they happen to be lighter or heavier, smoother or rougher, more or less adherent, or as local or general circumstances are more or less favoura- ble to their retention or expulsion, sometimes, they continue undischarged until they have attained a very considerable size. In particular instances, instead of remaining constantly in one place, they successively pass through the whole intestinal tube, lodging at dif- ferent points for a greater or less time. In the works of Haller and Conradi may be seen representations of the points of the intestinal canal, where these concre- tions have been found. The alvine concretion, of which Mareschal has given an account, was some \ ears in traversing all llie convolutions of the bowels. These gastric or alvine concretions, which are very common in animals, are less frequent in the human subject, as is proved by the observations of Fourcroy 20 ALVINE CONCRETIONS. and Vauquelin, inserted in their valuable essay on this subject in the Annales du Museum Nationals d'His- loire Naturelle de Paris. In the horse they are some- times of an enormous size, as we may learn ftom an in- stance on record, in which the concretion weighed thirteen pounds.—(Voigt, Magazin for das Neueste der Naturkunde, b. 3, p. 578.) As for the third species, which Rubini names mixed, or hepatico-gastric, they have their beginning in the hepatic organs, and augment in the intestinal tube. Here, if the extraneous body be detained, and the con- tents of the bowels have a disposition to become thick- ened and condensed round it, as a nucleus, it may be rendered larger by additional strata of matter, and would increase sine fine, if a stop were not put to the augmentation by the narrowness of the canal, or an effort made for the expulsion of the concretion. Morgagni cites two instances of this sort of concre- tion ; one from Gemma, the other from Bezold; and he gives his opinion that another alvine calculus, spoken of by Vater, must have been of the same nature. Dr. Coe describes another interesting specimen; and others are referred to by Vandermoude, Moreali, Por- tal, h'>i,u\ the cold; but when the al- cohol is boiled on it, it is dissolved in a proportion, ac- cording to Fourcroy, of one part in nineteen—accord- ing to Dr. Bostock, one in thirty.—(Nicholson's Jour- nal, 8vo. vol. 4, p. 137.) The solution, when it cools, deposites Ught brilliant scales. It is soluble in ether in the cold, and more abundantly if the ether be heated. Oil of turpentine generally dissolves biliary calculi; and, according to Gren, it dissolves those which con- sist almost entirely of this peculiar matter; yet Dr. Bostock has remarked, that oil of turpentine acts on it with difficulty, and even when digested with it, at a boiling heat, dissolves it only in a small degree. Pure soda and potassa dissolve it completely, and reduce it to a saponaceous state. Ammonia, as Dr. Bostock has remarked, exerts little action on it, except when boil- ing. Nitric acid dissolves it, and, according to Four- croy, converts it into a species of liquid similar to the oil of camphor. This becomes concrete, but without any crystalline structure, and is more soluble in ether and the alkalis than the original matter. "This substance (Fourcroy has observed) is con- tained in greater or less quantity in nearly all human biliary calculi, more or less intermixed with other mat- ter, but still so far predominant as to form their basis. Hence, they partake of its properties; are fusible, in- flammable, and more or less soluble in the agents which dissolve it."—See Murray's Syst. of Chemist. vol. 4, p. 594, ed. 2.) Fourcroy, on exposing the above peculiar substance to the action of oxygenated muria- tic acid, saw it whitened, and afterward resume its former silvery hue. However, Rubini repeated this experiment, and found that the whiteness which'was contracted remained permanent. While the hepatic system contains a fluid which is always nearly of the same quality, viz. the bile, the alimentary canal, as Rubini observes, contains a hun- dred different fluids, and is continually occupied by substances of various natures, kinds, and properties, consisting of food, drink, and several secretions. All the principles which are to serve for the formation and renewal of the different species of living solids, and of the many kinds of fluids, at first remain more or less time in the alimentary canal, and there undergo pecu- liar changes. All the principles which, under different circumstances, may contribute to the production of morbid concretions, either in the gall-bladder, the uri- nary bladder, the kidneys, or in any other part of the body, where they ever occur, pass at first into the in- testinal canal, where they continue for some time. Such a multiplicity of principles, disposed to crystal- lize, and be converted into calculi, would very often, almost daily, produce these concretions in the bowels, were there not many circumstances which counter- act this tendency, as, for instance, exercise, the in- cessant motion of the. matter itself along the intestinal tube, the variety of these elements, whereby their re- quisite tendency to unite is disturbed, and the decom- posing and recomposing influence of the gastric secre- tions, whereby parts are united, disposed of, dissolved, and analogous matter kept divided, &c. But when- ver these circumstances are not actively operating, as may be the case in a noose, or fold of the bowels, or in some preternatural cyst belonging to them; when- ever the intestinal fluids undergo such an alteration that the production of these concretions cannot be pre- vented ; or, lastly, whenever some favourable circum- stance, such as an extraneous nucleus, forms a centre of reunion for particular elements; then the saline matter, which is most disposed to crystallize, and the earthy and mucilaginous substances, s down a fourth criterion, deduced from the iiumber *>'f the calculi voided ;. which, if very nu- merous, are to be considered as.biliary. Rubini points out, however, the fallacy of this test; botAhepatic and gastric concretions being sometimes single, sometimes in various numbers even up to a thousand; and he refers to a ease where a very large number of concretions of the gastric description were voided, as reported by Konig. The test here suggested, however, may be considered as generally valid; for, the number of in- 2'2 ALVINE CONCRETIONS. testinal concretions is rarely more than two, though sometimes very considerable.—(T. Thomson. See Med. Chir. Journ. vol. 4, p. 189.) I shall now follow Rubini, and notice those charac- ters of alvine concretions, which he calls internal, and are deduced from their quality and composition, begin- ning with the criterion furnished by the size of the ex- traneous substance voided. As the biliary ducts are narrow, it is obvious, that if the calculus be above a certain size, it cannot have passed in this state sud- denly through those narrow tubes, and consequently must be either of the gastric description or mixed, having quitted the hepatic system while small, and afterward increased within the alimentary canal. Un- questionably, as Rubini admits, this criterion has con- siderable weight, especially when the discharge of the calculus has not been preceded by pain, or other symp- toms indicating such violent distention, as the above ducts must have suffered from the passage of the foreign body. These are certainly capable of being dilated in a remarkable degree, as some facts, already noticed in this article, sufficiently prove; but such dilatation can never happen without pain, irritation, and a serious train of sympathetic effects. Rubini re- marks, this criterion will only apply to large, and not to diminutive concretions. A biliary calculus, of pro- digious size, was found by Mr. Brayne, of Banbury, to have passed by ulceration directly from the cavity of the gall-bladder into that of the duodenum, whence it made its way through the rest of the bowels, and was Voided from "the anus.—(See Med. Chir. Trans, vol. 12,) A second criterion is the colour of the calculus; a test admitted by Moreau, who asserts, that biliary calculi are yellow or green, and intestinal ones gray- ish brown or black. But, says Rubini, one need only look at various specimens of alvine concretions, and read the statements of authors who have seen a great many of them, particularly Morgagni and Soemmer- ing, to comprehend, that any criterion deduced from (heir colour is most fallacious, every species of them presenting great variety in this particular. And it is to be remembered, that the bile and the intestinal fluids, whence these concretions arc formed, differ in colour in different individuals, according to a variety of cir- cumstances, in health and disease. One species of hepatic calculus has a white colour, but is sometimes yellow or greenish. Another is of a round or poly- gonal shape, and often of a gray colour externally, and brown within. A third is of a deep brown or green colour.—(See Ure's Diet, of Chemistry, art. Gall- stones.) The smaller intestinal concretions examined by Dr. T. Thomson, destitute of coating, resembled bad yellow ochre; the larger were encrusted with an earthy matter, of a coffee colour, and purple or some- times white.—(See Monro on the Human Gullet, &c, and Med, Chir, Journ. vol. 4, p. 1880 Third criterion. The presence or absence of a nu- cleus will enable one to judge whether a calculus be gastric or hepatic. A biliary concretion has no nucleus, property so called; that is to say, it has no foreign body in its centre. When a transverse section is made of such a calculus, one finds either a cavity in its mid- dle, or else nothing by which this part of its substance can be distinguished from the rest; or if a nucleus dif- ferent from the other part of the concretion be apparent there, jx consists merely of bile, either grumous, dif- ferently coloured, or more or less fluid than the rest of the calculus, but which is nevertheless invariably bile. On the contrary, every gastric concretion has, as it were, an extraneous nucleus, as Fourcroy and Vauquelin have explained in their essay upon the intestinal calculi met with in animals, Ruysch in the Phil. Trans, gives an _account of some alvine concretions which were formed "round grains of seed. Birch records an example of *tajPryBtallized calculus formed round a leaden bullet. Hagtor met with a calculus in the centre of which was an irfiknail. Concretions formed upon fruit-stones are reco'roHjbby Clarke, White, and Hey, and also in the Edinb. M*LEssays. Instances in wlueh the nucleus was a snHfeportion of bone are related in the latter work, aiflflfca by Hooke and Coe. ffomberg and Others descrwEtlvine concretions formed round indu- rated excremerKjbpus matjer; and many similar cases are specifi«4f|j,vallisnieri, Van Swieten, and others. In the hera^ojtastric calculus the biliary concretions serve as rnfjeteus for the gastric. According to Dr. *I_ Tiwms>n, the nucleus is commonly a cherry-stone. a small piece of bone, or a biliary calculus — (See Med. Chir. Journ. vol. 4, p. 188.) A fourth criterion is deduced from a certain unctu- osity which belongs to biliary calculi, but not to those of the gastric class. This character is more palpable when the calculus has been recently voided, or when it is handled with warm fingers. The unctuosity is still more evident when the concretion is cut or sawn, as then the knife, saw, or fingers become smeared with sapona- ceous particles, which adhere to them. In order to denote an hepatic calculus, however, the unctuosity must pervade its whole substance, and not merely ap- pear towards its outside; for a gastric, earthy, saline concretion may by accident become coated, as it passes through the bowels, with a stratum of bile or sapona- ceous matter. When the unctuosity is deficient exter- nally, or in the outer lamina? of a calculus, but is found in its interior, it is a clear indication of the hepatico- gastric formation of the concretion. Fifth criterion. The specific gravity of a calculus, the property which it has of floating or sinking in wa- ter, has been long considered as a test of its species. The hepatic calculus is generally specifically lighter than water, as most oily substances are: on the con- trary, gastric calculi are specifically heavier than wa- ter, like all earthy saline matter, and of course sink in that fluid. This criterion was often employed by Re- verhorst, Fernelius, ard others, for distinguishing va- rious concretions. But it is by no means regular, as many biliary calculi swim only a little while and then sink. The specific gravity of that analyzed by Dr. Ure, of Glasgow, was 1.0135.— See Med. Chir. Jouni. vol. 4, p. 179.) As Rubini observes, this test will not answer for hepatico-gastric calculi, which are subject to great anomalies.—(Pensieri, &c. p. 22.) Neverthe- less, the most correct modern examinations prove, that gastric concretions have a specific gravity varying from 1.376 to 1.540 (Dr.T.Thomson in Monro's Morb. Anat. pia nervosa. A degree of squinting (strabismus), there- 26 AMAUROSIS. fore, is a very common symptom of incipient amauro- sis, particularly when only one eye is affected; for this always deviates more or less frcm the axis of vision. It is owing to this loss of correspondence, that persons affected with an imperfect amaurosis of one eye often mistake the relative distance of objects, and frequently see them reflected.— Traver's Synopsis, p. 170. - It is less usual for imperfect amaurosis to be accompanied with what Beer terms obliquity of the eye Luscitas ; either a paralysis, or a ceaseless, irregular action of one or more of the muscles of the organ, being evidently a condition of this symptomatic appearance.— See Beer's Lehre von den Augenkrankheiten, b. 2, p". 427.) Beer has often met with patients labouring under imperfect amaurosis, who could plainly distinguish all objects which were not very small; but saw them of a different colour from then- real one ; for instance, yel- low, green, purple, vho was in the habit of having it restored again, for half an hour, whenever she walked a quick pace up and down her garden. He likewise acquaints us with the case of a lady, who had been blind for years, but ex- perienced a-short recovery of her sight, on having a tooth extracted.— Anfangsgr. Sec. b. 3, kap. 14.) Whether the benefit arose from the stimulus of the operation, as Richter seems to imply, or from the AMAUROSIS. 27 removal of an irritating cause, doubts may rationally he entertained. A similar fact is recorded by Mr. Tra- vers, who says, that he has seen an incipient func- tional amaurosis distinctly arrested by the extraction of" a diseased tooth, when the delay of a similar opera- tion had occasioned gutta serena on the opposite side two years before.—(Synopsis, p. 299.) When the disorder is accompanied with diminished sensibility in the eye in general, Beer joins Richter, with respect to the temporary improvement of the sight after a nourishing meal, or drinking spirituous li- quors ; or when the patient's mind is elated with joy, or anger, though such melioration of sight, it is true, is but of very short duration.— See also Vetch's Trea- tise on the Diseases of the Eye, p. 137 ; On the other hand, it may be remarked, that every thing which tends to depress the passions and spirits, augments the imperfection of sight. Where marks of increased sensibility prevail, the above-mentioned cir- cumstances exercise a transient disadvantageous opera- tion; tbe patient carefully retires from every strong light, and frequently shelters his eye with bis hand, &c.— Lehre von den Augenkr. b. 2, p. 430.) Mr. Travers also knows patients, whose vision is benefited in a high degree, and others, in whom it is much deteriorated, by the quickened circulation of a full meal, and a few glasses of wine. The former, he says, are persons of spare and meagre habits; the latter plethoric.— Synopsis of the Diseases of the Eye, p. 157. j According to Beer, this amaurosis differs from the preceding, by its formation being usually very slow, and its not exhibiting any traces of those two very differ- ent stages which are peculiar to the other case. It also invariably commences with the visus reticulatus, or nebulosus, without any alternation with a blinding glare of light; and the eyesight is sometimes considera- bly better, and sometimes weaker, which always de- pends upon the accidental operation of the above in- ternal or external circumstances. The melioration of the eyesight never continues long, while the diminu- tion of it not only remains, but gets worse and worse. It is not at all uncommon for this species of amaurosis to make its appearance as a night-blindness, because common artificial light is much too feeble to make due impression upon the diminished sensibility of the optic nerve, and consequently these patients always show a partiality to a very strong light. To such weak-sighted individuals, the flame of a candle, or the moon, appears as if covered by a dense veil, with an expanded halo round it of various colours. There is no complaint made of pain in the head or eyes ; and no sensation of fulness or weight is experienced in the eyeball; much less are there any signs of the disease in the structure and form of the eye, or in the action of its irritable textures; but when it has been long complete, it is usually conjoined with a debilitated habit. Amaurosis either presents itself as a genuine un- complicated affection, or, at least, with the appearance of such a form of disease of the eye, depending solely upon a morbid state of the optic nerve, and cognizable by a diminution, or complete abolition, of the power of vision; or the disease is co-existent with other dis- eased appearances, either in the eye, its vicinity, or some other organs at a distance from the eye, or in the general constitution. These appearances merit the most earnest consideration, because they are for the most part connected with the cause of amaurosis. Ac- cording to this statement then, there is a genuine local amaurosis, and a complicated amaurosis, which last may be either local, or general, or of both descriptions together, and therefore named by Beer, "perfectly complicated."—Vol. cit. p. 43.) The general symptoms of the simple uncomplicated species of amaurosis, putting out of consideration the morbid increase, or diminution of the sensibility of the optic nerve, are thus described by Beer. In the first place, all morbid appearances are absent, which might be produced in the amaurotic eye by any one preternatural change in the texture, form, or state of that organ. Hence we are obliged to trust almost ex- clusively to the patient's assertion that his sight is bad, or quite gone; and not unfrequeutly it is necessary, especially in judicial cases, to employ political artifices in order to determine whether such assertion be true, particularly when the patient affirms that the blindness is restricted to one eye. Secondly, when the amau- rosis is indeed nearly or quite formed in two eye, a slight degree of strabismus is at most perceptible, aris- ing from the circumstance of the patient's not fixing the eye affected ujion any object. This degree of stra- bismus is noticed by Ackerman and Fischer as the surest sign of amaurosis.— SeeKltnische Annalen von Jena st. 1, p. 144.) And it is particularly pointed out by Richter as an invariable attendant upon amaurosis. The patient, says he, not only does not turn either eye towards any object, in such a manner, that the ob- ject looked at is in the axis of vision, but he does not turn both his eyes towards the same thing. This was regarded by Richl.er as the only symptom which we can trust, where implicit confidence should not be put in the mere assurance of the patient that he cannot see, while all the coats and humours of the eyes pre- sent their natural appearance — See Anfangsgr. der Wundarzn. b. 3, kap. 14.; Provided this observation be correct, it must be highly interesting to the military surgeon, amaurosis being a mj^jBon affliction of sol- diers, many of whom, how^T., endeavour to avoid service by pretending (o labour under a disqualification which they well know does not necessarily produce any very considerable alteration in the natural appearance of the part affected. Thirdly, while the disorder is only in the stage of amblyopia, the patient always com- plains of continually multiplying muscae volitantes, or of the visus reticulatus, or nebulosus. Fourthly, lu- minous forms appear before the eyes, especially in the dark, even when the patient is entirely blind. Fifthly, the deer ase of vision goes on to complete blindness, without any material interruption, or retrogression. Sixthly, when only one eye is quite blind, and the eye- sight on the other side is perfectly undisturbed, there is one infallible symptom of this amaurosis; namely, if the sound eye be very carefully covered, the pupil of the blind one immediately expands, and the iris be- comes quite motionless, notwithstanding the diseased eye be exposed to the strongest light possible. How- ever, this criterion is mostly wanting, because the amaurosis, unattended with any perceptible effect, ex- cept loss of vision, is seldom confined to one eye, but usually affects both—^See Lehre von den Augenkr. b. 2, p. 481, 482.) ' Mr. Travers divides amaurotic affections into two classes, the organic and the functional. The first comp ehends alterations, however induced, in the tex- ture or position of the retina, optic nerve, or thalamus. The second includes suspension, or loss of function of the retina and optic organ, depending upon a change, either in the action of the vessels, or in the tone of the sentient apparatus. As causes of organic amaurosis, Mr. Travers enu- merates; 1. Lesion, extravasation of blood, inflamma- tory deposition upon either of its surfaces, and loss of transparency of the retina. 2. Morbid growths within the eyeball, dropsy, atrophy, and all such disorganiza- tions as directly oppress or derange the texture of the retina. 3. Apoplexy, hydrocephalus, tumours or ab- scesses in the brain, or in or upon the optic nerve or its sheath, and thickening, extenuation, absorption, or ossification of the latter. As causes of functional amaurosis, Mr. Travers specifies; I. Temporary de- termination ; vascular congestion, or vacuity, as from visceral or cerebral irritation ; suppressed or deranged or excessive secretions, as of the liver, kidneys, uterus, mammae, and testes; various forms of injury and dis- ease ; and hidden translations of remote morbid ac- tions. 2. Paralysis idiopathica, suspension or ex- haustion of sensorial power from various constitu- tional and local causes; from undue excitement or exer- tion of the visual faculty; and from the deleterious action of poisons on the nervous system, as lead, mercury, &c. From this description, says Mr. Travers, it will be understood that organic, and many forms of functional amaurosis are incurable; and the functional, by con- tinuance, lapses into the organic disease. Functional amaurosis is subdivided by Mr. Travers into, 1st, the Symptomatic, or that which is only a symptom of some general disease, or disorder of the sysjtem; as, for example, general plethora, general de- bility : 2dly,' the Metastatic, or that produced by the sudden translation of the morbid action from another organ of the body; as, for example, from the skin, the testicle, &c. : 3dly, the Proper, or that which de- pends upon a peculiar condition of the retina; as, for example, the visus nebulosus, muses volitantes — (Synopsis, p. 13»-1».) 20 AMAUROSIS. On the whole, genuine local amaurosis, that is to say, a diminution or total loss of the eyesight, unat- tended with any other apparent local or constitutional defect, may be said to be a very rare case, the disorder being usually more or less complicated. To the Jocal complications, says Beer, belong the ca- taract ; glaucoma; a general varicose state of the eye- ball (cirsophthalmia ; exophthalmia; atrophy of the eye; spasms in the organ and surrounding parts; para- lysis of one or more muscles of the eye ophthalmop- legia ; paralysis of the eyelids; ophthalmia in general, and internal ophthalmia in particular; a scorbutic blood-shot appearance of the eye (hypoema scorbuti- cumi; and finally, wounds or contusions of the eye or adjacent parts. With these cases should also be men- tioned that important case, fungus luemutodes of the eye. From this simple enumeration of local complica- tions one may see how frequently amaurosis is only a symptomatic effect of another disorder of the eye, with which it is conjoined, and how often it is connected with the same common causes which pertain to another or several other diseases of the eye. Among the general complications Beer enumerates those which are purely nervous: impairment of the health in various forms by infection, contagion, or mias- mata ; a bad habit of body; typhoid fevers, the amau- rotic effects of which upon the eye the author of this work has frequently noticed; asthma ; internal and ex- ternal hydrocephalus; organic defects of the abdominal viscera; worms; chlorosis; consumption; old ulcers of the legs; organic disease of the brain and skull; com- plaints arising from pregnancy ; hemorrhage, See. In these general complications Beer remarks that the casual connexion between amaurosis and some remote disease of another organ, or of the whole constitution, cannot be mistaken; and in these cases we often see the disease of some other distant part from the eye sud- denly or gradually diminish, and immediately appear again as a sympathetic action in the form of amaurosis, of which the most remarkable instance is seen after the sudden healing of old ulcers of the legs.—(Beer, Lehre von den Augenkr. b. 2, p. 433.) From the above general remarks upon amaurosis it is quite manifest that the symptoms of the disease vary considerably according to the violence of its causes, and of the local and general complications, though the seat of the disease and what is particularly the proximate cause of the loss of vision be in the optic nerve; and it depends especially on the nature of the causes, whether this or that morbid appearance take place in the eye. One may consider as the only really inseparable symptom of amaurosis that weakness of sight ambly- opia , or that complete blindness, in which neither with the unassisted or assisted eye the least defect can be perceived in the structure and shape of the affected or- gan. Hence Beer names-such impairment of vision, or blindness, amaurotic. But how rarely this essential symptom is met with alone, and how frequently it is obscured by some 'other defect in the structure and form of the eye, is proved by daily experience. The incidental symptoms of amaurosis have hitherto been set down as merely consisting of a considerable dilatation of the pupil, and immobility of the iris, be- cause these appearances are indeed the most frequent; but, as Beer observes, this is another proof what igno- rance has prevailed respecting the true nature of that disease of the eye and its modifications, which are usually termed amaurosis. The"incidental symptoms of amaurosis may consist in the faulty size and shape of the pupil. In many ^ases the pupil is very much dilated, immoveable, and possesses its natural black colour and usual transpa- rency. It cannot be denied that this is the state of numerous cases, but it is equally true that there are many exceptions. Sometimes, according to .Richter, jn the most complete and incurable cases the pupil is ef its proper size, and even capable of free motion (Turbes, Recueil Periodique, on minute objects. But however long and assiduously objects are viewed, if they are diversified, the eye suffers much less, than when they are all of the same kind. A frequent change in the objects which are looked at has a material effect in strengthening and refreshing the eye. The sight is particularly injured by looking at objects with only one eye at a time, as is done with telescopes and magnifying glasses; for when one eye remains shut, the pupil of that which is open always becomes dilated beyond its natural diameter, and lets an extraordinary quantity of light into the organ. The eye is generally very much hurt, by being employed in the close inspection of bril- liant, light-coloured, shining objects. Among the occupations enumerated by Mr. TrAvere as particularly exposing persons to amaurosis, are those of needle- workers, writers, draughtsmen, inspectors of linen and scarlet cloths, and of new banknotes; money counters; smiths, stokers in iron-furnaces and glass-houses; tavern-cooks; watchmakers, engravers, philosophical instrument makers, sea officers, &c.— Synopsis, p. 144.) They are greatly mistaken, says Richter, who think that they save their eyes, when they illuminate the object which they wish to see in the evening with more lights, or with a lamp that intercepts and collects all the rays of light, and reflects them ujion the body which is to be looked at. Richter mentions a man, who, in the middle of winter, went a journey on horse- back, through a snowy country, while the sun was shining quite bright, and who was attacked with amau- rosis. He speaks of another person, who lost his sight in consequence of the chamber in which he lay being suddenly illuminated by a vivid flash of lightning. A man was one night seized with blindness, while his eyes were fixed on the moon in a fit of contemplation. Richter also expresses his belief, that a concussion of the head from external violence, may sometimes ope- rate directly on the nerves, so as to weaken and render them completely paralytic. Beer corroborates the foregoing statement; for, he says, among the most frequent causes is to be consi- dered every abuse of the eyesight, especially in dark- eyed persons, as a long and close inspection of one object particularly with a microscope, when the thing examined is very brilliant, or reflects back much light into the eye. Hence the view of jewels at night, and long journeys through snowy countries &c, are con- ducive to the disease. In this respect, every kind of employment which strains the eyes much, and requires a strong reflected light, must be considered injurious.— (See also Travers's Synopsis, p. 144.) Thus, reverbe- rating lamps, like Argand's; the view of a white wall illuminated with the sun's rays; and looking a long while at the moon, or more especially the sun, with the unassisted eye, are circumstances likely to bring on the disease. That a flash of lightning, especially when it suddenly wakes a person in the night-time out of a sound sleep, may produce an amaurotic amblyopia in an irritable eye or even perfect blindness, is a well- known fact, and it is on the same principle that going suddenly out of a dark bedroom, immediately after wak- ing in the morning, into an apartment that commands an open extensive prospect, must be hurtful to an irrita- ble eye, though the bad effects may only be very slow. Here is also to be included every kind of over-irritation of the eye by light, as happens to typhoid patients, when they lie with their eyes open all the day in a large sunny chamber. Very often the cause of amaurosis consists in local or constitutional debility, proceeding from impairment of the nerves in general, or of the nerves of the head, especially those of the forehead and eyebrow; either 3C AMAUROSIS. from a concussion of the spinal marrow, falls from a considerable height with the weight of the whole body upon the heels; •concussions of the eyeball, sometimes caused by violent sneezing, but more generally by con- tusions of the eye with blunt weapons, dec. Some of the cases of amaurosis from blows on the temple or the eye, observed by Mr. Travers, were attended with signs of disorganization; some were superficially inflamed; and others presented no external appearance of injury. We learn also from the same authority, that it is not always the eye on the struck side of the head that is affected.—.Synopsis, &c. p. 152.; If we are to believe Beer, and other foreign practitioners, considerable direct weakness may arise from cholera, iong-continued diarrhoea, salivation, and the incessant spitting of tobacco smokers; bleedings ; injudicious tapping of the abdomen; excessive indulgence in veuery, and the mis- employment of issues. A general debility, which has the worst effect on the ejes, may also arise from long trouble, especially when the diet is poor and bad ; also from a deficiency of proper food ; long watching; vio- lent and sudden fright; imprudently washing the eyes with very cold water, especially when they are already weakish and irritable ; and keeping them long in a dark place, particularly when they are also exerted a good deal in some particular kinds of labour, a case which, Beer says, is very frequent in Vienna. The amaurosis following typhus, without any unusual irri- tation of the eye by light, Beer also refers to general debility.—(Lehre von den Augenkr, b. 2, p. 449.) Like nervous deafness (says Mr. Travers, amaurosis sometimes follows typhus and scarlet fever, and the various forms of acute constitutional disease. He has several times met with it as a consequence of infantile fevers. He observes that it is also sometimes a conse- quence of chronic wasting diseases, in which organic changes interrupt the nutrition of the system. lie has seen a rapid and severe salivation instituted for a remote affection, and where no disease had previously affected the eyes, terminate in gutta serenaof both.— Synopsis, p. 155.) With regard to the doctrine that certain forms of amaurosis are diseases of debility, Mr. Lawrence ex- presses his disbelief in its correctness, and asserts, that, the only scientific and successful treatment of amaurotic affections is found to be antiphlogistic. Whether the amaurosis resulting from typhoid fevers, of which I have seen several instances, proceed from debility, or from too great a determination of blood to the head, may admit of dispute; but 1 conceive, that iu many of such cases, tonic treatment is clearly indi- cated, if not for the eye itself, certainly for the generally enfeebled state of the health, with which the amaurosis is connected. Yet Mr. Lawrence's doctrine, that ful- ness and congestion of the vessels originally lead to the amaurotic affection, may be more correct than the theory which refers the blindness simply to weak- ness. However, as the amaurosis generally does not show itself till an advanced stage of'fever, or that of great debility, and as it only recedes as the patient regains strength, it can hardly be considered as a case in which any other treatment than tonic can be avail- ing. It is right to state that Mr. Lawrence himself, notwithstanding his belief in amaurosis being a kind of inflammation of the retina, modifies the antiphlogistic treatment accordingjto^he state of the constitution. The third class of causes consists of irritations, most of which are asserted to lie in the abdominal viscera, whence they sympathetically operate upon the eyes. The observations of Richter, Scarpa, and Schmucker, all tend to support this doctrine. Many amaurotic patients are found to have suffered much trouble and long grief, or been agitated by repeated vexations, anger, and other passions, which have great effect in disorder- ing the bilious secretion and the digestive functions in general. Richter tells us of a man who lost his sight, a few hours after being in a violent passion, and reco- vered it again the next day, upon taking an emetic, by which a considerable quantity of bile was evacuated. A woman is also cited, who became blind whenever she was troubled with what are termed acidities In the stomach.—(See Anfangs. der Wundarzn. b. 3, kap. 14. i However, according to Beer, imperfect amaurosis sel- dom depends upon disorder of the gastric organs, excepting the case from worms. 'Lehre von den Augenkr. b. 2, p. 456 : a very' important difl'erencc from the sentiments entertained by Schmucker, Richter, and j | Scarpa. The close sympathy between the stomach and the ejes is well illustrated by a rase recorded in one of the journals, and referred to b\ Air. Lawrence in his Lectures. It was an amaurosis,'with fixed pain over the eyebrow, in a child. It w as not relieved by purging and other depletive measures: an emetic was at last given ; and under its action, a bead was rejected from | the stomach, and the amaurosis immediately disap- i peared. Amaurosis sometimes proceeds from mechanical irri- tation. A small shot pierced the upper eyelid, and lodged at the upper part of the right orbit, between the e>eiid and eyeball, so that it could be lelt externally. The patient shortly afterward became blind in the left eye; but recovered his sight after the excision of the shot.— Anfangsgr. der Wundarzn. band 3, p. 439.; According to Beer, several constitutional disorders, but more especially gout, are frequently concerned in the production of amaurosis. \\ hoever reads Beer's history of what he terms gouty amaurosis, will na- turally doubt the correctness of the name; and Mr. Lawrence distinctly affirms, in his Lectures, that he lias never seen gout or rheumatism occasion any ten- dency to affections of the nervous structure of the eye. It is not because amaurosis sometimes occurs in gouty or rheumatic constitutions, that the affection ol the sight is necessarily of a gouty or rheumatic origin; for the fact merely proves, that such constitutions are not exempt from the risk of being attacked by disor- ders of the e> e. Mr. Lawrence has also never seen any case, in which the origin of amaurosis could be referred to syphilis. Respecting the causes of amaurosis, the following remarks by Beer claim attention. Various swellings in the orbit, as, lor instance, encysted tumours, tophi, hydatids in the sheath of the optic nerve, may and must gradually produce complete amaurosis by their pressure upon the optic nerves and retina. Some of these cases are usually characterized by a protrusion of the eye from its socket.— See Exophthalmia.) In Mr. Langstaff's museum is a specimen of two amau- rotic eyes, in which the optic nerves are shrunk to about one-third of their natural size. Similar instances are recorded by Dr. Monteith.— See Weller's Manual.) According to .Mr. Lawrence, Mr. Langstaff has also some interesting specimens of enlargement in front of the third ventricle, the parietes of which bulge so as to press upon the optic nerves, and thus to account for the amaurosis under which the patients laboured. In the same manner different morbid changes in the brain itself, and in the bones of the cranium in par- ticular, may be the direct cause of amaurosis: for ex- ample, hydrocephalus intemus, caries, and exostoses at the basis of the skull. Just as amaurosis is frequently a pure symptomatic effect of various disordered states of the constitution, so may different morbid changes, occasioned in the eye by those states of the health, become the proximate ' cause of amaurosis, as hydrophthalmia, cirsophthal- mia, fungus nematodes, dissolution of the vitreous humour, glaucoma, moii? hsmi^rania; or which are the consequence ofviolent, long-continued, internal ophthalmia, may be set down as incurable. Nor can any cure be expected when amaurosis pro- ceeds from a direct blow on the eye; foreign bodies in the eyeball; lues venerea, or exostoses about the orbit; or when it is conjoined with a matufest change in the figure and dimensions of the eyeball. Recent, sudden cases, in which the pupil is not exces- sively dilated, and its circle remains regular, while tho bottom of the eye is of a deep black colour; cases un- accompanied with any acute, continual pain in the head and eyebrow, or any sense of constriction in the globe of the eye itself; cases which originate from violent anger, deep sorrow, fright, gastric disorder, general plethora, or the same partial affection of the head, sup- pression of the menses, habitual bleedings from the nose, piles, Sec, great loss of blood, nervous debility, not too inveterate, and in young subjects, are all, ge- nerally speaking, curable. Amaurosis is also mostly remediable, when produced by convulsions or the efforts of difficult parturition ; when it arises during the course, or towards the termination of acute or intermittent fevers; and when it is periodical.—(Scar- pa, Osservaziom sulle Mallatie degli Ocelli, cap. 20, Venez. 1-02.) According to Mr. Travers, it is rather the degree than the nature and origin of the symptomatic func- tional amaurosis, that should in most cases influence our prognosis; yet the latter circumstances, it is equally clear, afford more or less encouragement, in proportion as the pre-existing states of disease ordinarily admit of relief or not. Thus, says he, the amaurosis from gas- trie diseases, from plethora, from irritation, are all of th.-.i. relievable, and if treated at an early period, reme- diable. Whereas paralysis, the sequel of fever, or of epilepsy, or severe constitutional diseases, whether acute or chronic, or depending upon habitual cerebral congestions combined with organic visceral disease, or induced by theoperation of noxious agents on the system, is a hopeless form of the malady.-^- Synopsis, p. 296 ) I mi) remark, however, that various examples of recovery from amaurosis induced by fevers have fallen under my own notice. In general, when the treatment proves successful, the return of the power of vision is accompanied with a regression of the same characteristic effects, which were disclosed in the gradual advance of the disorder, viz. appearances as if there were before the eyes flashes of light, a cobweb, net-work, mist, or flaky substances. — Beer, Lehre von den Augenkr. b. 2, p. 460. Wien, 1817.) Upon the commencement of the cure, there is also a return of the obliquity of sight; one of the most con- stant symptoms of imperfect amaurosis. This is a circumstance which Hey took particular notice of; ho says, that it was most remarkable in those persons who had totally lost the sight in either eye; for in them the most oblique rays of light seemed to make the first perceptible impression upon the retina; and, in pro- portion as that nervous coat regained its sensibility, the sight became more direct and natural.—(See Med. Obs and Inq. vol. 5.) TRKATMEKT OF AMAUROSIS. When amaurosis is to be fundamentally cured, not upon empirical, but scientific principles, all the causes of the disorder must be ascertained, and, if possible, removed, as in the treatment of every othei' complaint. How often, however, it is impossible to accomplish either the one or the other of these objects, must be clear enough from the preceding observations, particu- larly those concerning the etiology of the disease; and hence it is net surprising, that amaurosis should so frequently resist every endeavour to cure it. The plan of treatment is to be regulated, first by the number aijd kinds of circumstances, which determine the form of the disorder; secondly, by its presence degree, and duration. When only the chief causes can be ascertained, a scientific mode of treatment may always be instituted; though here it is very necessary to pay the utmost attention to those morbid effects in the constitution, and in the eye in particular, which appear to have no connexion with the causes of amau- rosis, and merely exist as accidental contemporary de- fects. If no particular circumstances can be assigned as the cause of amauios.es, the s>uifceou has no aiiciuaiive AMAUROSIS. 35 but tlic adoption of some empirical method of treat- ment ; but, exclaims Beer, wo to the patient whose surgeon, under these circumstances, draws from a heap of what are considered remedies for amaurosis, as from a lottery, the first as the best! In order to avoid this erroneous method, and not render a half-blind person completely blind, instead of improving, or at least preserving, whatever remnant of vision there may be, the surgeon should act with great caution, and constantly bear in his mind, first, the con- stitution, sex, and age of the patient; secondly, his ordinary employments, and general mode of living; and thirdly, the principal morbid appearances under which the amaurosis originated and was developed.— (Beer, Lehre von den Augenkr. b. 2, p. 462.) But what will be the greatest assistance is a correct acquaintance with the remedies for amaurosis in general, and the circumstances under which the use of this or that particular means is likely to be useful or detrimental. I know of no writer who has been so ninute on this part of the subject as Beer, whose sen- timents 'be it also remarked) are here in many respects different from those of Richter and Scarpa; for, like the surgeons oP'this metropolis, he rarely employs the emetic plan of treatment, which, according to his prin- ciples, is not only ineffectual, but hurtful, whenever the blindness is attended with determination of b'ood to the head and eyes, plethora, an accelerated circula- tion, or i what is understood by) a phlogistic diathesis. Beer's opinions, respecting the employment of emetics and other means for the cure of amaurosis, may be partly collected from the sequel of this article, but more especially fhim the fuller statement which will be made at aAiture opportunity.—(Sec (iutta Serena.) Iu the mean time, I shall endeavour to offer a general Account of the practice recommended by Schmucker, Richter, Scarpa, Travers, and Lawrence, according to the arrangement of causes adopted by the second of these valuable writers; for I need not repeat, that whenever the method of cure can be directed against the causes of the disease, it is the most proper and sci- entific. The present article will, then, close with some practical observations, chiefly taken from Professor Beer. In that species of amaurosis, which arises from the first class of causes, or those which induce the disease, by means of a preternatural fulness and dilatation of the blood-vessels of the brain or eye, the indication is to lessen the quantity of blood, and the determination of it to the head. For this purpose, the patient may be bled in the arm, temporal artery, or, as is often pre- ferred by foreign surgeons, in the foot. This evacua- tion is to be repeated as often as seems necessary, and it will be better to begin with taking away from twelve to sixteen ounces. The efficacy of bleeding, in the cure of particular cases of gutta serena, is strikingly exemplified by numerous well-authenticated obser- vations. Richter informs us of a woman, who, on leaving off having children, lost her sight; but reco- vered it again by being only once bled in the foot. A spontaneous hemorrhage from the nose also cured a young woman, who had been blind for several weeks. — Anfangsgr. der Wundarzn. b. 3, p. 442.) That bleeding is sometimes hurtftilly and wrongly practised in amaurotic cases, is a fact which admits of no doubt. Mr. Travers particularly refers to one descrip- tion of cases where the lancet does harm: these are rases of undue determination of blood to the organ, which are especially common after deep-seated chronic inflammation or distress firom over-excitement, by which its vessels have lost their tone; an effect decidedly in- creased by depletion. In one interesting case of this kind, a gradual but perfect recovery followed a regu- lated diet, and a course of the blue piil, with saline aperients —(Synopsis, p. 159.) All cases of direct de- bility and proper paralysis of'the retina (says Mr. Tra- vers are aggravated by loss of blood, and the great prevailing mistake in the treatment of amaurosis, is the Indiscriminate detraction of blood.—(Synopsis, p. *)3.) When, in addition to general bleeding, topical is also I necessary, leeches may be applied to the temples, or J cupping-glasses to the back of the neck, or temples. HcMdes bleeding, purgatives, blisters, bathing the feet in warm water, low diet, repose of the organs, Sec. are frequently proper. In some cases, the foregoing means fail in producing 1 I the desired benefit, even when followed up as far as the pulse and strength will allow. Here the continu- ance of the disease may depend either upon the stop- page of some wonted evacuation of blood, or else upon some other cause of the first class. In the first of these cases (says Richter) experience proves, that the disease will sometimes not give way before the accus- tomed discharge is re-established. A woman, who (as this author acquaints us) had lost her sight in conse- quence of a sudden suppression of the menses, did not recover it again till three months after the return of the menstrual discharge, notwithstanding the trial of every sort of evacuation. He also tells us of another woman, who had bwn blind half a year, and did not menstruate, and to whose external parts of generation leeches were several times applied. As often as the leeches were put on (says Richter) the menses in part recommenced; and as long as they made their ap- pearance, which was seldom above two hours, the wo- man always enjoyed a degree of vision.—(Anfangsgr. der Wundarzn. b. 3, p. 443.) For the amaurosis arising from suppression of tho menses, Scarpa recommends leeches to the pudenda, bathing the feet in warm water, and afterward exhi- biting an emetic, and laxative pills, made of rhubarb and tartrate of antimony, combined with gummy and saponaceous substances. If these means fail in esta- blishing the menstrual discharge, he says, great confi- dence may be placed in a stream of electricity, con- ducted from the loins across the pelvis, in every direc- tion, and thence repeatedly to the thighs and feet. He enjoins us not to despair at want of success at first, as the plan frequently succeeds after a trial of several weeks. For tho amaurosis proceeding from the stoppage of an habitual copious bleeding from piles, Scarpa recom- mends leeches and fomentations to the hemorrhoidal veins, then an emetic, and afterward the same opening pills.— Osservazioni suUe principali Malattie degll Occhi, cap. 19.) When the disease does not originate from the stop page of any natural or habitual discharge of blood, and does not yield to the evacuating plan, Richter thinks the surgeon justified in concluding, that the preterna- turally dilated vessels have not regained their proper tone and diameter, and that topical corroborant reme- dies, particularly cold water, ought to be employed. In this kind of case, he is an advocate for washing and bathing the whole head with cold water, especially the part about the eyes; a method, he says, which may often be practised after evacuations, with singular and remarkable efficacy. When the return of sight cannot be brought about in this manner, Richter advises us to try such means as seem calculated to stimulate the nerves, and remove the torpid affection of the optic nerves in particular. Of these last remedies, says he, emetics are the princi- pal and most effectual. The principle on which Mr. Lawrence directs the treatment, is that of putting a stop to vascular excite- ment, with the view of preventing the permanent in- jury of altered structure, and impaired function of the retina. Hence he is a zealous advocate for the anti- phlogistic treatment, in the early stage of amaurosis. '• But," says he, " if this treatment be not found to remove tbe change which has been produced in the re- tina, we must have recourse to mercury, which appears to be as decidedly beneficial in these esses as in iritis, or general internal inflammation. The remark which I made respecting the use of mercury in those affec- tions, applies also to the present case; namely, that its good effect mainly depends upon the promptitude with which it is employed. The alterative form is in-. sufficient: we give it with the view of arresting in*.. (lamination in the structure, which is the very sqatof' vision; that structure is easily changed by the inflam- matory process; our only remedy is to push the mer- cury in a decided manner, and if we do so, we shall put a stop to the affection." When the antiphlogistic treatment and a fair trial of mercury have failed, Mr. Lawrence contents himself with recommending such management as is most conducive to general health; as a residence and frequent exercise in a pure air; plain nutritious diet; mild aperients, with the occa- sional use of an active purgative; and repose of tbe affected organ. He mentions also a trial ofa seton, or repeated blisters behind the ears, or at the side or back 36 AMAUROSIS. of the neck. As already stated, however, Mr. Law- rence does not wish it to be supposed, that all amau- rotic patients require to be bled and salivated. Amau- rosis, he says, often comes on in a slow and very insi- dious manner in persons of enfeebled constitution: the organ suffers from habitual excessive exertion at the same time that the general powers are depressed by residence in confined dwellings, bad air, sedentary oc- cupations, unwholesome diet, costiveness, and the other injurious influences of such causes. If you should see a thin, pallid, and feeble woman, who had destroyed her health by close confinement to needle-work, and whose eyes were beginning to fail, the same active measures would by no means be admissible. You would empty the alimentary canal, perhaps take a little blood by cupping, or by leeches to the temples, and then use mercury in the alterative form, together with mild aperients. A few grains of Plummer's pill may be given every night, or every second night, and the bowels may be kept open with electuary, castor oil, or rhubarb and magnesia, taken occasionally. The blue pill may be taken in combination with aloes or colocynth. It may be necessary, says Mr. Lawrence, to peraevere with the mercury, slowly increasing the dose until a slight influence is visible in the mouth. A nutritious diet without stimuli, good air, and exercise, and repose of the affected organ, are important auxilia- ries, and a succession of moderate-sized blisters may be advantageously combined with these means. Thus, observes Mr. Lawrence, you see, that the same princi- ples regulate our treatment, but that it is modified in degree according to the violence of the symptoms, and the patient's strength. In the latter description of cases, after mild antiphlogistic means, and clearing the alimentary canal, ie admits that it may be expedient to coniDiiie tonics with aperients, or rhubarb with bark, columba, or cascarilla: and to allow a little por- ler and wine. We come now to the consideration of that species of the gutta serena, which is regarded as the effect of some unnatural irritation. Here, according to the pre- cepts delivered by Richter, we should endeavour to discover what the particular irritation is, and then en- deavour to effect its removal. When it cannot be ex- actly detected, we are recommended generally to em- ploy such remedies, as will lessen the sensibility of the nerves, and render them less apt to be affected by any kind of irritation. Sometimes the irritation is both discoverable and re- moveable, and still the effect, that is to say, the blind- ness, continues. In this circumstance, Richter thinks that the surgeon should endeavour to obviate the im- pression which the irritation has left upon the nerves, by the use of anodynes; or else try to remove the tor- por of the nerves by stimulants. But, according to Schmucker, Richter, and Scarpa, the curable imperfect amaurosis commonly depends on some disease or irritation, existing in the gastric sys- tem, occasionally complicated with general nervous debility, in which the eyes participate. Hence, in the majority of cases, we are assured that the chief indi- cations are, to free the alimentary canal from all irri- tating matter, improve the state of the chylopoietic viscera, and invigorate the nervous system in general, and the nerves of the eye in particular. For an adult, dissolve three grains of antimonium tartarizatum in four ounces of water, and give a spoon- ful of this solution every half hour, until nausea and copious vomiting are produced. The next day some opening powders are to be exhibited, consisting of an ounce of the supertartrate of potash, and one grain of antimonium tartarizatum, divided into six equal parts. The patient must take one of these in the morning, another four hours afterward, and a third in the eve- ning, for eight or ten days in succession. They will create a little nausea, rather more evacuations from the bowels than usual, and perhaps, in the course of a few days, vomiting. If the patient, during their use, should make vain efforts to vomit, complain of bitter- ness in his mouth, loss of appetite, and no renovation of 6ight, the emetic, as at first directed, is to be pre- scribed again. This is to be repeated a third and fourth time, should the morbid state of the gastric system, the bitter taste in the mouth, the tension of the hypo- chondria, the acid eructations, and the inclination to vomit, make it necessary. The first emetic often pro- duces only an evacuation of an aqueous fluid, blended with a little mucus, but, if it be repeated, a few day* after the resolvent powders have been administered, it then occasions a discharge of a considerable quantity of a yellow, greenish matter, to the infinite relier o! the stomach, head, and eyes. The stomach having been thus emptied, the foUow- ing aperient pills are to be ordered: ft. Gum. sagapen. ) Galban. > an. 3j. Sap. venet. ) Rhei optim. 3 iss. Tart. emet. gr. xvi. Sue. liquerit. 3 j. fiant pilulas gran, quinque. Three are to be taken every morning and evening, for a month or six weeks. When the state of the stomach has been improved, and the restoration of sight partly effected, such reme- dies must be employed, as strengthen the digestive or- gans, and excite the vigour of the nervous system in general, and of the nerves of the eye in particular. With this intention Scarpa prescribes bark and vale- rian in powder, and recommends a diet of tender suc- culent meat, and wholesome broths, with a moderate quantity of wine, and proper exercise in a salubrious air. For exciting the action of the nerves of the eye, the vapour of liquor ammonite, properly directed against the eye, he says, is of the greatest service. This remedy is applied by holding a small vessel con- taining it sufficiently near the eye to make this organ feel a smarting, occasioned by the very penetrating va- pours with which it is enveloped, and which cause a copious secretion of tears, and a redness, in less than half an hour after the beginning of the application. It is now. proper to stop, and repeat the application three or four hours afterward. The plan must be thus fol- lowed up till the incomplete amaurosis is quite cured The operation of these vapours may be promoted by other external stimulants, applied to such other parts of the body as have a great deal of sympathy with the eyes. Of this kind are blisters to the nape of the neck; friction on the eyebrow with the anodyne liquor; the irritation of the nerves of the nostrils by sternuta- tive powders, like that composed of two grains of tur- beth mineral, and a scruple of powdered betony leaves; and, lastly, a stream of electricity.—(See Gutta Se- rena.) Bark, which is efficacious in intermittent fevers, and other periodical diseases, far from curing periodical amaurosis, seems to aggravate it, rendering its return more frequent, and of longer duration. On the other hand, this disease is most commonly cured, in a very- short time, by exhibiting, first, emetics, then the above laxative pills, and lastly, corroborants, and even bark, which was before useless and hurtful. Such is Scarpa's statement, which agrees with that of Richter, respecting the effect of bark in periodical amaurosis. As if, however, practitioners were doomed always to differ, and learners to be puzzled, Beer tells us, that he has seen only two cases of periodical inter- mittent amaurosis, both of which were soon perfectly cured by large doses of bark. Other periodical amau- rotic affections he has seen, however, attendant on in- termittent fever, but they spontaneously subsided with the febrile paroxysms, without any particular treat ment being applied to the eyes. Sometimes, when the paroxysms recurred frequently, a considerable weak ness of sight remained after them; but this always went off of itself, except in a single instance, in which the functions of the eyes were perfectly re-established by the exhibition of arnica joined with bitters.—(Lehre. von den Augenkr. b. 2, p. 585.) In the two cases, which were unaccompanied with fever, the vitreous humour had the appearance of be- ing turbid during the attacks, but regained its natural clearness on each return of vision, the loss of which used to be complete. Here we see another instance in which a cloudiness behind the pupil in amaurosis did not impede the cure, and went away in the most ready manner. Possibly, the opacity, which, in speakin* of the prognosis, I said that Langenbeck had not found to> prevent the cure of certain cases, might also have had its seat in the vitreous humour, and not depended upon disease of the retina. Cases, in the formation of which man* other causes operate, demand the employment of particular curative means, in addition to those which have been already described. Such is, for example, the imperfect amau- AMAUROSIS. 37 rosis, which occurs suddenly in consequence of the body being excessively heated, or exposure to the sun, or violent anger in plethoric subjects. This case re- quires, in particular, general and topical evacuations of blood, and the application of cold washes to the eyes and whole head. An emetic should next be given, and afterward a purge of potasste tartras, or small re- peated doses of antimonium tartarizatum. By means of bleeding and an emetic, Schmucker often restored the eyesight of soidiers who had lost it in making forced marches, with very heavy burdens. In amau- rosis, suddenly occasioned by violent anger, an emetie is the more strongly indicated after bleeding, as the Blindness, thus arising, is always attended with a bit- ter taste in the mouth, tension of the hypochondria, and continual nausea. Richter mentions a clergyman, who became completely blind after being in a violent passion, and -whose eyesight was restored the very next day, by means of an emetic, given with the view of relieving some obvious marks of bilious disorder in the stomach. Scarpa's treatment of the imperfect amaurosis brough t on by fevers, deep sorrow, great loss of blood, intense study, and forced exertions of the eyes on very mi- nute or brilliant objects, consists also in removing all irritation from the stomach, and afterward strengthen- ing the nervous system in general, and the nerves of the eye in particular. In the case originating from fe- vers, the emetic and opening pills are to be given; then bark, steel medicines, and bitters; while the vapour, of the liquor ammonia? is to be applied to the eye itself. When the disorder has been brought on by grief, or fright, the stomach and intestines are to be emptied by means of antimonium tartarizatum and the opening pills ; and the cure is to be completed by giving bark and valerian; applying the vapour of liquor ammonia; to the eyes; ordering nourishing, easily digestible food ; diverting the patient's mind, and fixing it on agreeable objects, and recommending moderate exercise. The amaurosis from fright is said to require a longer per- severance in such treatment, than the case from sor- row.—(Scarpa's Osservaz. cap. 19.) In this country, the emetic practice, which has proved so decidedly efficacious^ on the continent, has not been attended with much"" success; Mr. Travers even states, that he does not recollect an instance of decided benefit from it, though he has often tried it fairly. He agrees, however, in the indication, as he remarks, that the removal of an irritating or oppress- ing cause, will often effect a sudden and marked relief, as by clearing the intestinal canal of vitiated secre- tions, restoring the digestive functions, or taking away blood where the necessity is indicated. In gastric cases for which emetics have been particularly recom- mended, he prefers a long-continued course of the blue pill, with gentle saline purgatives and tonic bitters.— (Synopsis, p. 299—304.) Beer is also a high authority against the use of eme- tics, even in the amaurosis from disorder of the gas- tric organs. When, says he, the saburrse have a ten- dency to be discharged upwards, as indicated by con- tinual nausea and disposition to vomit, emetics, which never operate without some violence, are to he most carefully avoided in plethoric individuals, or those who have a manifest determination of blood to their heads and eyes, or any acceleration of the circulation. The caution here given must be observed, even though erne- • tics may on other accounts seem advisable; and, ac- cording to Beer, the determination of blood and the state of the system here mentioned, are commonly at- tendant upon this species of amaurosis. Indeed (not- withstanding the testimony of Schmucker, Richter, and Scarpa, in favour of emetics in this case), Beer posi- tively affirms, that the violent operation of an emetic frequently converts this sympathetic amaurotic weak- ness of sight all on a sudden into blindness. Although I apprehend that Beer may here be somewhat preju- diced against emetics, candour obliges me to add, that in this country, their efficacy in the present disease is by no means equal to the representations of Richter and Scarpa. When there is less tendency to vomiting, but the case is attended with an oppressive sense of weight about the stomach, frequent eructations, as if arising from rotten eggs, an inflated belly, and tense hypochondria, a gentle aperient clyster may be ordered, especially when the bowels have been for some days confined, in which circumstances Beer has found, that, tolerably brisk purgatives are always of the greatest service, both in regard to the general complaints, and the amaurotic weakness of sight; the removal of the offensive matter from the alimentary canal being im- mediately followed by a cessation of the determination of blood already mentioned. Lastly, when this amau- rosis originates altogether from the presence of worms in the bowels, common anthelmintics are to be pre- scribed. In all these cases, says Beer, mere local treatment is quite inapplicable, and may do mischief.— (Beer, Lehre von den Augenkr. b. 2, p. 517—521.) The third species of gutta serena, or that which arises from debilitating causes, is of two kinds; in one, the disease is the consequence of a general weakness of the body; in the other, it is the effect of debility, which is confined to the eye itself, and does not extend to the whole constitution. According to Scarpa, the incomplete amaurosis from general nervous debility, copious hemorrhage, convul- sions ab inanitione, and long-continued intense study, especially by candle-light, is less a case of real amau- rosis, than a weakness of sight from a fatigued state of the nerves, especially of those constituting the im- mediate organ of sight. When this complaint is re- cent, in a young subject, it may be cured or diminished, by emptying the alimentary canal with small repeated doses of rhubarb, and then giving tonic cordial reme- dies. At the same time, the patient must abstain from every thing that has a tendency to weaken the nervous system, and, consequently, the eyesight. After empty- ing the stomach and bowels, it is proper to prescribe the decoction of bark with valerian, or the infusion of quassia with the addition of a few drops of sulphuric ether to each dose, with nourishing easily-digestible food. The aromatic spirituous vapours (mentioned in the article Ophthalmy) may then be topically applied; or, if these prove ineffectual, the vapour of liquor am- moniae. The patient must take exercise on foot, horse- back, or in a carriage, in a wholesome dry air, in warm weather, and avail himself of sea-bathing. He must avoid all thoughts of care, and refrain from fixing his eyes on minute shining objects. The impression of vivid light on the retina is always to be moderated by means of flat green glasses.—(Saggio di Osservaz. cap. 19.) One case of temporary palsy of the retina from over-excitement, mentioned by Mr. Travers, yielded to blistering the forehead, and a gentle salivation excited by calomel joined with opium.—(Synopsis, p. 164.) Another case, brought on by the use of telescopes and sextants, gave way to a copious bleeding, brisk purg- ing with jalap and calomel, blisters to the temples, and a course of mercury.—(Op cit. p. 166.) Mr. Travers remarks, that the amaurosis from de- pletion is sometimes mistaken for the opposite case, viz. that from plethoric congestion: this is owing to the coincidence of a dilated and immoveable pupil, muscae, and a deep-seated pain in the head, with occa- sional vertigo ; and its frequent occurrence in a corpu- lent habit. By a cautious use of tonics (says Mr Travers j it is relieved ; by whatever lowers or stimu- lates, whether die: or medicine, it is decidedly aggra- vated. In this form of amaurosis, vision is farther enfeebled by the loss of as much blood as flows from two or three leech-bites.— (Sj'nopsis, &c. p. 160.) When the weakness is confined to the eye, Richter thinks corroborant applications alone necessary. Bath- ing the eye with cold water, says he, is one of the most powerful means of strengthening the eye. The pa- tient should dip in cold water a compress, doubled into eight folds, and sufficiently large to cover the whole face and forehead, and this he should keep applied, as long as it continues cold. Or else he should frequently apply cold water to his eyes and face with his hand, on a piece of rag. The eye may also be strengthened by repeatedly ap- plying blisters of a sermlunar shape above the eye- brows, just long enough to excite redness. Richter likewise speaks favourably of rubbing the upper eye- lid, several times a day, with a mixture of the tincture lyttse and spiritus serpilli.—(Anfangsgr. der Wundarzn. b. 3, p. 452.) When no probable cause whatsoever can be assigned for the disease, the surgeon is justified in employing such remedies, as have been proved by experience to be sometimes capable of relieving the affection, al- though upon what principle is utterly unknown.—(See Gutta Serena.) To this article I would refer the reader, 38 AMAUROSIS. before he makes up his mind about any empirical method of treatment, because he will there find many cautions and instructions given by Beer, respecting the remedies for amaurosis in general. To his remarks, I have also annexed such others, on the same topic, as appeared to me interesting. Cat-eye amaurosis. This species of the disorder, of which Beer met with but one form, rarely increases to complete blindness; it occurs chiefly in very old persons, and it is perhaps this affection to which some oculists have given the unmeaning name of " amblyopia senilis." Sometimes, however, this kind of amaurosis takes place in young persons and children : and one circumstance that de- mands particular notice in its nosology is, that it al- ways takes place either in thin, dwindled, old, gray- headed subjects, nearly in the state of marasmus senilis, in whom consequently the exchange of organic matter is carried on but tardily, or else in young subjects, who are unhealthy, and disposed to consumption, hectical adults, emaciated children, and as a consequence of severe injuries of the eye. While tills amaurosis is not perfectly formed, the iris retains its mobility, and the pupil is neither preternaturally dilated nor con- tracted ; but when once the patient is quite bereft of yision, the motions of the iris are slow, and the pupil larger than in a healthy eye in an equal degree of light. At the bottom of the eye, very for behind the pupil, a concave pale-gray, bright-yellowish, or variegated red- dish opacity is developed. By this the eyesight is not merely weakened, but rendered quite confused, since all objects, but especially smallish ones, appear to be confounded together, particularly when the patient tries to inspect closely any determinate body, The far- ther the disease advances, the brighter and more visible is the bottom of the eye, the paler is the colour of the jris (a thing very conspicuous in dark-eyed persons;; and when-once the amaurosis is complete, so that no susceptibility of the impression of light is left, then, Upon an attentive examination of the eye, one can mostly perceive, at the troubled deeper part of the eye, a very slender vascular plexus, which merely consists of the ordinary ramifications of the central artery and vein, which are now visible at the pale-coloured bot- tom of the eye. In a half-darkened place, such an eye presents a shining yellowish or reddish appearance, but only in certain positions of the eyeball; and, in this respect, it is somewhat similar to the eye of a cat, whence Beer chooses to term the complaint cat-eye amaurosis, The disorder is also not accompanied with any other essential morbid appearances, except the de- cline of vision or complete blindness.—(Lehre von den Augenkr. b. 2, p. 496.) Beer, in fig. 1, tab. 4 of bis second vol., has given from nature an admirable repre- sentation of this very remarkable species of amaurosis. The differences in the appearances at the bottom of the eye, in this case, from those presented in the early stage of fungus nematodes of that organ, will be best understood by referring to the article Fungus Haema- todes. On this point, however, I may here briefly state, that in the cat-eye amaurosis, there is no projec- tion, but, on the contrary, a concave depression in the axis of vision. Cat-eye amaurosis may be known from incipient cataract, by the opacity being more deeply situated, and having a shining, pearly lustre.— (See Journ. of Foreign Med. vol. 4, p. 168.) Beer observes that the causes of this species of amau- rosis are so obscure, that whatever is offered upon the subject can be received only as conjecture. After what has been said in the foregoing paragraph is considered, about the particular individuals who are liable to be affected, and the change of the iris to a pale colour, as a constant symptom of this case, a suspicion may be entertained that a deficiency of the pigmentum nigrum and of the tapetum of the uvea, in consequence of the stoppage of this secretion, may be the cause of the dis- ease. Beer justly remarks that much might be learned on this itoiiit from the dissection of eyes thus affected; but he has never met with the opportunity. The prognosis cannot but be very unfavourable; for, as '.he surgeon is ignorant of causes, he cannot know what means ought to be adopted for their removal. It is fortunate, however, that this amaurosis rarely attains its highest degree, but almost constantly remains in the form of a more or less considerable amblyopia. Just as little is yet known respecting any well-regu- lated mode of treatment; but the disease may some- times be kept from getting worse by the careful em- ployment of such general remedies, regimen, and diet, as are calculated to improve the health. However, in the most fortunately managed cases, Beer never knew a step made towards the removal of the disease.— (Lehre von den Augenkr. b. 2, p. 497, 498.) Amaurosis produced by bitters, certain articles of food in particular constitutions, or the poison of lead. The reality of the first alleged cause is sometimes doubted in this country. The following treatment is recommended by Beer. In the first stage he advises gentle antiphlogistic means. When plethora exists, a few ounces of blood may be taken away by venesection, or leeches applied behind the ears, when after bleeding a determination of blood to the head and eyes still continues in full habits, or there is any tendency to inflamma- tion. The same topical bleeding without venesection, but with lukewarm pediluvia, containing salt or mus- tard, is proper when no general plethora exists; and merely a determination of blood to the head and eyes and some acceleration of the circulation prevail. Inter- nally, lemon-juice or the liquor ammonia? acet. has ex- cellent effects; and externally, poultices composed of bread-crumb and vinegar, or fomentations containing oxycrat, are the means which Beer has found most suc- cessful in the first stage of this form of amaurosis. As in the first stage, a moderate antiphlogistic gene- ral or local treatment is the only one which can be adopted, and which in urgent cases may yet save the patient from blindness, so in the second stage the in- ternal and external employment of fluid stimulants is of great service; for example, naphtha combined with camphor inwardly, liniments to the eyebrow, and the vapours of ether to the eye. The amaurosis produced altogether by the poison of lead, and complicated with lead-colic and ileus, will require, in addition to the fore- going means, such remedies as are known to be of service in these latter disorders,—(Beer, Lehre von den Augenkr. b. 2, p. 499—503,) Symptomatic amaurosis in individuals affected with hysteria, hypochondriasis, epilepsy, and convulsions. This amaurosis is rarely permanent, and usually subsides as soon as the spasmodic, epileptic, or convul- sive attack is over. However, the complaint may be- gin at two periods, viz. either during such an attack, or (what is more uncommon) afterward, and it never loses its symptomatic character. The pupil always remains perfectly clear, and of a shining blackness, even when the disease has induced entire blindness; but a slight dull pain in the forehead, especially about the eyebrow, constantly preceding and accompanying the blindness, generally lasts a good while after the amaurosis has completely subsided. Besides the foregoing general symptoms, the follow- ing characteristic appearances present themselves in hysterical and hypochondriacal patients, who suffer frequent attacks of violent spasm. The pupil is much dilated, and the iris, which is immoveable, seems evi. dently to project in a convexity forwards, when the eye is inspected sidewise; consequently, the anterior chamber js lessened. The eye itself does not move freely in its socket, the patient experiencing an annoy- ing and sometimes a truly painftil sensation, as if the eyeball were forcibly compressed (Ophthalmodynia), Every attempt which the patient himself makes to move the eye, or the surgeon to push it out of the position which it has assumed, is unavailing and excessively painftil. The eyelids are either painfully shut, or in- capable of being shut at all; the eyesight is very weak, but seldom quite impeded; and at the termination of each attack vision returns, though every paroxysm leaves it more and more debilitated, until at length the spasmodic attacks of blindness frequently occurring and lasting a long while, it is entirely lost. But when the disorder has acquired its utmost degree, the eye always still retains the power of discerning the light and it seldom happens that vision is abolished by the first or second attack. It is different with respect to the characteristic phenomena of this amaurosis, in hysterical or hypochondriacal patients, especially when often affected with spasms, before, during, or after which the impairment of sight originates ; for though the pupil may continue quite clear, it cannot escape tho notice of an attentive observer, that, together with a AMAUROSIS. 39 pupil of diminished diameter, there exists a peculiar motion of the iris, a constant fluttering of it between expansion and contraction, technically called hippus pupillae. This convulsive state of the iris is mostly accompanied with a similar affection of the eyelids, namely, with an involuntary blinking (nictitatio), and not unfrequently with an involuntary pendulum-like rolling of the eyeball (nistagmus). In these patients the amaurotic injury of sight hardly ever proceeds di- rectly to complete blindness, but more commonly re- mains as a weakness of vision, characterized during the rest of life by ceaseless oscillations of the eyeball, aversion to light, and frequent sensations as if there were shining fiery objects before the eyes. This case of symptomatic amaurosis is distinguished by an untroubled, but very expanded pupil; considera- ble diminution of the motion of the iris; a dilated state of the pupil, even under the stimulus of the strongest light, and tremulous motions of the eyeball, which con- tinue during life, after the epilepsy and amaurosis are cured; and the case is farther characterized by ambly- opia, which rarely increases to complete blindness. According to Beer, the amaurosis connected with convulsions is most frequent in children. The first and most prominent symptom of this incomplete or complete amaurosis consists in an extremely violent convulsive rotation of the eyeball, especially upwards, not unfrequently attended with the most violent con- vulsive motions of the eyelids. The pupil is exces- sively dilated, and scarcely the least movement of the iris is distinguishable on exposing the eye to the strongest light. When the general twitchings are over, and only an amaurotic weakness of sight is left, stra- bismus occurs in both eyes in various directions, though the eyes very seldom deviate from the axis of vision in the direction towards the inner canthus. When the general convulsions happen frequently, and are violent and of long duration, the amaurotic weakness of sight usually changes into perfect blindness, in which the pupil, though it be regularly clear, and of a shining blackness, is greatly expanded, and the eyes constantly retain their faulty position and pendulum-like motion. With respect to the prognosis, it is observed by Beer, that even when merely an amaurotic weakness remains, the prognosis is always serious; but it is naturally still more unfavourable, when the blindness is complete, and when the loss of sight has suddenly recurred after violent spasmodic, epileptic, or convul- sive attacks, without such attacks themselves ever returning. Under these circumstances, Beer has not hitherto seen more than two instances of such blind- ness partially cured. Generally some hope of recovery may be entertained, when the amblyopia, or even com- plete amaurosis, begins with these attacks, but always terminates with them, without leaving any serious im- pairment of vision. On the contrary, it is a very bad sign, not only in regard to the removal of this symptom- atic amaurosis, but likewise to the cure of the original disease, when the amaurosis invariably precedes these attacks, and lasts a considerable time after their cessa- tion. As yet, Beer says, he has not known any such patients cured, either of their spasms, epilepsy, or con- vulsions, much less of their blindness: on the contrary, after three or four attacks, perfect amaurosis remains, and some of the patients die in one of these paroxysms. As this amaurosis is merely a symptomatic effect of the above general disorders, its removal must entirely depend upon the success with which their treatment is conducted. Were the blindness to continue, however, after the cure of the original disease, the surgeon coidd do nothing more than try an empirical mode of treat- ment, and ascertain what good could be effected with antispasmodic and tonic medicines.—(Beer, Lehre von den Augenkr. b. 2, p. 506—510.) Rheumatic amaurosis. According to Beer, rheumatic amaurosis is not very uncommon, and is so plainly denoted by certain symp- toms, that it cannot well be mistaken ; namely, a per- fectly clear pupil wavers in the mid state between* con- traction and dilatation, the iris seeming to be nearly motionless ; the eyes weep from the slightest causes, and constantly betray more or less aversion to light; the case is invariably attended with wandering, irrita- ting pains, sometimes affecting the eyeball itself, some- times the vicinity of the eye, and in other instances, the teeth or neck. Also when both eyes are affected to- gether, which is not regularly the case, a cast of the eye, which cannot be called actual squinting, may be remarked, and frequently the motion of the eyehall is chiefly obstructed only in one direction, though some- times a true obliquity of the organ exists (luscitas). In nearly every instance there is considerable weak- ness of the levator muscle of the upper eyelid, and not unfrequently a complete blepharoplegia; but total blindness is seldom produced. According to Beer, this amaurosis, which is to be considered as chronic rheumatism, often arises from keeping the head long exposed to the air, and is chiefly met with in individuals who, while sweating profusely from the scalp and brow in warm weather, have taken off their hats, and remained with their heads a long while uncovered. As, however, in warm weather, the generality of persons expose themselves in this man- ner, and few are attacked by amaurosis, I infer that something more is requisite for the production of the disease. Under certain circumstances the prognosis is by no means unfavourable, and Beer mostly succeeded in ef- fecting a perfect cure, when the amaurosis was not completely formed, and not of very long standing, the patient had no tendency to gout, and when during the treatment every thing likely to bring on an attack of that disease was avoided. The treatment consists not simply of local means, which indeed are always needftil, but likewise of ge- neral remedies. With regard to the latter, Beer as- sures us that manifold experience has convinced him of the preference which ought to be given to the extract of guaiacum joined with camphor, and given alternately with the compound powder of ipecacuanha; which remedies, as soon as the wandering pains about tho eye and eyebrow begin to be milder, and more fixed to one part, are to be succeeded by the extract of aconi- tum, antimonial preparations, and flowers of sulphur. Externally, the most powerful operating means are not to be omitted, especially blisters applied successively behind the ears, to the temples, and eyebrows ; and as soon as the pain has completely subsided in these last parts, and is perhaps more concentrated in the eye, frictions are to be made on the eyebrow with liniments, containing at first a moderate quantity of opium, and afterward of the extractum conii. At length, when the pain in and about the eye is nearly subdued, but some degree of amaurotic weakness of sight is left, frictions with naphtha and a small proportion of tinctnra lyttffl and tinctura opii will be found exceedingly beneficial. Afterward, when a considerable time has transpired without the recurrence of the slightest rheumatic pain in the eye, its vicinity, or the head, but the eyesight is not perfectly re-established by perseverance in the above general arid local treatment, and especially when the pa- ralytic affection of the levator of one or other of the upper eyelids continues (as often happens , galvanism maybe tried, with the cautions elsewhere premised.—(See Gutta Serena.) And in the most desperate cases, Beer approves of making an issue in the depression between the angle of the jaw and the mastoid process, and keep- ing it open for a fortnight after the recovery seems complete.—(Lehre von den Augenkr. b. 2, p. 526—529.) Traumatic amaurosis. Beer applies the epithet " traumatic" to such cases of amaurosis as are the consequence of a considerable wound of the eye itself, its surrounding parts, or the skull. Here, consequently, is first arranged the amau- rosis produced by the laceration and stretching of the branches of the frontal nerve from irregular scars about the eyebrow. Secondly, Beer reckons the amaurosis arising from external violence directed in such a degree against the upper or lower side of the orbit, that the retina is torn, and many of the internal softer textures" of the eye forced out of their natural situations, Thirdly, Beer includes every weakness of sight or perr, feet amaurosis, which is the result of such injuries of the eyeball itself as extend to the retina, so as either violently to bruise or lacerate it, or cut or pierce it. For the prognosis and treatment of all these cases, he refers to his observations upon ophf halmy. Nor does he choose here to treat of the perfectly complicated amaurosis, which is a direct consequence of a coup-de-soleil, be- cause it never happens unpreceded by a violent general inflammation of the eyeball, and therefore is to be re- garded as an effect both of the injury and the inflara- 40 AMAUROSIS. mation together; but which, like the symptomatic amaurosis, following common and genuine internal ophthalmy, may be easily known by the total insensi- bility to light, and the evident changes in the texture and shape of the eye; and is quite as incurable as the other example to which we have alluded.—(Lehre von den Augenkr. b, 2, p. 542.) Gouty amaurosis. According to Mr. Travers, gout attacks the eye through the medium of the stomach. Vomiting occurs with pain in that organ, on the subsidence of an in- flammation in the extremities, and is succeeded by vio- lent pain in the head. The loss of sight, he adds, is sudden and permanent.—(Synopsis, &c. p. 163.) The gouty amaurosis described by Beer, is perhaps badly named; at all events, there are some circumstances in Its history which must create doubts on the subject. Gouty amaurosis, he says, has two forms: the first is characterized by a very considerable dilatation and an- gular displacement of the pupillary edge of the iris towards the canthi; a continually increasing slowness in the movements of the iris, and final immobility of this organ; an actual change of colour at both its cir- cles ; a dull, glassy blackness of the pupil, and even a tarnish in the lustre of the cornea; an alternate ap- pearance of the gray and black cloudy substances de- scribed in the account of the general symptoms of amaurosis, which effect lasts while the patient is not totally blind. The disorder is farther indicated by a fleeting, wandering, irritating, yet not very severe pain, all about the vicinity of the eye ; a manifest tendency to a varicose enlargement of the blood-vessels of the conjunctiva and sclerotica; a transient melioration of sight after meals, or any accidental excitement or sti- mulus ; a considerable temporary decrease of it after the operation of any causes which depress the spirits; the excessively slow formation of the disease, for which several years are usually required; and lastly, by the nature of the patient's constitution. For, in general, this amaurosis (if we are to believe Beer) always at- tacks both eyes at once, and is confined to dark-eyed and very irritable, slender, weak, maiden females, who either have suffered from scrofula in their childhood, or from severe acute or chronic diseases at a later pe- riod of their lives; who are not yet far advanced in years; and whose menses have never been very irre- gular though profuse. It is remarked by Beer, that although the second form of gouty amaurosis makes its attack upon males as well as females, the latter, on the whole, are most frequently affected, particularly about the period when the menses cease. This amaurosis, which is seldom formed quickly, that is to say, in a few weeks or months, but mostly requires years for its production, begins yntb cloudy, indistinct vision; an appearance of dif- ferent colours before the eyes; and a peculiar sensation, as if insects were crawling over the skin around the eye. The pupil becomes manifestly dilated, and pre- sents a dull .greenish-gray colour, which, however, is easily distinguished from the colour seen behind the pupil in the amaurotic cat-eye, and plainly depends upon some defect in the vitreous humour (glaucoma). Also the iris, the pupillary edge of which is drawn towards both angles of the eye, as in the first form of the disorder, undergoes an obvious change of colour, first at its less circle, which becomes of an uncom- monly dark hue, and then at its greater circle. The alteration of colour here spoken of certainly proceeds from a general varicose state of the blood-vessels of the eye, which affection daily augmeuts, and is at- tended with vehement pain in the organ and surround- ing parts, or even in the whole head, or one side of it, whether the blindness attack one or both eyes together. This violent pain, however, which is such as often to distract the patient, is unsteady and irregular, being immediately aggravated by every violent mental emo- tion, whether of the exalting or depressing kind, every sudden and considerable change of temperature, every quick accession of wet cold weather, or when the pa- tient stays only for a short time near a very heated fire- place, lies on feather pillows with the affected eye rest- ing upon them, or covered with flannel, or he has been eating any indigestible food. These attacks of pain subside without any medical assistance, in the dry, warm season of the year, and in a mild, not too hot, cli- mate are often kept off for several years. Upon every such attack the glaucoma becomes more evident, the pupil larger and more angular, and the eyesight per- ceptibly weaker. At length, during one of these pain- ful exacerbations, vision is completely abolished, not the least sensibility to light remaining; and the pupil- lary edge of the iris, together with the less circle of the same organ, then entirely disappears, being inverted towards the lens. The cirsophthalmia also gets so much worse, that the sclerotica acquires a smutty, gray- ish-blue colour; and at length the bluish windings of vessels may be noticed at various points, particularly about the place where the tendons of the muscles are affixed. Afterward the green, or what may be more properly called the glaucomatous cataract, is manifestly developed, and the eye then generally wastes under the most violent attacks of pain. The light which the patient always thinks he sees, but which, according to Beer, is produced of a reddish or bluish colour in the interior of the eye, like galvanism, keeps up the hope of recovery; but all consciousness of this luminous appearance ceases as soon as the eye begins to waste. The first degree of gouty amaurosis readily changes to the second, especially in persons who are getting into years, or are near the period of life when menstruation terminates. According to Beer, the apothecary's magazines con- tain no remedies which are adequate to the cure of the first form of this amaurosis. A total change of the whole constitution would be requisite, ere success could be expected, and such change it is not in the power of physic to accomplish. In one single exam- ple Beer succeeded in checking the disease, by per- suading the' patient to observe a strict regimen, not a grain of medicine being given; but the patient still re- mains weak-sighted, though various medicines have latterly been tried. With respect to the treatment of the second form of gouty amaurosis, Beer observes that it should be like that of gouty iritis. In\ particular, attention must be paid to the attacks of pain, and palliative means adopt- ed. The patient should not lie upon feather beds, nor especially feather pillows, but only employ articles of this kind which are stuffed with horse-hair. Neither must he expose himself to an atmosphere which is at the same time both cold and damp; and if he cannot altogether take care of himself in this respect, at all events let him keep his head and feet warm and dry j shun every thing which tends to impede the functions of the skin; and avoid pork-meat, every thing cooked with hogs' lard, and all acid and salt dishes, like her- rings. With what are usually considered as gout me- dicines, the practitioners should act very circumspectly; and, as in gouty iritis, he should pay close attention to the state of the constitution, rather seeking to afford relief by means of a well-regulated diet, than by the employment of much physic. Of the amaurosis occasioned by the sudden cure of cutaneous diseases, and of old ulcers of the leg. When this amaurosis assumes its ordinary form, Beer has not yet been able to remark in it any peculiar Characteristic symptoms by which it can be effectually distinguished from the second form of gouty amaurosis, excepting, first, that it originates and increases very suddenly, while the true arthritic amaurosis is a long time, atid for the most part several years, in forming. Secondly, that at its commencement it is never at- tended with violent pain in the eyes or head. Hence, the diagnosis will depend very materially upon a cor- rect recollection of circumstances. But, according to Beer, there are some cases in which, besides the com- plete blindness, unattended with the slightest power of perceiving light, there is no characteristic symptom, but extraordinary enlargement of the pupil, total im- mobility of the iris, and an inanimate projection of the eye. Respecting the causes of this amaurosis, Beer says that he has nothing important to offer. He owns that, after the sudden cure of certain cutaneous diseases, and of old ulcers of the legs, an amaurotic blindness does not always ensue; and he believes that the reason why the bad effects take place in other organs, some- times the brain, the lungs, or the bowels, Sec, may pro- bably depend upon this or that organ happening to be most predisposed to disease. Here the discerning reader will not require me to point out to him that such a mode of accounting for things is entirel) hypothetical, AMAUROSIS. 41 and destitute of proof: it is indeed so convenient a sort of explanation that it admits of being extended to all diseases without exception. If we are to believe Beer, the prognosis is very uncertain, and in many cases highly unfavourable; first, because an organic part, namely, the optic nerve, is directly affected, which, by the operation of external and internal causes, is soon rendered unfit for the performance of its functions. Secondly, because in the majority of examples impor- tant changes immediately take place in the organiza- tion of the whole eye, which are particularly difficult of removal when the nervous textures are affected. Thirdly, because it is impossible to know whether mor- bid changes may not already exist in the retina or course of the optic nerve. In the treatment, Beer, who places implicit reliance upon the above statement of causes, is an advocate for reproducing as quickly as possible the original disease ; and if that cannot be done, he thinks some artificial disease should be formed in lieu of it. For these pur- poses, he often employs blisters and friction with anti- monial ointment. His treatment, where amaurosis happens to follow the cure of itch, seems very ob- jectionable, as it consists in inoculating the poor patient again with psoric infection, as if it were not more to- lerable to remain blind than live perpetually scourged with the other disorder; for the professor's theory leaves us uninformed of the circumstances under which the patient whose sight is restored by this expedient could ever venture to have a sound skin again without the risk of a fresh attack upon his eyes. But it seems, even from Beer's account, that the patient's subjecting himself to the itch will not always cure his eyes; for, says he, when this method fails, friction with antimo- nial ointment should be tried. When amaurosis follows the healing of old sores, Beer recommends the formation of them again, by applying to the cicatrix strong mustard cataplasms, and the muriate of soda; and if the new ulcers can- not be made to discharge properly, he praises the appli- cation of issues to the calves of the legs, and, in urgent cases, to the thighs. These plans are to be aided by such medicines as act specifically upon the skin, like antimonials, especially the sulphur auratum antimonii. Beer also speaks favourably of sulphur baths; and in cases complicated with debility, administers tonics, particularly the calamus aromaticus and bark.—(See Lehre von den Augenkr. b. 2, p. 556—563.) Of the sympathetic amaurosis in lying in women, from suppression of the secretion of milk. This case is set down by Beer as one of the most uncommon varieties of amaurosis. It comes on rapidly, after sudden stoppage of the secretion and excretion of the milk, with violent headache, concentrated about the forehead and eyebrows; troublesome luminous appear- ances ; an inconsiderable dilatation of the pupil; and scarcely any perceptible irregularity in the pupillary edge of the iris, which is quite motionless, somewhat altered in colour, and swollen. The disease is also accompanied with great aversion to light; a palpable turgescence of all the blood-vessels of the conjunctiva; a slight turbidness of the transparent media of the eye; and, at first, with a mere weakness of sight, which, in the end, suddenly changes into complete amaurotic blindness. The breasts, which before the attack were full of milk, are now empty, and hang down like bags, but are quite free from pain. ■ From the few cases which Beer had seen, he inferred, that the prognosis is always unfavourable when the blindness is complete, and particularly when there is a manifest diseased change in the transparent parts of the eye ; for, in the latter case, he has. known patients remain perfectly blind, though the secretion of milk had been most successfully and expeditiously re-esta- blished. In one instance, the remedies applied to the breast, instead of reproducing the secretion of milk, excited in the part a painftil inflammation and abscess, during which the weakness of sight subsided, though it was very considerable. In considering other analogous cases of amaurosis, enough has already been said concerning tbe first and most important indication, namely, the re-establishment of the action which is obstructed; and here the only question is, about tho manner in which that object can be most expeditiously and safely effected. For, says Boer, it should be distinctly understood, that the pre- vention of a complete amaurotic blindness essentially depends, not only upon the renewal of the secretion from the breasts, but upon this change being made without delay. The remedies which Beer has found most effectual for this purpose are warm poultices applied to the breasts, and at first composed of simple emollients, and afterward of more stimulating ingre- dients, such as hemlock, chamomile flowers, &c. When the breasts have more of a leucophlegmatic appearance, than that indicative of a fulness of the mammary gland, and disposition to a renewal of the milk secre- tion, Beer strengthens these poultices with aromatic herbs, and applies them alternately with well-warmed bags, full of dry aromatic plants, and sprinkled with camphor. These last means are very useful at night, or when the patient is asleep, and fresh warm poultices cannot be put on sufficiently often. In the daytime, the breasts should be frequently and gently rubbed with warm flannels, medicaud with olibanum and mastic. This plan is to be followed up until the secretion and excretion of milk are renewed, and the amaurotic amblyopia has subsided. When the secretion either cannot be restored by the foregoing means, or the eyesight does not return with the re-established secretion, internal remedies must be tried, especially arnica, joined with calomel and camphor. Issuen or setons should also be formed, and kept open for a con- siderable time.—(Lehre von den Augenkr. b. 2, p. 572 —575.) Of the symptomatic amaurosis from morbid changes, either in the optic nerves and their sheaths, or in the bones of the cranium, or the brain itself. Beer says, a very considerable number of cases of this form of amaurosis, which have fallen under his notice, have enabled him, as it were, not only to know it at once, but to describe its exact symptoms.—1st. Its formation is constantly very slow, and in all cases the patient is not only completely deprived of vision, but, for more or less time previously to his death, rendered quite incapable of distinguishing light. 2dly. A second peculiar symptom of this amaurosis consists in morbid changes in the structure of the eye, which are at first scarcely perceptible, and increase very slowly. 3dly. The amaurosis either originates during an attack of violent headache, which continues almost uninterrupt- edly until death, or the headache does not come on until complete blindness has taken place; or the patient may have no pain whatever either in his eyes or head. 4thly. Ih the progress of this amaurosis, objects inva- riably seem to the patient to be perverted, disfigured, &c. Symptoms when the disorder proceeds from disease of the optic nerves or their sheaths. This case comes on slowly, and rarely attacks both eyes together. It always commences with a black cloud, which grows more and more dense, and with a troublesome, alarming perversion and disfigurement of every object, without the least painful sensation in the eye or head. The patient merely complains of a slight sensation of dull pressure at the,bOttom of the orbit, as if the eyeball were about to be forced from its socket, of which displacement, however, there is not yet the smallest appearance. In the very beginning of the disease, the pupil is already considerably dilated, and the pupillary edge of the motionless iris presents angles at several points, the pupil sometimes representing an irregular pentagon or hexagon. By degrees, though very slowly, a glaucomatous change of the vitreous humour ensues, and afterward of the lens itself; the only species of glaucoma which Beer has ever noticed quite unattended with a varicose affection of the blood- vessels of the eye. At last, the globe of the eye becomes perceptibly smaller than natural; but a com- plete atrophy does not ensue. Symptoms when the case proceeds from disease of the skull or brain. In this form of amaurosis, which usually attacks both eyes together, or at least one very soon after the other, the blindness also commences very slowly, with appearances as if every object looked at wereperverted or disfigured. However, there is no black cloud, but rather an obscurity or confusion of every object. The disease in this stage is also accompanied with frequent giddiness, ugly luminous spectra, and, for the most part, 42 AMAUROSIS. with aversion to light, uncommonly lively motions of the iris, a contracted pupil, angles in the upper and lower portions of the pupillary margin of the iris; an evident turgescence of the blood-vessels of the eye, gradually augmenting with most violent headache into actual cirsophthalmia; frequent convulsive motions of the eyes and eyelids, and strabismus of one or both eyes, ending in a true deviation of one or both of these organs from their natural positions. Under these symp- toms, vision is afterward entirely abolished; and the headache, though subject to remissions, grows so much worse, extending back to the spine, that the patient is often nearly frantic, and, indeed, after a time, a de- struction of the external senses happens, followed by that of the intellectual faculties. The first of the ex- ternal senses which is lost is always the hearing, which infirmity is next followed by loss of the smell, or taste, or both these senses together; and then the memory and other intellectual powers decline. In this stage of the disorder, the eyeball not unfrequently pro- trudes from the orbit, a pathognomonic symptom, to which Beer attaches great importance, because it is an infallible criterion of a diseased state of the bones of the orbit, of the parts which invest this cavity, and of the optic nerve and dura mater, in the sella turcica. In such cases, complete mania now usually follows, and this sometimes in its most violeiit form, unless the patient happen to be first carried off>by paralytic symp- toms; life, under these circumstances, never lasting any considerable time. As far as our external senses can discover, the cause of both these forms of amaurosis, as the title of this section specifies, lies in certain morbid changes in the structure of the optic nerve^nd its investments, or in diseased alterations of the" bones of the cranium, the dura mater, and the brain. But how these changes arise, is not so easy of explanation. The morbid changes m the structures above mentioned, which Beer had himself ascertained by dissection, consist in a real induration of the optic nerves, and an adhesion of them to their sheaths, while within the skull these ash-co- loured, gray, very much diminished nerves presented no vestige of medullary structure even as far as their origin from the brain. On the contrary, the optic tha- lamus presented externally its natural appearance. The retina seemed to have lost its pulpy matter, was tough, not easily torn, and appeared to consist but of a vascular membrane. In one example, although both eyes had been completely deprived of sight together, Beer found only the retina and optic nerve of the left side in this state of atrophy as far forwards as the point of union in the sella turcica. On the other hand, the optic nerve of the right eye was hard, without being in the least dwindled, and was closely adherent to its ex- ternal coverings. Anteriorly to their decussation, nothing at all preternatural in either nerve could be discerned. But the left corpus striatum was so indu- rated, that a very sharp, strong scalpel was required for its division, though in colour and shape it was per- fectly natural. On this side, also, the plexus choroides was entirely wanting. In three amaurotic patients of this kind, Beer found hydatids between the coverings of the optic nerve, and where such hydatids lay, the medullary matter seemed to have been displaced by their pressure. With the utmost care, he could not trace the ophthalmic ganglion. Paw also found in the optic nerve a large hydatid, which had produced amaurosis.—(Obs. Anat. Rarior. Obs. 2.) In Mr. Heaviside's museum, there is a prepa- ration Gf the optic nerve of an amaurotic eye, where a tumour of considerable bulk has grown from the neu- rilema.—(See Wardrop's Essays on the Morbid Ana- tomy of the Human Eye, vol. 2, p. 157.) In this work are specified examples of various other morbid changes of the optic nerve, especially calculous concretions within it, the presence of a viscid, maddy, gray fluid in the thickened neurilema, instead of pulp, a dwindling of the nerve, &c. To the present description of cases, Beer refers the instance recorded by Haller (Opusc. Pathol. Obs. 65, p. 1721, in which a calcareous mass was found between the membrane of Ruysch and the vitreous humour. According to Beer, there is preserved in the patholo- gical and anatomical museum of the general hospital at Vienna, an eye, distended with a similar osseous mass, without the capsule of the lens being at all affected. Examples, in which the amaurotic blindness arose from abscesses in the brain, are reported by Bal- lonius (Paradigmata Hist. 7 , by Pelargus (Med. Jahrg. 3, p. 198 , Peyronie (Mem. de l'Acad. Royale de Chir. 1, p. 212), Schaarschmid (Berlin Nachrichte, 1740. No. 26;, Langenbeck 'Neue Bibl. 1, p. 61), and Mr. Travers (Synopsis, p. 143). The latter author has recorded an instance in which a firm lardaccous tumour, of the size of a garden bean, situated on the same side as the blindness, compressed the optic gan- glion and nerve at its origin from it.—(Synopsis, p. 151.) I have seen a case of amaurosis, in which a tumour as large as a middling-sized apple was found in the anterior lobe of the brain, attended with protrusion of the eye, and vast destruction of the bones. Mr. Travers has seen amaurosis produced by a medullary fungus of the brain. A case, occasioned by disease of the thalamus, is related by Villeneuve (Journ. de Med. continue, 1811, Fevr. p. 98); another, of a tumour of the thalamus on the same side as the blindness, is recorded by Ford (Med. Commun. vol. 1, No. 4); and other swellings in various parts of the brain are de- scribed in Ephem. Nat. Cur. Dec. 3, Ann. 9, and 10, Obs. 253; De Haen's Ratio Medendi, P. 6, p. 271; Journ. des Savans, 1697; Muzell's Wahrnehm. 2, No. 13 ; Plater, Obs. lib. 1, p 108; Thomann, Annalen fur 1800, p. 400, &c. On this part of the subject, I beg leave to refer also particularly to my friend Mr. Wardrop's valuahle Essays on the Morbid Anatomy of the Human Eye, vol. 2, p. 174, &c. The morbid alterations of the bones of the cavity of the skull mostly happen at its basis, and not only may caries take place, but still more frequently exostoses of various forms, which are sometimes so small that they are first detected by the bone giving tbe feel of a rough grater. At 'the same time they are so sharp, that if the finger be passed rudely over them, it will be painfully hurt. In these cases the bones of the cavity of the skull are always found extremely thin; the diploe is almost entirely wanting, and the parietes of the orbit are preternaturally diaphanous, and in some places imperfect. Beer speaks of a lady's skull who had been completely blind, and for some weeks previously to her death insensible, in which instance scarcely any part of the cavity of the skull could be carelessly touched without risk of scratching the fingers with spiculae. Once in an amaurotic boy, who for a short time before his death was so insane that he used to de- vour his own excrement, Beer found at the side of the sella turcica a long considerable spicula, which passed directly through the optic nerves at the place of their decussation. A case of amaurosis produced by a spi- cula of bone injuring the opposite side of the brain is related by Anderson.—' See Trans, of the Society of Edinb. vol. 2.) Sometimes the ethmoid bone has been found carious (Ballonius, Paradigmata, No. 7); some- times other parts of the cranium.—(Mursinna, Beobacht. 1, No. 6; Schmucker, Vermischte Schrift. 2, p. 12.) Nor is it unfrequent to find the medullary substance of the brain itself as soft as pap, while the cortical sub- stance is full of blood-vessels, and unusually firm, the convolutions being hardly distinguishable. Many of the causes of amaurosis are of such a na- ture as to render the disease totally incurable. Of this description is fungus hsematodes, in which the struc- ture of the retina and optic nerve is changed in a re- markable manner, the whole cavity of the eyeball be- coming filled with a substance resembling medullary matter, and the optic nerve changed in its form, colour, and structure.—(See Wardrop's Essays on the Morbid Anatomy of the Human Eye, vol. 2, p. 156, 8vo. Lond. 1818.) On the authority of Ecker, one case is upon record, Where the cause of amaurosis depended upon an aneu- rism of the central artery of the retina.—(Pinel, Noso- graphie Philos. vol. 2, p. 122.) In another instance the macula lutea, which is natu- rally a yellow spot near the centre of the retina, was iuund black.—(Mem. de la Societe Med. d'Emulation an 1798.) Bonetus, in his Sepulchretum Anatomicum, lib. 1, sect. 18, describes various cases which were quite in- curable : after death the blindness in one instance was found to be occasioned by an encysted tumour, weigh- ing fourteen drachms, situated in the substance of the cerebrum, and pressing on the optic nerves near their origin. In the second, the blindness vipa produced by a cyst containing water and lodged on the optic nerves AMA AMP 43 where they unite. In the third, it arose from a caries of the os frontis, and a consequent alteration in the figure of the optic foramina. In a fourth, the cause of the disease was a malformation of the optic nerves themselves. In some of the instances in which no apparent alteration can be discovered in the optic nerve, the late Mr. Ware conjectured that a dilatation of the anterior portion of the circulus arteriosus may be the cause of the affection. The circulus arteriosus is an arterial circle, surrounding the sella turcica, formed by the carotid arteries on each side, branches passing from them to meet each other before, and other branches passing backwards to meet branches from the basilary artery behind. The anterior part of the circulus arte- riosus lies directly over, crosses, and is in contact with the optic nerves, and just in the same way as the ante- rior branches lie over the optic nerves, the posterior ones lie over the nervi motores oculorum. Hence Mr. Ware attempted to refer the amaurosis itself, and the paralytic affection of the eyelids and muscles of the eye, sometimes attendant on the complaint, to a dilata- tion of the anterior and posterior branches of the circu- lus arteriosus. The frequently diseased state of the trunk or small branches of the carotid arteries at the side of the sella turcica is noticed by Dr. Baillie in his useful work on Morbid Anatomy, and, he says, the same sort of diseased structure is also found in the ba- silary artery and its branches.—,See Ware's Chir. Obs. on the Eye.) In 1826, M. Magendie related to the French Academy of Sciences various facts exemplifying the remarkable inrluenceof the fifth nerves over all the senses; and with respect to the sense of sight, he finds that the action of the eyeball and optic nerve cease immediately they are completely deprived of the influence of those nerves. Thus a state of the eye is produced that has the greatest analogy to amaurosis. Indeed, when the fifth nerves are divided in an animal, it is instantly bereft of sight on the side on which the nerve has been cut, notwith- standing the eye retains at the moment all the physical conditions necessary for vision It is not to be sup- posed, however, that the fifth nerves perform the func- tion usually referred to the optic ones. To perceive the light, and to see, as Magendie remarks, are, expe- rimentally speaking, two different things. An animal whose fifth nerves have been divided does not see, neither is it conscious of the daylight or of the strongest artificial light; yet it decidedly perceives the impression of the rays of the sun when they fall directly on the eye. Hence a healthy, sound condition of the optic nerve on the one part, and of the fifth nerve on the other, is essential to perfect vision; and M. Magendie therefore deems it highly probable that there are two kinds of amaurosis, one depending on a particular affection of the optic nerve and retina; the other on disease of the fifth nerve, and the defect of its influence on the organ of vision. These reflections led him to make trial of a combination of acupuncture and galvanism for the cure of certain cases of amaurosis. Thus in one case, having introduced one needle into the frontal nerve, and another into the upper maxillary, he brought the needles into repeated contact with the two poles of a Voltaic pile. lu a fortnight the patient had received considerable benefit from the plan. Other facts are also recorded in favour of this treatment.—(See Journ. Exper. de Physiol, t. 6, p. 156 et seq.) Vy. Heister, Apologia et uberior Illustratio Systema- tissuidr Cataractd,Glaucomati:,etAmanrosi,VZino.Al- torf. 1717. J.B. G, (Ehme,deAmaurosi,4to. Lips.1748, in Hidleri Disp. Chir. 2, 265. Jos. Warner, Descrip- tion of Human Eye, and Diseases, 8oo. Lond. 1754. Trnka de Krzowitz, Historia Amauroseos, 8vo. Vin- dob. 1781. Gius. Flajani, Collezione a" Osservaz. H-c. t. 4, p. 173, 187, 8vo. Roma, 1803. D. G. Kieser, Ucberdiejfatur, Ursachen, Kennze.ichenund Heilung des schwarie Staars, 8vo. GUtt, 1811. Langenbeck, JVcue Bibl. fiir die Chirurgie, b. 1, Hanover, 1815. ./. Beer, Lehre von den Augenkrankheiten, b. 2, 8oo. Wien, 1817. James Wardrop, Essays on the Morbid Anatomy of the Human Eye, vol. 2, Hi»o. jLonrf. 1818. The two latter bonks are works of the highest merit; and as vie have no translation of the first, I have thrown a good deal of the information which it con tains on amaurosis, into the present edition. B.A. Winkle, De Amaurosi, 12mo. Berol. 1818. Ver- mischte Cliirurgische Schriften von J. L. Schmucker, b. 2, Berlin, ed. 2, 1736. Remarks on Ophthalmy, Sc. hy James Ware. Inquiry into the causes preventing success in the extraction of the Cataract, ire. by the same. Osservazinni sulle Malatlie degli Occhi di A. Scarpa, Venez. 1802. This book has gone through many editions in Italy. The last, which is much im- proved, has been well translated by Mr. Briggs. W. Hey, in Practical Observations in Surgery, and Med. Obs. and Inquiries, vol. 5. Schmucker's Wahrneh- mungen, b. 1, p. 273. Richter's Anfangsgrunde der Wundarzneykunsl, b. 3. Frick on the Diseases of the Eye, by We.lbank, 8no. Lond.ed. 2, 1826. Some scat- tered remarks in the posthumous work on the Diseases of the Eye, of the late J. C. Saunders, &-c. De Wen- zel, Manuel de V Oculiste, ou Dictionaire Ophthalmolo- gique, 8vo. Paris, 1808. J. Stevenson, On the Nature, &c, of the different Species of Amaurosis, 8ve. 1821. B. Traoers's Synopsis of the Diseases of the Eye, Src. 8vo. Lond. 182%). Also Lawrence's lectures on Dis- eases of the Eye, the republication of which in a sepa- rate form, with references to the best works and autho- rities, would make one of the most useful books on the subject. Many additional observations, connected with the subject of amaurosis, will be found in the articles Cata- ract, Diplopia, Fungus Haematodes, Gutta Serena, He- meralopia, Hemiopia, Nyctalopia, Sight, Defects of, Sec. AMBE. (From ap6n, the projecting edge of a rock.) An old chirurgical machine for reducing dislocations of the shoulder, and so called because its extremity projects like the prominence of a rock. Its invention is referred to Hippocrates. The ambe is the most ancient mechanical contrivance for the above purpose; but it is not at present employed. Indeed, it is scarcely to be met with in the richest cabinets of surgical appara- tus. It is composed of a piece of wood, rising vertically from a pedestal. With the vertical piece is articulated, after the manner of a hinge, a horizontal piece, wdth a gutter formed in it, in which the luxated limb is laid and secured with straps. The patient places himself on one side of the machine; his arm is extended in the gutter and secured; the angle formed by the union of the ascending piece and by the horizontal branch is lodged in the armpit, and then the horizontal branch is depressed. In this way extension is made, while the ver- tical part makes counter-extension, and its superior part tends to force the head of the humerus into the articular cavity. But there is nothing to fix the sca- pula, and the compression made by the superior por- tion of the vertical piece of the machine tends to force the head of the humerus into the glenoid cavity, before it is well disengaged by the extension.—(See Boyer on Diseases of the Bones, vol. 2.) AMBLYOPIA. (From au6~\v<, dull, and <*ty, the eye.) Hippocrates means by this word, in his Aph, 31, Sect. 3, the dimness of sight to which old people are subject. Modern writers generally understand by am- blyopia incomplete amaurosis, or the weakness of sight attending certain stages and forms of this disorder. AMMONITE MURIAS. AMMONIA MURIATA. Sal ammoniac. Its chief use in surgery.is as an external discutient application.—(See Lotio Amnion. Muriata cum Aceto.) Mr. Justamond recommends the following applica- tion to milk abscesses : R. Ammonise muriatae 5 j. Spiritus roris marini Ibj. Misce. Linen rags are to be wet with the remedy, and kept continually applied to the part affected. There can be little doubt of the utility of this lotion in dispersing the induration left after mammary ab- scesses ; but while these cases are accompanied with much pain, tension, and inflammation, emollient foment- ations and poultices are to be preferred. If muriate of ammonia be mixed with its weight of powdered nitre, and dissolved in six or eight parts of water, it produces a very cold lotion, which may be used as a substitute for ice in cases of strangulated hernia. AMPUTATION. The operation of cutting off a limb, or other part of the body, as the breast, penis, &c. Such an operation frequently becomes indispensably proper, on the principle of sacrificing a branch, as it were, for the sake of taking the only rational chance of saving the trunk itself. Indeed the suggestion of this measure, in cases of mortification, where there is no chance of the parts recovering, may be said to be derived from nature herself, who, by a process to which I shall advert in speaking of mortification, detaches 44 AMPUT the dead from the living parts; this separation is fol- lowed by cicatrization, and the patient recovers. The necessity for amputation has always existed, and ever will continue, as long as the destructive effects of injuries and diseases of the limbs cannot be obviated in any other manner. As Graefe observes, there was once a period (I should say, about forty years ago) when the operation was more frequently practised than at present, and this fact is to be imputed less to the caprice of surgeons than to the imperfection of the means which used to be employed for the relief of local diseases. For then aueurisms of the limbs, and some other cases, at present treated with success, were al- ways deemed incurable without amputation. Boucher, Gervaise, Faure, and Bilguer inveighed against the frequent performance of amputation on the field of bat- tle ; yet their arguments must prove of little value; unless a path were at the same time traced which would conduct us to the method of remedying the cir- cumstances which form the necessity for the operation. When this condition is fulfill d, and more effectual modes of treatment are devised, as- for instance with respect to the gun-shot wounds specified by Bilguer, then the necessity for amputation in such cases would cease of itself.—(Normen fur die Ablosung grosserer Gliedmassen, p. 13, 4to. Berlin, 1812.) As the author of another valuable modern work has said, it is an excellent observation, founded on the purest humanity, and justified by the soundest profes- sional principles, that to save one limb is infinitely more honourable to the surgeon, than to have per- formed numerous amputations, however successful; but it is a remark, notwithstanding its quaintness, fully as true, that it is much better for a man " to live with three limbs, than to die with four."— (Hennen on Mili- tary Surgery,p.251, ed. 2.) To this saying should be added the reflection, that some unfortunate beings, influenced by a relish for life, have been known to submit to the loss of all their legs and arms, and yet recover. In the H6tel des In- valides at Paris, mutilated objects are in recollection, who had lost all their thighs and arms, so that, unless assisted, they could not stir, and it was necessary to feed and wait upon them like new-bom infants—(Mo- rand, Opusc. de Chir. p. 183, and Graefe, op. cit. p. 23.) The amputation of the large limbs was anciently practised under many disadvantages. The best way of making the incisions was unknown; the ignorance of the old surgeons about the right method of stopping hemorrhage was the death of a large proportion of the patients who had courage to submit to the operation; Jhemode of healing the wound by the first intention was not understood, or not duly appreciated; and the instruments were as awkward and clumsy, as the dressings were irritating and improper. Modern practitioners have materially simplified all the chief operations in surgery; an object which has been accomplished not merely by letting anatomical science be the main guide of their proceedings; not simply by devising more judicious and less painful methods; not only by diminishing ihe number, and improving the construction, of instruments; but also, in a very essential degree, by abandoning the use of a multitude of external applications, most of which were useless or hurtful. The Greek, Roman, and Arabian practitidners ampu- tated limbs with feelings of alarm, and, in general, with the most melancholy results; while modern sur- geons proceed to the operation completely fearless, well knowing that it mostly proves successful: hence, as Graefe justly remarks, nothing can.be more evident, than that the patient's safety must depend very much upon the kind of practice.—(See Normen for die Abld- sung grosserer Gliedmassen, p. 1.) By practice is here implied the mode in which the operation is per- formed, the way in which the wound is dressed, and the whole of the after-treatment. But, much improved as amputation has been, it can- not be dissembled, that it is an operation at once terri- ble to bear, dreadful to behold, and sometimes severe and fatal in the consequences which it itself produces, while the patient, if saved, is left for ever afterward in a crippled, mutilated state. Hence it is the surgeon's duty never to have recourse to so serious a proceeding without a perfect and well-grounded conviction of its necessity. Amputation should be generally regarded as the la3t expedient to which a surgeon ought to re- sort ; an expedient justifiable, as a late writer says, only when the part is either already gangrenous, or the seat of so much injury or disease, that the attempt to preserve it any longer, would expose the patient's life to the greatest danger.—(Diet, des Sciences Med. t. 1, p. 472.) Although, says a distinguished modern surgeon, this amounts to a confession, that the cure of some local disorders is not within the limits of our art, yet, on the other hand, it furnishes a proof, that surgery may be the means of saving life under circumstances which, without its assistance, would infallibly have a fatal termination. Tbe operation is adopted as the safest measure: the cause is removed for the prevention of consequences.—(Graefe, op. cit. p. 14.) Nothing can be more absurd or more misapplied, than (he censures sometimes passed upon amputation, because the body is mutilated by it, Sec. Although, as a modern writer remarks, the objection proves the limitation of human knowledge and ability, it must be very unfair on this account to throw blame on surgery, or the practitioner who thus saves the patient's life. For, without dwelling upon the fact, that a humane surgeon would never amputate through a mere love of operating, and without urgent cause, one may simply ask, are all diseases in their nature curable 1 Does not the surgeon cure such as are curable without mutila- tion 1 And are not cases, which were in the begin- ning remediable, often first brought to the surgeon when, from neglect, they have become totally incu- rable ] Is it not his duty then to employ the only means left for saving the patient ? And is not the preserva- tion of a long and healthy life a compensation for the sacrifice ? Would it not be just as reasonable to blame an architect, when the irresistible force of lightning or a bomb destroys his building ? Indeed, is it not rather a greater honour to surgery, that even when death has already taken possession as it were, of a part, and is threatening inevitable destruction to the whole, a means is yet furnished, not only of saving the patient's life, but of bringing him into a state in which he may recover his former good health?—(Briinninghausen, Erfahrungen und Bemerkungen iiber die Amputation, p. 11, 12mo. Bamberg, 1818.) Though amputation is in every respect much better than in former times, and its right performance is by no means difficult, I would not wish to be thought to say, that it is always, or even usually done secundum artem, because long opportunities of observation have convinced me of the contrary; and the reason of the knife being yet so badly handled in this part of sur- gery, may generally be imputed to carelessness, slo- venly habits, or, what is as bad, a want of ordinary dexterity. There are several egregious faults in the method of amputating, which even many hospital sur- geons in this metropolis are guilty of; but these we shall find, when we criticise them, are for the most part easily avoidable, without any particular share of skill being required. A greater difficulty is to ascer- tain with precision the cases which demand the opera- tion, those in which it may be dispensed writh, and the exact periods at which it should be practised. These are considerations requiring profound attention, and the brightest talents. The most expert operator (as Mr. O'ftalloran observes; may not always be the best surgeon. To do justice to the sick and ourselves, we must, in many cases, rather avoid than perform capital operations; and with respect to amputation, if we consider the many cases in which it has been unneces- sarily undertaken, or done at unseasonable periods, it may be suspected, that this operation, upon the whole, may have done more mischief than good. At all events, it is not enough for a surgeon to know how to operate; he must also know when to do it.—(See O'Halloran on Gangrene and Sphacelus: preface.) For such reasons I shall first take a view of the cir- cumstances under which the best surgeons deem am- putation necessary; though it may be proper to ob- serve, that in each of the articles relative to the parti- ■ cular diseases and injuries which ever call for the ope- ration, additional information will be offered. 1. Compound fractures. In a compound fracture the necessity for amputation is not altogether proportioned to the seriousness of the accident, but also frequently depends in part upon ' other circumstances. For example, in the field, and AMPUTATION. 45 on board of a crowded ship, it is not constantly in the surgeon's power to pay such attention as the cases de- mand, nor to procure for the patient the proper degree of rest and good accommodation. In the field, there is often a necessity for transporting the wounded from one place to another. Under these circumstances it is proper to have immediate recourse to amputation, in numerous cases of bad compound fractures, some of which, perhaps, might not absolutely demand the ope- ration, were the patients so situated, as to be capable of receiving all the advantages of the best and most scientific treatment in a well-ventilated quiet house or hospital, furnished with every desirable convenience. At the same time, daily experience proves, that there are many other cases, in which it would be improper to have recourse to the knife, even under the most un- favourable circumstances of the above description. So, when a compound fracture occurs, in which the soft parts have not been considerably injured; in which the bones have been broken in such a direction that they can be easily set and kept in their proper position, or in which there is only one bone broken, amputation would be unnecessary and cruel. But when the soft parts have been more extensively hurt, and the bones have been so badly broken, that perfect quietude and incessant care are required to afford any chance of re- covery, it is a good general rule to amputate whenever these advantages cannot be obtained. The bad air in crowded hospitals and large cities, a circumstance so detrimental to wounds in general, is another consideration which may seriously lessen the chances of saving a badly broken limb, and should be remembered in weighing the reasons for and against amputation. On this part of the subject, I find the sentiments of Graefe interesting: besides an absolute, says he, there is a relative, necessity for amputation: it is the most mournful, and proceeds altogether from unfavourable external circumstances, though, alas! in many cases nearly unavoidable, when life is to be preserved. In war, every bloody action furnishes proof of what has been stated. The number of the woundedis immense; the number of surgeons for the duty too limited. The supplies most needed are at a distance. In these emer- gencies, though the military surgeon may, from routine and genius, be able to suggest the quickest method of _ obtaining what is wanted, know how to avail himself of every advantage which circumstances permit, and contrive tolerable substitutes for such things as are de- ficient, yet this will not always do. Were we (says Graefe) here to complain of the government not pro- viding due assistance for the defenders of our native soil, to many the remonstrance would only appear rea- sonable. Yet they who manage the medical affairs of the Prussian army may not constantly have it in their power to avert the inconvenience. The general cannot loretel the number and nature of the wounds which may happen, so as to enable the medical department to take with them exactly the apparatus required, without encumbering the army with a redundance of useless articles. The enemy, perhaps, captures the medical stores, or the rapid movements of particular corps cut us off from tho principal depdts. Detachments often skirmish at remote points. The hospitals may lie se- veral miles in the rear of the line; and, for want of means, the transport of the imperfectly-dressed wounded may continue night and day. Hardly are the sufferers brought into the nearest hospital, in the most pitiful state from pain, anxiety, and cold, when an order is given to break up, and they must be conveyed still far- ther towards their grave; and a thousand other circum- stances, as Graefe observes, which deprive the wounded of the requisite attendance, and essential, number of surgeons, together with the most necessary stores, make it desirable to simplify every wound as much as possible ; which, indeed, is the only means of shunning the reproach, that, while we are endeavouring to save one man's limb, we let another die. Who doubts, says Graefe, that a soldier with a gun- shot wound, complicated with a smashed state of the bones, may sometimes be saved, without loss of his limb, by employing all the means which the resources of surgery offer ? But these very resources are often wanting in a campaign; and the business of dressing the patient would occupy the surgeon several hours daily, during which his useful assistance could not be extended to other sufferers. Notwithstanding the ut- most care, the removal of patients from one place to another frequently makes their wounds extremely dan- gerous, or fatal; and we now lose many a man, who, had he undergone amputation, would have been able to bear the journey.—(See Normen for die Ablosung grosserer Gliedmassen, p. 15,16.) From what I have seen of the ill effects of moving patients with bad compound fractures of the lower ex- tremity, produced by gun-shot violence, I am convinced that, as a general rule, it is better to perform amputa- tion ; but if this be not done, and an attempt is to be made to save the member, it will be more humane, when the army is retreating, and the enemy are not savages, to leave such wounded behind, than subject them to all the fatal mischief of hastily and roughly transporting them in such a condition. It gives me particular pleasure to find the preceding sentiment con- firmed by Dr. Hennen, whose knowledge and experi- ence in military surgery entitle all his opinions to the greatest attention : in noticing what ought to be done with the wounded, when the army is compelled to re- treat, he says, " it then becomes the duty of a certain proportion of the hospital staff to devote themselves for their wounded, and become prisoners of war along with them; and it may be an encouragement to the iif- experienoed, while it is grateful to me, to observe, that I have never witnessed, nor traced, on inquiry, an act of unnecessary severity practised either by the French or English armies on their wounded prisoners." Compound fractures of the thigh, produced by gun- shot violence, too often have an unfavourable termina- tion, especially when the accident has been caused by grape-shot or even a musket-ball, fired from a mode- rate distance, and the patient is moved from one place to another after the receipt of the injury. In the mili- tary hospital at Oudenbosch, in the spring of 1814,1 had charge of about eight bad compound fractures of the thigh, of which cases only one escaped a fatal ter- mination. This was an instance in which the femur was broken a little way above the knee. Another pa- tient was extricated by amputation from the perils immediately arising from the splintered displaced state of the bone, the serious injury of the muscles, and enormous abscesses, but was unfortunately lost by se- condary hemorrhage. All these patients had not merely been struck by grape-shot, or else by balls fired from a short distance, but they had been moved from Bergen-op-Zoom into my hospital five or six days after the receipt of the injury, the very worst period possible on account of the inflammation being then most vio- lent. From the ill success of these cases; many a sur- geon who saw them might be inclined to think that immediate amputation ought generally to be performed for all compound fractures of the thigh as soon after the receipt of the injury as possible. And such is my own sentiment, whenever the accident has been caused in the violent manner above specified, or when- ever the patient must be moved any distance in a wa- gon after the occurrence of the injury. It may be right to state, however, that I have known more than one compound flracture of the thigh cured, where the acci- dent had not been occasioned by gun-shot violence, and I have been informed of one or two successful cases where the bone was broken by a pistol-ball. In St- Bartholomew's hospital, two compound fractures of the thigh were pointed out to me some time ago, as= cases hkely to end favourably. However, these may only have been lucky escapes, deviations from what is common, and not entitled to any stress, with the view of affecting the general excellent rule of amputating where the thigh-bone is broken by gun-shot violence. As Mr. Guthrie has accurately observed, one circum- stance which increases the danger of fractures of the femur from gun-shot violence is, that the bone is very often broken obliquely, the fracture extending far above' and below the point immediately struck by the ball.— (On Gun-shot Wounds, p. 189, 190.) This disposition of the thigh-bone to be splintered for several inches when hit by a ball, and the increased danger arising from the occurrence, are also very particularly com- mented upon by the experienced Schmucker, who was surgeon-general to the Prussian armies in the cam- paigns of Frederick the Great.—(See his Vermischte Chirurgische Schnften, b. 1, p. 39, 8vo. Berlin, 1785.) In several of the cases under the care of Dr. Cole and- myself in Holland, the bone was split longitudinally to the extent of seven or eight inches. 46 AMPUTATION. According to Schmucker, all fractures of the middle or upper part of the femur are attended with great danger. " But ksays he) if the fracture be situated at the lowest part of the bone, the risk is considerably less, the muscles here not being so powerful; in such a case, therefore, amputation should not be performed before every other means has been fairly tried; and very frequently I have treated fractures of this kind with success, though the limb sometimes continued stiff. But ^says Schmucker) if the bone be completely fractured or splintered by a ball at its middle, or above that point, I never wait for the bad symptoms to commence, bat amputate ere they originate; and when the operation has been done early enough, most of my patients have been saved. However, when some days had transpired, and inflammation, swelling, and fever had come on, I must candidly confess that the issue was not always fortunate. Yet the operation should not on this account be dispensed with; for if only a few can thus be saved out of many, some benefit is ob- tained, as, without this step, such few would also pe- rish."— Vermischte Chir. Schriften, b. 1, p. 42.) What I saw of compound fractures of the thigh, after the as- sault on Bergen-op-Zoom, we may remark, coincides with the results of Schmucker's ample experience; for the only two patients who survived the bad symptoms proceeding directly from the fracture were, one whose femur was broken near the knee, and another whose limb I took .off on account of a fracture of the middle of the bone, accompanied with abscesses of surprising extent. The latter was a case, however, in which the limb ought to have been removed earlier. The follow- ing remarks, by Mr. Guthrie, I consider judicious and correct. " The danger and difficulty of cure attendant on frac- tures of the femur from gun-shot wounds, depend much on the part of the bone injured; and in the considera- tion of these circumstances it will be useful to divide it into five parts. Of these, the head and neck in- cluded in the capsular ligament, may be considered the first; the body of the bone, which may be divided into three parts, and the spongy portion of the lower end of the bone exterior to the capsular ligament, form- ing the fifth part. Of these, the fractures of the first kind are, I believe, always ultimately fatal, although life may be prolonged for some time. The upper third of the body of the bone, if badly fractured, generally causes death at the end of six or eight weeks of acute suffering. I have seen few escape, and then not with a useful limb that had been badly fractured in the mid- dle part. Fractures of the lower or fifth division are in the next degree dangerous, as they generally affect the joint; and the least dangerous are fractures of the lower third of the body of the bone. Of these even I do not mean to concealj that when there is much shat- tered bone the danger is great, so that a fractured thigh by gun-shot, even without particular injury of the soft parts, is one of the most dangerous kinds of wounds that can occur."—(See Guthrie on Gun-shot Wounds, p. 190.) In compound fractures, as Mr. Pott has correctly pointed out, there are three points of time when ampu- tation may be proper. The first of these is immedi- ately or as soon as possible after the receipt of the in- jury. The second is, when the bones continue for a great length of time without any disposition to unite, and the discharge from the wound has been so long and is so large that the patient's strength fails, and general symptoms foreboding dissolution come on. The third is, when a mortification has taken such complete pos- session of the soft parts of the inferior portion of the limb quite down to the bone, that upon the separation of such parts the bone or bones shall be left bare in the interspace, The first and second of these arc matters of very se- rious consideration. The third hardly requires any. When a compound fracture is caused by the pas- sage of a very heavy body over a limb, such, for in- stance, as the broad wheel of a wagon or loaded cart, or by the fall of a very ponderous body on it, or by a can- non-shot, or by any other means so violent as to break the bones into many fragments, and so to tear, bruise, and wound the soft parts, that there shall be good rea- son to fear that there will not be vessels sufficient to carry on the circulation with the parts below, the frac- ture, it becomes, as Mr. Pott observes, a matter of the most serious consideration, whether an attempt to save such a limb will not occasion loss of life. This consider- ation must be before any degree of inflammation has seized the part, and therefore must be immediately after the accident. When inflammation, tension, and a dispo- sition to gangrene in the limb have arisen, the period is highly disadvantageous for operating, and the patient's chances of being saved by amputation under these cir- cumstances are much smaller than before the changes here spoken of had taken place. At the same time, there are certain examples of mortification from external causes, where, as far as one can judge from the results of later experience than that of Mr. Pott, the surgeon should not defer amputation, even though the disorder be yet in a spreading state, attended with considerable swell- ing and tension reaching far up the limb. This is a sub- ject, however, which will require more explanation hereafter.— See what is presently said on Mortification.) Nor are the cases to which reference is made meant to affect the general truth of the observation delivered by the most experienced surgeons of every age, that when a iimb is extensively swelled and inflamed, with a jiart of it either in a state of spreading mortification or ready to become gangrenous, the period is so unfa- vourable for amputation that very few patients so cir- cumstanced ever recover after the operation. Nor is it meant to be insinuated, that in the very cases which form exceptions to the general rule of not amputating before the tendency to gangrene has ceased, the pa- tient might not have had an infinitely better chance of his life, had the operation been done immediately after the first receipt of the injury, before any disposition to gangrene bad had time to be produced. The necessity of immediate or very early decision in this case makes it a very delicate part of practice; for however pressing the case may seem to the surgeon, it will not, in general, appear in the same light to the patient, to the relations, or to bystanders. They will be inclined to regard the proposition as arising from ignorance, or an inclination to save trouble, or a desire to operate; and it will often require more firmness on the part of the practitioner, and more resignation and confidence on the part of the patient, than is generally met with, to submit to such a severe operation in such a seeming hurry, and upon so little apparent delibera- tion ; and yet it often happens, that the suffering this point of time to pass decides the patient's fate. This necessity of early decision arises from the quick tendency to mortification which ensues in the injured limb, and too often ends in the patient's death. That this is no exaggeration, says Pott, melancholy and fre- quent experience evinces, even in those whose consti- tutions previous to the accident were in good order; but much more in those who have been heated by vio- lent exercise, or labour, or liquor, or who have led very debauched and intemperate lives, or who have habits naturally inflammable and irritable. This is often the case when the fracture happens to the middle part of the bones, but is much more likely to happen when any of the large joints are concerned. In many of these cases a determination for or against amputation is really a determination for or against the patient's ex- istence. That it would have been impossible to have saved some limbs which have been cut off, no man will pre- tend to say; but this does not render the practice in- judicious. Do not the majority of those who get into the above hazardous condition, and on whom amputa- tion is not performed, perish in consequence of their wounds ? Have not many lives been preserved by am- putation which, from the same circumstances, would otherwise most probably have been lost ? Pressing and urgent as the state of a compound frac- ture may be at this first point of time, still it will be a matter of choice whether the limb shall be removed or not; but at the second period the operation must be submitted to, or the patient must die. The most unpromising appearances at first do not necessarily or constantly end unfortunately. Some- times, after the most threatening first symptoms, after considerable length of time, great discharges of mat- ter and large exfoliations of bone, success shall ulti- mately be obtained, and the patient shall recover his health and the use of his limb. But sometimes, after the most judicious treatment through every stage of the disease; after the united efforts of physic aud surgery; the sore, instead of granulating kindly, and contracting daily to a smaller AMPUTATION. 47 size, shall remain as large as at first, with a tawmy, spongy surface, discharging a large quantity of thin Bauies, instead of a small one of good matter; the fractured ends of the bones, instead of tending to ex- foliate or to unite, will remain as perfectly loose and disunited as at first, while the patient shall loose his sleep, his appetite, and his strength; a hectic fever, with a quick, small, hard pulse, profuse sweats, and colliquative purging, contributing at the same time to bring him to the brink of the grave, notwithstanding every kind of assistance: in these circumstances, if amputation be not performed, Mr. Pott asks, what else can rescue the patient from destruction ? The third and last period is a matter which does not require much consideration. Too often the inflam- mation consequent upon the injury, instead of producing abscess and suppuration, tends to gangrene and morti- fication, the progress of which is often so rapid, as to destroy the patient in a very short space of time, con- stituting that very sort of case in which amputation should have been immediately performed. But some- times even this dreadful malady is, by the help of art, put a stop to, but not until it has totally destroyed all the surrounding muscles, tendons, and membranes quite down to the bone, which, upon the separation of the mortified parts, is left quite bare, and all circulation between the parts above and those below is by this totally cut off. In this instance, whether the surgeon saw through the bare bone, or leave the separation to be effected by nature, the patient must lose his 1 mb. —(See Pott's Remarks on the Necessity, &c. of Ampu- tation in certain Cases, &e. Chir. Works, vol. 3.) For the consideration of a variety of complicated cases which affect the question of amputation in com- pound fractures, I must refer to the article Gun-shot Wounds. 2. Extensive contused and lacerated wounds. These form the second class of general cases re- quiring amputation. Wounds without fracture are not often so bad as to require this operation. When a limb, however, is extensively contused and lacerated, and its principal blood-vessels are injured, so that there is no hope of a continuance of the circulation, the immediate removal of the member should be recommended, whether the bones be injured or not. Also, since no effort on the part of the surgeon can preserve a limb so injured, and such wounds are more likely to mortify than any others, the sooner the operation is undertaken the better. In these cases, as in those of compound fractures, though amputation may not always be necessary at first, it may become so afterward. The foregoing observations, relative to the second period of compound fractures, are equally applicable to badly lacerated wounds, unattended with injury of the bones. Some- limes a rapid mortification comes on; or a profuse suppuration, which the system can no longer endure.— (Encyclopedic M&hodique; partie Chir. t. 1, p. 80.) 3. Cases in which part of a limb has been carried away by a cannon ball. When part of a limb has been torn off by a cannon- ball, or any other cause capable of producing a similar effect, the formation of a good and serviceable stump, the greater facility of healing the clean, regular wound of amputation, and the benefit of a far more expedi- tious, as well as of a sounder cure, are the principal reasons which here make the operation advisable. This was an instance, in which some former sur- geons disputed the necessity of amputation. They urged as a reason for their opinion, that the limb being already removed, it is better to endeavour to cure the wound as speedily as possible, than increase the pa- tient's sufferings and danger, by making him submit to amputation. It must be remembered, hovVever, that the bones are generally shattered, and reduced into numerous fragments; the muscles and tendons are unequally divided, and their ends torn and contused. Now, none of the old surgeons questioned the absolute necessity of extracting the splinters of bone, and cut- ting away the irregular extremities of the tendons and muscles, which operations would require a longer time than amputation itself. Besides, we should recollect that, by making the incision above the injured part, so as to be enabled to cover the bone with flesh and integu- ments perfectly free from injury, the extent of the wound is so diminished, that the healmgcan be accom- plished in one-third of the time which w ould otherwise be requisite, and a much firmer cicatrix is also obtained. Such reflections must convince us, that amputation here holds forth very great advantages. It cannot in- crease the patient's danger, and as for the momentary augmentation of pain which he suffers, he is amply compensated by all the benefits resulting from the ope- ration.—(See Gun-shot Wounds.) 4. Mortification. Mortification is another cause, which, when ad- vanced to a certain degree, renders amputation indis- pensably proper. We have noticed, that bad compound fractures and wounds often terminate in the death of the injured limb. Such surgeons as have been deter- mined, at all events, to oppose the performance of am- putation, have pretended, that the operation is here totally useless. They assert, that when the mortifica- tion is only in a slight degree, it may be cured, and that when it has spread to a considerable extent, the patient will perish, whether amputation be performed or not. But this way of viewing things is so contrary to facts, and the experience of every impartial practitioner, that I shall make no attempt to refute the assertion. While it is allowed that it would be very bad practice, to am- putate on every slight appearance of gangrene, it is equally a fact, that when the disorder affects the sub- stance of a member, the operation is generally the safest and most advantageous measure. Nay, there are, as we shall presently see, certain forms of morti- fication, in which the early performance of amputation is the only chance of saving the patient. Practitioners have entertained very opposite opinions, concerning the period when one should operate in cases of mortification. Some pretend, that whenever the dis- order presents itself, and especially when it is the effect of external violence, we should imputate immediately the mortification has decidedly begun to form, and while the mischief is in a spreading state. Others be- lieve, that the operation should never be undertaken before the progress of the disorder has stopped, even not till the dead parts have begun to separate from the living ones. The advocates for the speedy performance of ampu- tation declare, that the farther progress of the mortifi- cation may be stopped, and the life of the patient pre- served, by cutting above the parts affected. However, according to the reports of the greater number of emi- nent surgical writers, this practice is highly dangerous, and undeserving of confidence. Whatever pains may be taken, in the operation, only to divide sound parts, there is no certainty of succeeding in this object, and the most skilful practitioner may be deceived. The skin may appear to be perfectly sound and free from inflammation, while the muscles which it covers, and the parts immediately surrounding the bone, may actually be in a gangrenous state. But even when the soft parts are found free from apparent distemper, on making the incision, still, if the operator should not have waited till the mortification has ceased to spread, the stump will almost always be attacked by gangrene. Surgeons who have had opportunities of frequently seeing wounds which have a tendency to mortify, en- tertain the latter opinion. Such was the sentiment of Pott, who says that he has often seen the experiment made, of amputating a limb in which gangrene had) begun to show itself, but never saw it succeed, and it invariably hastened the patient's death. The operation may be postponed, however, too long. Mr. S. Sharp, in particular, recommended too much delay, advising the operation never to be done, till the natural separation of the mortified parts had considera- bly advanced. Mr. Sharp was a surgeon of immense experience, and his authority carries with it the great- est weight. But, perhaps, he was too zealous in his opposition to a practice, the peril of which he had so often beheld. When the mortification has ceased to- spread, there is no occasion for farther delay. We now obtain, just as certainly, all the benefits of the operation, and get rid of a mass of putridity, the exhalations from which poison the atmosphere which the patient breathes, and are highly detrimental to his health. Nay, according to the reports of writers, patients in these circumstances may actually fall victims to the absorption of the putrid matter which is suffered to remain too long. However, this danger would not be fATION. 48 AMPW so considorable as that which would arise from too precipitate an operation ; and it is better to defer ampu- tation a little more than is absolutely requisite, than run any risk of doing the operation before it is certain that the parts have lost their tendency to gangrene. In the article Mortification, we have noticed particu- lar cases of gangrene, where, according to Larrey's experience, the surgeon is not to wait for the line of separation being formed, but have recourse to the im- mediate performance of amputation. The experience of Mr. Lawrence tends also to confirm the propriety of such practice.—(See Medico-Chir. Trans, vol. 6, p. 156, .fee.) In an example, where a large part of the arm was deeply affected with gangrene from external violence, and the disorder was yet making rapid progress, I once recommended the performance of amputation at the shoulder-joint. On the whole this instance was fa- vourable to the practice; for, though the patient died at the end of a fortnight, probably he would not have lived twenty-four hours, had the operation not been done; nor was the stump attacked with mortification, a cir- cumstance worthy of attention, because it is a danger particularly insisted upon by the opponents of amputa- tion, under the preceding circumstances; and, had it not been for a large abscess, which formed in the back, as was supposed, from a violent blow received in the fall which produced the original injury, there were well-grounded hopes of recovery. The patient, here spoken of, was attended by Dr. Blicke, of Waltham- stow. There is likewise a species of gangrene, which is pointed out by Mr. Guthrie as requiring early amputa- tion. " A soldier (says he) shall receive a flesh-wound from a musket-ball in the middle of the thigh, which passed through the limb apparently, on a superficial inspection, without injuring the main artery; or it shall pass close behind the femur, where the artery turns to the back part of the bone; or it may go through the middle of the bone, from behind forwards, between the condyles of the femur, into the knee-joint, and the patient shall walk to the surgeon with little assistance, be superficially dressed, and, in many cases be consi- dered slightly wounded; yet the femoral artery and vein of the whole of these cases, and, indeed, in many others, shall be wounded, or cut across, and the local inflammation be so slight as to obtain little attention. On the third or fourth day, the patient shows his toes discoloured, and complains of pain and coldness in the limb below the wound, the constitution begins to sym- pathize with the injury, and the surgeon probably thinks the case extraordinary. Perhaps he suspects the real state of the injury; but is surprised that a wound of the femoral or popliteal artery, with so little attendant injury, could cause mortification, &c. He is anxious to do something; but mortification, or at least gangrene, having commenced, he must, according to general rule, await the formation of the line of separation. The temperature of the leg, a little above the gangrene, is good, perhaps higher than natural; he hopes it will not extend farther, and it probably does remain station- ary for a little time. At last, the parts originally affected, the toes, become sphacelated, and gangrene quickly spreads up the leg as far as the wounded ar- tery, by which time the patient dies." For the purpose of preventing such a disaster, where the artery, or artery and vein, have been divided, Mr. Guthrie recommends the performance of amputation as soon as the gangrene is perceived to extend beyond the toes; and the swelling and slight attendant inflam- mation, which is marked more by thexumefaction, than the redness of the part, has passed higher up than the ankle.—(See Guthrie on Gun-shot Wounds, p. 60, 61.) 5. White swellings. Scrofulous joints, with diseased bones, and distem- pered ligaments and cartilages, is another case, in which amputation may become absolutely necessary. As Mr. Pott remarks, there is one circumstance attend- ing this complaint, often rendering it particularly un- pleasant, which is, that the subjects are most frequently young children, so as to be incapable of determining for themselves, which inflicts a very distressing task on their nearest relations. All the efforts of physic ■ and surgery often prove absolutely ineffectual, not only to cure, but even to retard, the disease in question. Notwithstanding many cases admit of cure, there are numerous others which do not. so. The disease often begins in the very inmost recesses of the cellular texture of the heads of the bones forming the large articulations, such as the hip, knee, ankle, and elbow; the bones become diseased, in a manner which we shall explain in the article Joints, sometimes with great pain and symptomatic fever; sometimes with very little of either, at least in the beginning. The cartilages covering the ends of these bortes, and designed for the mobility of the joints, are totally destroyed; the epi- physes in young subjects are either partially or totally separated from the said bones; the ligaments of the joints are so thickened and spoiled by the distemper, as to lose all natwal appearance, and become quite unfit for all the purposes for which they were intended: the parts appointed for the secretion of the synovia become distempered in like manner; all these together furnish a large quantity of stinking sanious matter, which is discharged either through artificial openings, made for the purpose, or through small ulcerated ones These openings commonly lead to bones which are diseased through their whole texture. When the dis- ease has got into this state, the constant pain, irritation, and discharge bring on hectic symptoms of the most destructive kind, such as total loss of appetite,, rest, and strength, proftise night-sweats, and as profuse purgings, which foil all tbe efforts of medicine, and bring the patient to the brink of destruction. It is an incontestable truth, that unless amputation be performed, a patient thus situated must perish; and it is equally true, that numbers, in the same circum- stances, by submitting to the operation, have recovered vigorous health.—(See Pott on Amputation.; It is a fact, highly important to be known, that in these cases amputation is attended with more success, when performed late, than when undertaken at an early period, before the disease has made great ad- vances. This is particularly fortunate, as it affords time for giving a fair trial to such remedies as are best calculated to check the progress of the disorder, and obviate all necessity for the operation.—(Encyclopedic Methodique, torn. 1, p. 83. See Joints, White Swell- ing.) 6. Exostoses. Here it will be sufficient merely to mention, that this disease may render amputation necessary, when the tumour becomes hurtful to the health, or insup- portable, on account of its weight or other circum- stances, and cannot be removed by any of the plans specified in the article Exostoses. 7. Necrosis. Another distemper, sometimes producing a necessity for amputation, is necrosis, or the death of the whole, or of a very considerable part, of the bones of tha ex- tremities, accompanied with such extensive abscesses, such disease of the soft parts, such disorder of the constitution and prostration of strength, that every hope of a cure being effected by a natural process must be renounced. By necrosis, is here meant, not merely some disease which destroys the surface of a bone, but one which extends its depredations to tbe whole of the internal substance, and that from end to end. Por- tions of the bones die from a variety of causes, such as struma, lues venerea, deep-seated abscesses, pressure, Sec.; and bones in this state, when properly treated, often exfoliate and cast off their dead parts. But when the whole substance of a bone becomes diseased from end to end, frequently no means will avail. In the words of Mr. Pott, the use of the scalpel, the rasp- atory, and the rugine, for the removal of the diseased surface of bones; of the trephine, for perforating into the internal texture of the diseased bone, and of exfo- liating applications (if there be any such which merit the name), Vill prove in many instances unavailing, and, unless the whole bone be removed by amputation, the patient will die. Mr. Pott's refutation of Bilguer, who asserts that amputation is not requisite in these instances, is a masterly and most convincing produc- tion ; but I would not exactly do as the former of these writers has done, and positively affirm, that every ex- tensive necrosis, affecting a bone nearly its whole length, must inevitably require amputation. The power of nature in restoring the bones is sometimes wonder- ful, as will be hereafter explained —(See Necrosis.) The very late period at which an extensive neero- AMPUTATION. 49 Bis may follow the injury of a bone, and make am- putation necessary, is sometimes almost incredible. Schmucker details the case of a captain who received a musket-ball through the left arm, four or five inches above the elbow. The bone was violently struck, but not broken; several exfoliations followed, and after Inore than a year's treatment, the patient appeared per- fectly cured. For nine years this officer remained well; but at the end of this time, being on a journey, he was attacked with pain and inflammation in the wounded part, and febrile symptoms. He hastened to Berlin, and put himself under the care of Theden and Schmucker, who found an abscess in the situation of the former wound, and as an opening had been already made, the bone could be felt stripped of its periosteum. At length a piece of bone exfoliated, and became loose, precisely under the brachial artery, which interfered with its removal. Notwithstanding the discharge, the elbow-joint continued swelled, and there were red points observable, not only above that joint, but also over the heads of the ulna and radius, indicating disease of those bones. Amputation was therefore performed by Theden, and the patient got quite well. On examin- ing the os brachii, a sprinter was found, three inches in length, and one in breadth, its edges being thin and sharp, while its centre was more than three lines thick. The bone, every where about the place where it had been struck by the ball, seemed to consist of callus without any medullary cavity, and the whole of it down to the elbow had no periosteum. The car- tilage appeared also disposed to separate, and the peri- osteum was detached from the radius and ulna, which were likewise affected with necrosis.—(See Schmuck- er's Vermischte Chir. Schriften, b. 1, p. 23, ed. 2.) 8. Cancerous and other inveterate diseases, such as fungus htematodes. Cancerous, inveterate diseases, and malignant incura- ble ulcers on the limbs, sometimes render amputation a matter of necessity. In treating of cancer, we shall remark that little or no confidence can be placed either In internal or any kind of topical remedies, and that there is nothing, except the total separation of the part affected, upon which any rational hopes of cure can be built. Cancer is not frequently seen on the extremi- ties. Every man of experience, however, must occa- sionally have seen, in this situation, if not actually cancer, diseases quite as intractable, and which cannot be cured except by removing the affected part. This may often be accomplished without cutting off the whole limb. But when the disease has spread beyond certain bounds, amputation above the part affected is the only thing to which recourse can be had with any hope of success. Sometimes, when the operation has been delayed too long, even amputation itself will not effect a cure. In a few cases of fungus hsematodes, the operation has succeeded, however, after the dis- ease had reappeared, and a cure had been seemingly achieved by the excision of the diseased parts. Yet, from what I have seen of fungus hsematodes, I should much doubt whether the benefit obtained by amputation would be lasting; as when this disease shows itself only externally, internal organs are mostly at the same time similarly affected.—(See Fungus Hsematodes.) Besides cancerous, there are other ulcers, which may render amputation indispensable. Thus, when an ex- tensive ulcer, of any sort whatsoever, is evidently im- pairing the health; when, instead of yielding to reme- dies, it becomes larger and more inveterate; Svhen, in short, it puts life in imminent danger; amputation should be advised. 9. Various tumours. That there are numerous swellings, which destroy the texture of the limbs, rendering them useless; caus- ing dreadlul sufferings, and bringing the patients into the most debilitated state, no man of observation can fail to have seen. When such tumours can neither be dispersed nor cut out with safety, amputation of the limb ;s the only resource. Mr. Pott has particularly described a tumour affect- ing the leg, for which the operation is sometimes re- quisite. It has its seat in the middle of the calf of the leg, or rather more towards its upper part, under the gastrocnemius and soleus muscles. It begins by a small, hard, deep-seated swelling, sometimes very painful, sometimes but little so, and only hindering the Vol. I.—D patient's exercises. It does not alter the natural colour' of the skin, at least until it has attained a considerable size. It enlarges gradually, does not soften as it en- larges, but continues through the greatest part of it in- compressibly hard, and when it is got to a large size, it seems to contain a fluid, which may be felt towards the bottom, or resting, as it were, on the back part of the bones. If an opening be made for the discharge of this fluid, it must be made very deep, and through a strangely distempered mass. This fluid is generally small in quantity, and consists of a sanies mixed with grumous blood; the discharge of it produces very little diminution of the tumour, and very nigh symptoms of irritation and inflammation come on, and, advancing with great rapidity, and most exquisite pain, very soon destroy the patient, either by the fever, which is high and unremitting, or by a mortification of the whole leg. If amputation has not been performed, and the ■ patient dies after the tumour has been freely opened, the mortified and putrid state of the parts prevents all satisfactory examination; but if the limb was re" moved, without any previous operation (and which Mr. Pott, in his experience, found to be the only way of-preserving the patient's life), the posterior tibial ar- tery will be found to be enlarged, distempered, and . burst; the muscles of the calf to have been converted into a strangely morbid mass; and the posterior part of both the tibia and fibula more or less carious.-* (Pott on Amputation.) It seems only necessary to adduce another species of tumour to illustrate the necessity of amputation. The following case is related by Mr. Abemethy. A woman was admitted into St. Bartholomew's Hospital with a hard tumour in the ham. It was about four inches in length, and three in breadth. She had also A tumour in front of the thigh, a little above the patella, of less size and hardness. The tumour in the ham, by its pressure on the nerves and vessels, had greatly les- sened the sensibility, and obstructed the circulation of the leg, so that the limb was very cedematous. As it appeared impossible to remove this tumour, and its ori gin and connexions were unknown, amputation was performed. On examining the amputated limb, the tumour in the ham could only be divided with a saw. Several slices were taken out of it by this means, and I appeared to consist of a coagulable and vascular sub- stance, in the interstices of which a great deal of bony matter was deposited. The remainder of the tumour was macerated and dried, and it appeared to be formed of an irregular and compact deposition of the earth of bone. The tumour on the front of the thigh was of the same nature as that of the ham, but contained so little lime, that it could be cut with a knife. The thigh-bone was not at all diseased, which is mentioned, because, when bony matter is deposited in a limb, it generally arises from the disease of a bone.—(Surgical Observations, 1804.) Before the late facts and improvements relative to the treatment of aneurisms, these cases, on the extremi- ties, were generally set down as requiring amputation. Even Mr. Pott, and J. L. Petit, wrote in recommenda- tion of such practice, and their observations on this subject are among the few parts of their writings which the enlargement of surgical knowledge, since their time, has rendered objectionable. The surgeon to whom the honour of first correcting this erroneous doctrine belongs is A. N. Guenault, who opposed the advice delivered on this subject -by Petit—(Haller, Disp. Chir. vol. 5£g. 155.) I shall concluwtfiese remarks on the cases requir- ing amputation, with advising surgeons never to un- dertake this serious operation, without consulting the opinions of other professional men, whenever their ad- vice can be obtained. The best operators are often de- ficient in that invaluable kind of judgment by which the cases absolutely demanding amputation are dis- criminated from others, in which the operation may be wisely postponed, and a chance taken of preserving the limb. Historical remarks on Amputation. The history of amputation evinces that the steps of surgery to perfection are slow, and that they even sometimes deviate from the straight path, though upon all essential points no retrogration has ever taken place. Here nature has acted as the guide, and the surgeon's chief merit has consisted in obeying the 60 AMPUTATION. hints which she herself has thrown out. As already mentioned, the following natural occurrence, no doubt, was one of the circumstances which first led to the bold practice of amputation : in consequence of dis- ease and grievous local injuries, whole limbs were sometimes seized with mortification. In the majority of cases, this was attended with so much constitutional disturbance that the patients died; but in other less numerous instances, the mortification was confined to the part; suppuration was established between the dead and living parts; the whole of the mortified limb fell off; the suppurating surfaces healed up; and thus, by the powers of nature, the patients were re- stored to health. Here was clearly proved the possi- bility of recovery, notwithstanding the loss of a limb. The surgeon, as Briinninghausen remarks, viewed With surprise this course of nature, and hardly ven- tured to promote it by the feeble means formerly em- ployed, which, however, were not really needed. But as the mortified parts, previously to their detachment, caused great annoyance by their fetor, a surgical at- tempt was at length made to get rid of them; in doing which the knife was always kept from touching the living flesh, on account of a well-grounded fear of bleeding, for the suppression of which no effectual methods were known. Such was the practice that prevailed; from Hippocrates down to Celsus.—(Erfahr. &c. uber die Amp. p. 14.) " Partes autem corporis, quae infra terminos denigrationis fuerint, ubi jam pror- sus emortuae ftierint et dolorem non senserint, ad ar- ticulos auferendas ea cautione ut ne vulnus inferatur," &c.—(De Articulis-, sect. 6.) Here we find that the earliest mode of amputation was that done at the joints. A. C. Celsus, who lived in the reign of Tiberius, and whose book, De Re Medica, should be read by every surgeon, has left us a short description of the mode of amputating gangrenous Jimbs.—(Lib. 7, c. 33.) It has been often remarked, that Celsus has left, no in- structions for securing the divided blood-vessels; but it has not been commonly noticed, that in his chapter on wounds he directs us to stop hemorrhage by taking hold of the vessels, then tying them in two places and dividing the intermediate portion. If this measure cannot be adopted, he advises the use of a cauterizing iron. Several hints are to be met with in the writings of Celsus, from which it may be inferred that the liga- ture of bleeding vessels was sometimes practised at the early age in which he lived; and this supposi- tion is strengthened by a fragment of Archigenes pre- served by Cocchius, on the subject of amputation, where he speaks of tying or sewing the blood-vessels. We are not, however, in possession of all the writings of medical authors prior to the time of Galen, and must therefore remain in doubt upon this point.—(Rees's Cy- clopaedia, art.'Amputation.) This anonymous writer argues, therefore, with some appearance of reason, that if amputation often proved fatal in the days of Celsus, " saepe in ipso opere," as the expression is, it was owing to the want of some efficacious method of compressing the blood-vessels during the operation itself; for whether the use of the ligature were known to the ancients or not, no doubt exists about their ignorance of the tourniquet. But admitting that the ancients were not altogether uninformed of the plan of tying arteries, it cannot be credited that they adopted the practice to any extent; for if they had, they would not have continued so par- tial to the cautery, boiling oils, and a farrago of as- tringent applications. They would also never have had recourse to the barbarous method of cutting the flesh with a red-hot knife, writh the view of stopping the hemorrhageby converting the whole surface of the stump into an eschar. Painftil in its execution and horrid in its consequence as this burning operation was, it seldom proved a lasting antidote to the bleed- ing, which generally came on in a fatal manner, as soon as the sloughs were loose. On this part of ihe sub- ject my own ideas fully agree with those of a distin- guished foreign surgeon, who says, that although the iocument left us may prove that the ligature was known to the ancients, and employed in cases of aneurisms and wounded blood-vessels, nay, that the arteries were secured with a needle and ligature; yet the practice could not have been extended to the operation of ampu- tation, since, with the custom of making the incisions in the dead parts, the method scarcely admitted of being put in execution.—(.Briinninghausen, Erfahr. uber die Amput. p. 29.) Ambrose Pare, therefore, scents to me to deserve as much praise for the introduction of the ligature into common use, as i'f no allusion to this me- thod whatsoever had existed in the writings of Celsus and other ancients. The different parts of the operation meriting parti- cular attention are, the choice of the part of the limb where the incisions are to begin; the measures for guarding against bleeding during the operation; the division of the integuments, muscles, and bones, which is to be accomplished in such a manner that the whole surface of the stump will afterward be covered with skin; tying the arteries, which should be done with- outincluding the nerves or any other adjacent part; placing the integuments in a proper position after the operation; and, finally, the subsequent treatment of the wound. At the period of making the incision, the ancients contented themselves with having the skin forcibly drawn upwards by an assistant; they next divided, with one sweep of the knife, the integuments and flesh down to the bone, and afterward sawed the bone on a level with the soft parts, which were drawn upwards. Celsus considered it better to let the incision encroach upon the living flesh than leave any of the diseased parts behind. " Et potius ex sana parte aliquid exci datur, quam ex aegra relinquatuT."—(De MedicinaV, lib. 7,c. 33.) It appears, however, that his views extended farther than those of most of his contemporaries, and even his followers, almost downto modern times. After cutting the muscles down to the bone, he says that the flesh should be reflected and detached underneath with a scalpel, in order to denude a portion of the bone, which is then to be sawn as near as possible to the healthy flesh which remains adherent. He states, that when this plan is pursued, the skin around the wound will be so loose that it can almost be made to cover the extre- mity of the bone. It is to be lamented that this ad- vice, inculcated by Celsus, should not have been com- prehended, or that it should have been so neglected as to stand in need, as it were, of a new discoverer, and that a suggestion of such importance should have re- mained so long useless. But the fact is, hemorrhage formerly rendered amputation so dangerous, that the ancient surgeons could not devote much attention to any thing else in the operation, and practitioners am- putated so seldom, that we read in Albucasis that he positively refused to cut off a person's hand, lest a fatal ' hemorrhage should ensue, and the patient did it him- self and recovered. Over that part of the stump which the small quantity of preserved skin would not cover, Celsus recommended compresses, and a sponge dipped in vinegar to be laid.—(De Re Medica, lib. 7, c. 33.) Archigenes, who was born at Apamia, in Syria, was the disciple of Agathinus, and physician to Philip, king of that country. He repaired to Rome, where he prac- tised physic and surgery in the reign of the emperor Trajan, about 108 years after the birth of Christ.—(Por- tal, Hist, de l'Anatomie et de la Chirurgie, vol. 1, p. 61.) In the history of amputation the name of Archigenes is conspicuous, not only because he is supposed to have been acquainted with the use of the needle and ligature for the stoppage of bleeding, but because his descrip- tion of the operation is in some respects more minute than that of Celsus. For the hindrance of loss of blood in the operation, says Sprengel (Gesehichte der Chir. b. 1, p. 404, Halle, 1805), he first of all tied up the vessels, and often the whole limb, over which he also sprinkled cold water. The integuments were then drawn upwards from the wound, and confined there with a band; and after the limb was off, he cauterized the stump, and applied folded compresses. The band was now loosened and a mixture of leeks and salt laid on the stump, to which were also applied oil and ce- rate.— 'Nicet, Coll. Chir. p. 155.) Such was likewise the practice of Heliodorus, who thus early made objec- tions to the plan of cutting off a limb by a single stroke a proposal that was renewed in far later days. The same author has also spoken of amputating at the joints; a method of which he disapproves.—(Nicet Coll. Chir. p. 155.) However, Galen entertained a fa- vourable opinion of it, on account of its safety and ex- pedition.—(Comm. 4, in lib. de artic. p. 650.) Galen's precepts concerning amputation are, upon the whole very like, those given by Hippocrates; for he directs only dead parts to be cut, and the stump to be caute- AMPUTATION. SI t-ized.—(De Arte Curativa ad Glauconem, lib. 2.) By all the old writers, amputation was entirely restricted lo cases of mortification; farther they were afraid to go; and this precept, and all the other doctrines of Galen, may be said to have been the guide of the whole surgical profession for full fourteen centuries. The timid Arabians were not partial to amputation, and even in cases of mortification generally preferred a farrago of useless applications, like Armenian bole, &c. Paulus jEgineta, like Galen, deviated from Celsus's good rule of making the incisions in the healthy parts, and only approved of making the requisite division near them.—(Lib. 4, c. 19, p. 140.) Avicenna, however, re- peated the directions left by the Greek writers (Can. lib. 4. Fen. 3, tr. 1, p. 454), and Abu'l Kasem proposed doing the operation with a red-hot knife.—(Chirurg. lib. 1, sect. 52, p. 99.) In the middle ages, little was done for the improvement of amputation. In the 14th cen- tury gunpowder was invented, and soon applied to the urposes of war, so that an abundance of cases must ave presented themselves in which the wise maxim of not deferring amputation until mortification had come on, but of preventing the mischief by the opera- tion, ought to have struck an intelligent surgeon. One might also expect that practitioners would now have been led to make the incisions in the sound flesh. Unfor- tunately, the invention of gunpowder and its immediate consequences in surgery, happened at a period when practitioners were ill qualified to profit by the new les- sons of experience set before them. The writings of their predecessors furnished them with no directions how they ought to act, and they were themselves too much confounded at the sight of'the mischief for which they were consulted, to be able to form any correct opinion about causes and effects. Their first idea was, that the terrible symptoms proceeded from the parts be- ing actually burned, and they afterward inclined to the belief that gun-shot wounds were poisoned. Hence the most absurd modes of treatment were insti- tuted, and, as Briinninghausen expresses himself, hu- man nature groaned under a new evil, for which there were for some time no true plans of relief.—(Erfahr. &c. uber die Amp. c. 19.) This deplorable state was the natural result of the depression of science in general, and of the healing art in particular, in the days to which I now refer. In these middle ages, as they are called, the population of all Europe was plunged in the deep- est ignorance; and whatever little knowledge remained, either of the arts or languages, was monopolized by the priesthood, the physicians of those times, who, instead of studying the volume of nature, wasted most of their time in discussing the doctrines of Galen. Surgery itself sunk to the lowest ebb, as may be well conceived from the decrees issued at Rheims by Pope Boniface the Eighth, forbidding any of the clergy to do any thing themselves which drew blood; and of course all the operative part of surgery, that which required the most skill and science, was transferred to a set of illiterate, low-bred mechanics, far inferior to the worst country farriers of modern times. Yet the clergy, who were here scrupulously averse to soiling their own hands with blood, or hurting their own tender feelings by viewing the agony of their fellow-creatures submitted to operations, had no hesitation in taking the chief emo- luments and honours of the profession, or in turning over these poor sufferers to men more qualified to tor- ture and murder than to give relief; and, what nearly staggers all credulity, the same professors of Christian- ity, who shuddered to spill a drop of blood themselves on a proper occasion, as Haller observes, eagerly had a hand, and acted an important part, in every sangui- nary war, where it was possible for them to interfere. In these dismal days of surgery, the advice delivered by Celsus was renewed by Theodoricus, who used to administer opium and hemlock previously to the ope- ration, for the purpose of rendering.the patient less sensible to pain, and afterward vinegar and fennel were given, with the view of dispersing the intoxica- ting effects of the preceding medicines.—(Chirurg. lib. 3, c. 10.) The renowned Guido di Cauliaco was the inventor of the plan of taking off limbs without any bloodshed. It is better, says he, for the limb to drop off than be cut off; as in the latter circumstance the conduct of the surgeon is viewed with spite, because it is supposed that the part might have been saved. Guido's practice consisted in covering the whole membrane with pitch- DS plaster, and applying round one of the joints so tight a band, that the parts below the constriction ultimately dropped off.—(Chirurg. tr. 6, Doctr. 1, cap. 8.) As Sprengel next observes, the method of amputating sug- gested by Celsus was again revived by Gersdorf, who after the operation not only drew down over the stump the skin which had been retracted, but applied a hog's or bullock's bladder over the stump, so as to render all burning and stitching of the parts needless.—(Feldbuch der Wundarzn. fol. 63.) Bartholomew Maggi also en- deavoured to preserve a considerable flap of integu- ments for covering the stump.—(De Vulner. bombard. et sclopet. 4to. Bonon. 1552; see Sprengel's Gesehichte der Chirurgie, p. 404. 406, 8vo. Halle, 1805.) At length, in the 15th century, the revival of learning occurred first in Italy. Men now began to think for themselves again, and physicians turned from compila- tions and scholastic nonsense to the consideration of nature. Anatomy was cultivated with great ardour, and made brilliant progress under the eminent charac- ters of the time: De la Torre, Berengarius Carpi, Ve- salius, Fallopius, Eustachius, and others, who were also for the most part very distinguished surgeons. " In Italia scientiarum matre medici se nunquam chi- rurgia abdicarunt. Seculo 15 et 16, professores medici academise Bononiensis, Patavinae, et aliarum in Italia illustrium scholarum et manu curaverunt, et consilio, et inter istos viros summi chirurgi exstiterunt.' —(Hal- ler, Bibl. Chir. b. 1, p. 161.) Practitioners now ven- tured to amputate limbs in the sound part for other incurable diseases besides mortifications; but the art of stopping hemorrhage after the operation continued imperfect. Though the method of applying the ligature in cases of wounded arteries and aneurisms was under- stood, yet from some unaccountable causes the practice was never thought of in amputations. Even Fallopius knew of no other means for stopping the bleeding but thecautery.—(DeTum.prsetem.p.665.) Onthewhole, the stoppage of bleeding was not attended with a de- gree of success proportionate to the advances of the healing art in general. Straps, bands, and compresses were indeed put round the member; but as the cir- culation of the blood was not yet correctly known, they were not applied in the proper places, being ar- ranged either close to the wound, or. several of them put at random round the limb. The effects of such immoderately tight, long-continued constriction could be nothing less than gangrene; and hence the actual cautery was still chiefly employed. The other means for suppressing hemorrhage scarcely merit the name. Terrified at the insecurity and ill consequences of such expedients, J. de Vigo (Practica in Chirurgia Copiosa, 491, Romas, 1514), and Fabricius ab Aquapendente (Op. Chir. Venet. 1619), disapproved of amputating in the sound flesh, and returned to the principle inculcated by the ancients, of making the incision in the mortified parts. Others endeavoured to lessen the peril of the bleeding by the rapidity with which the limb was re- moved, and the instantaneous application of the cau- tery. For this purpose L. Botalli invented a sort of guillotine, by means of which a member was severed from the body in an instant (De Curandis vulneribus sclopetorum, Lugd. 1560), while others laid a sharp axe upon the limb, and effected the dismemberment by the blow of a wooden mallet. An example of this barba- rous practice is recorded by Fabricius HUdanus, called by his countrymen the patriarch and ornament of the German surgery. In consequence of this fear of bleed- ing, before he knew of the use of the ligature, he was himself accustomed to amputate with a red-hot knife, the representation of which is given in his work.—(De Gangraena et Sphacelo, Op.) HUdanus became a better surgeon, however, as he grew older, and in the end partly contributed to the improvement of amputation, inasmuch as he made the incisions completely in the sound parts, and adopted the method of tying the arte- ries, as then recently proposed by Pare1; but, unfortu- nately, in weak persons he stUl preferred the actual cau- tery to the ligature.—(Op. p. 814.) One of his inven- tions was a linen bag or cap for the stump; and a sort of retractor for holding back the muscles. According to Sprengel (Gesehichte der Chir. b. 1, p. 407), his ob- servations on the pain following the operation are in- teresting.—(Op. p. 807. 814.) Ambrose Pare, a French surgeon, who flourished in the 16th century (Opera, Parisiis, 1582), and to whom I have already alluded, made some beneficial innova- 53 AMPUTATION. tions with regard to the operation of amputation. It is to his industry, good sense, and skUl that we are chiefly indebted for the abolition of cauterizing instruments, and the general use of a needle and ligature for the suppression of the bleeding.—(Lib. 6, c. 28, p. 224.) An anonymous writer has given the following ac- count of the practice and opinions of this disinguished silicon in relation to amputation. "Pare reco> amended to cu- off the whole of the gangrenous part if the limb be mortified, but to encroach as little as possible upon the living flesh. At the same time, he laid it down as a rule not to leave a very long stump to an amputated leg; because the patient could more conveniently make use of a wooden leg, with the stump only five finger- breadths long below the knee, than if much more of the flesh were to be preserved. In the arm, however, he left the whole of the living and healthy portion of the member, only separating the diseased part from the sound. In preparing for amputation, he directs the skin and muscles to be drawn upwards, and bound tight with a broad bandage a little above the part where the incision is to be made. This fillet was intended to answer a threefold purpose:—1st, to afford a quantity of flesh for covering the bone, and facilitating the cure; 2dly, to close the extremities of the divided blood-vessels; 3dly, to dull the patient's feelings by pressure on the subja- cent nerves. When this firm ligature has been applied, Pare directs an incision to be made down to the bone, either with a common large scalpel or a curved knife. Then with a smaller curved knife we are carefully to divide the muscle or ligament remaining between the bones of the forearm or leg; after which we may proceed to saw off the bone as high as possible, and to remove the asperities occasioned by the saw. With the assistance of a curved pair of forceps he drew out the extremities of the bleeding arteries, either by themselves alone, or with some portion of the sur- rounding flesh, to be firmly tied with a strong double thread. He now loosened his bandage, brought toge- ther the lips of the wound over the face of the stump, and kept them as close as he could without actual stretching, by means of four stitches or sutures. If the larger tied vessels should accidently become loose, he desires the ligature or bandage to be again passed round the limb; or else, what is better, to let an assist- ant grasp the limb firm with both hands, and press with his fingers over the course of the bleeding vessel, so as to stop the hemorrhage; then with a square edged nee- dle, about four inches long, and a thread four times doubled, the surgeon must secure the artery in the fol- lowing manner. Thrust the armed needle into the outside of the flesh, half a finger's breath from the ves- sel which bleeds, and bring it out at the same distance from the bleeding orifice; then surround the vessel with the ligature, pass it back again to within one fin- ger's breadth of the place where it first entered, and tie a fast knot upon a folded slip of linen rag to prevent its hurting the flesh. By this means, says Pare, the ori- fice of the artery wUl be agglutinated to the adjoining flesh so firmly, as not to yield one drop of blood; but if the hemorrhage were not considerable, he contented himself with the application of astringent powders, &c. Thus did this famous surgeon endeavour, by bis sin- gle example and precepts, to exclude the barbarous use of hot irons in amputation. He says, he knew not of any such practice among the old surgeons; except that Galen recommended us to tie bleeding vessels towards their origin in accidental wounds: and he thought pro- per to do the same in cases of amputation. But in an apology at the end of his book, Pare has quoted in his own defence a dozen authors who employed or recom- mended the ligature before him; and he might have cited many more. From the statement we have here given, it may be seen how far the best writers of almost every country have erred in ascribing the original invention of tying arteries to Ambrose Pare. Great merit, indeed, was due to him for the part he took in extending, and even reviving, this incomparable practice: nay, it is not cer- tain whether any one before him had ever applied the needle and ligature in slmUar cases, that is, after amputation; but how very wide of the truth Mr. John Bell's recent account of this matter is, will appear to every person who will inquire into the facts them- selves ; for not only were ligatures and needles in use among the ancients, but likewise the tenaculum or hook to lay hold of the bleeding vessels, when they had buried themselves in the muscles. We refer our in- quisitive readers to Avicenna, ^Etius Albucacis, Bru- nus, Theodoric, Guido di Cauliaco, John de Vigo, L. Bertapaelia, Tagaultius, Petrus Argillata, Andreas a Cruce, Sec. Sec, where they wUl find enough to satisfy them on this head."— (Rees's Cyclopaedia, art. Ampu- tation.) I shall not here expatiate upon the ill-treatment which Pare experienced from the base and ignorant Gourmelin; nor upon the slowness and reluctance with which the generality of surgeons renounced the cau- tery for the ligature. These circumstances may be conceived, from what has been already stated. Suffice it to add, upon the authority of Dionis, that almost 100 years after Pare, a button of vitriol was ordinarily em- ployed in the Hdtel-Dieu at Paris for the stoppage of hemorrhage after amputations. And Dionis was the first Frenchman who openly taught and recommended Pare's method. This happened towards the close of the 17th century, while Pare lived towards the end of the 16th.—(Dionis, Cours d'Operat. Paris, 1707.) As Pare, like the rest of the old surgeons, used to cut directly down to the bone, many of the stumps which he made must have been badly covered with flesh, and ill-fitted for bearing pressure. But all that I have read on the subject of amputation impresses me with a strong conviction, that in former times the projection of the end of the bone, the sugar-loaf form of the stump, the frequent exfoliations, and the difficulty in healing the part and keeping it healed, were as much owing to the mischief done with the cautery, the rude way of dressing the stump, and ignorance of the right method of promoting union by the first intention, as to the mode of operating or any other circumstance. By many surgeons, however, the tying of arteries con- tinued to be deemed too troublesome, and hence they persisted in the barbarous use of the actual cautery: of this number were Pigrai (Epitome des Preceptes de Med. et de Chir. 8vo. Rouen, 1642), F. Plazzoni (De Vuln. Sclopet. 4to. Venet. 1618), and P. M. Rossi (Con- sult, et Observ. 8vo. Francof. 1616). Nay, so difficult was it to eradicate the blind attachment to the ancients, that Theodoras Baronius, a professor at Cremona, pub- licly declared, in 1609, that he would rather err with Galen than follow the advice of any other person ; and Van Hoorne seems even to have countenanced the de- testable machine of Botalli.—(Mikpot{'xv»?, p. 75.) What, asks Briinninghausen, was the reason why the ligature of the arteries, which is now regarded by the surgeons of all civilized nations as the best, easiest, and safest method of stopping hemorrhage after ampu- tation, should so long have remained unadopted ? Be- sides the prejudice for the opinions of the ancients, already mentioned, another cause was undoubtedly the imperfect knowledge of the circulation of the blood, a correct description of which was first delivered by the immortal Harvey early in the 17th century.—(Exerci- tatio Anat. de Motu Cordis et Sanguinis in Animalibus. Francof. 1628.) For some time this grand discovery met with violent opposition; but after it had been ac- knowledged as an eternal truth, a happy application of it was made to surgery by a French surgeon, named Morell, who, at the siege of Besangon,in 1674, invented the field tourniquet, by means of which more certain pressure was made on the trunk of the artery. By this simple invention, founded, however, on a know- ledge of the circulation, the surgeon could at option let the blood of the stump spirt out, or stop its jet entirely ; and now both during and after the operation, he was first enabled to command the hemorrhage, and coolly and judiciously employ whatever measures were indi- cated; for the most powerful bandages and pressure previously in use either stopped the circulation in the whole limb, or could not be made to have the right effect with sufficient quickness.—< Briinninghausen Erfahr. &c. uber die Amp. p. 36.) MoreU's tourniquet' however, was very imperfect, and it was not till the year 1718, that J. L. Petit, whose name shines so brightly in the history of surgery, invented the kind of tourni- quet now employed. Richard Wiseman, who is justly considered as the father of good English surgery, saw the necessity of making the incision in the sound parts, because gan- grene does not always spread evenly, but frequently extends much higher up one side of the limb than the other. He deemed the actual cautery objectionable, as AMPUTATION. 53 the sloughs were so long in being thrown off. He ap- plied a ligature round the limb, two inches above the limits of the mortification, and, drawing up the mus- cles, made the incision with a large curved knife, with the back of which he scraped off the periosteum. The bag, or sort of retractor, employed by Fabricius HUda- nus, Wiseman thought, unnecessary, as the muscles spontaneously drew themselves up as soon as divided. He tied the blood-vessels after the manner of Pare, and deprecated all burning of the stump. After the opera- tion, he drew the flaps over the bone, and either fastened them in this position with stiches or a tight bandage, though he generally preferred the former, as the surest means of keeping the end of the bone from protruding. Across the stump he laid a pledget of wax-cerate, and over this a thick layer of Armenian bole and other styptics, and the whole was covered with a bullock's bladder and a roller, applied spirally from the upper part of the remaining portion of the limb down to the extremity of the'stump. On the third day, the dress- ings were taken off, and a digestive ointment applied. —(Chirurg. Treatises, vol. 2, p. 220, 8vo. Lond. 1690.) From this time, amputation may be considered as being an infinitely safer proceeding than what it used to be ; for, as we have explained, the ligature of the arteries was now practised and commended in Germany by F. Hildanus, in England by Wiseman, and in France by Dionis. Much, however, remained to be done. The wound was large, and suppurated long and pro- fusely ; the healing was slow; the ends of the bones perished, and, projecting far beyond the soft parts, re- tarded the cure so long, that the patient was not unfre- quently worn out. Hence the best surgeons began seriously to consider what fartiier could be done, with a view of lessening the exposed surface of the wound, and making a better covering of flesh for the ends of the bones. According to Sprengel, most of the old surgeons preserved a flap of flesh, and he is therefore by no means disposed to regard our countryman, Lowdham, as the inventor of this method, though it is acknow- ledged that the latter surgeon's practice was novel, inasmuch as the flap was formed by making an oblique incision through the integuments from below upwards. —(See James Yonge's Currus Triumphalis e Terebintho, 8vo. Lond. 1679; and Sprengel's Gesehichte der Chirur- gie, b. 1, p. 408.) Here, if Sprengel means that many of the old surgeons endeavoured to preserve a partial covering of flesh for the bone, there can be no doubt of his correctness; because we And, that they drew back the flesh before they divided it, and Celsus and some -others even did more, for, after cutting down to the bone, they detached the flesh farther from it upwards, previ- ously to taking the saw: but, on the contrary, if Spren- gel wishes us to believe, that there were practitioners who, previously to Lowdham, in the operation of am- putation formed what in England is usually under- stood by a flap, that is, a portion of flesh, generally of a semilunar shape, and saved particularly from one side of the member for covering the bone, I cannot see any reason for coinciding with Sprengel's observation. Upon the merit of Lowdham's suggestions, and the practice and principles inculcated by J. Yonge, some reflections lately sent me by Mr. Carwardine I insert with great pleasure, as perhaps he is right in thinking that the third edition of this work did not do justice to the memory of the latter writer. "At the time Yonge wrote (1679)," says Mr. Car- wardine, " it was supposed impossible to heal a stump before the bone had exfoliated, and therefore no sur- geon would venture upon an attempt at uniting the surface by the first intention. Now this union by the first intention was the chief object of Mr. Yonge in proposing the flap-operation, and it is to him, and not to Mr. Alanson, who wrote precisely 100 years after him, that we must attribute the honour of ttiis improve- ment. It is related in a letter addressed to bis friend Thomas Hobs, chirurgeon, in London, dated Plymouth, August 3, 1678, and published, 1679, at the end of his Currus Triumphalis e Terebintho. It begins thus: •Sir, I find by yours that you are surprised with the intimation I gave you, of a way of amputating large members, so as to be able to cure them per sym- physin in three weeks; and without fouling or scaling the bone. It is a paradox which I wiU now evince to you to be a truth, after I have first taken notice of what you affirm, that there is a necessity of scaling the ends of those bones left bare after the usual manner of dismembering, before the stump can be soundly cured ; that you never yet found it otherwise, but that where it hath been attempted, the stumps have apostu- rnated, and the caries come off thereby.' Yonge jfften acknowledges, that- it was from an ingenious ^Brother, Mr. C. Lowdham of Exeter, that he had the first hint thereof. He then describes the ope- ration—the laying down the flap over the face of the stump, and sewring it by four or five stitches, &c. After this, Yonge proceeds with a methodical enumeration of the advantages of this mode of operating over all others then in use, viz. that it is more speedy—the cure not occupying a fourth of the usual time—no sup- puration—no exfoliation—less danger of hemorrhage —not liable to break open again from slight injury— and lastly, much better adapted to the pressure from an artificial leg, &c. The foregoing abstract wUl sh6w (says Mr. Car- wardine) how far Mr. O'Halloran's method, presently to be described, in which he dresses the flap and the stump as distinct surfaces, can be regarded as a revival of Lowdham's operation, or whether it has been super- seded or improved upon by the mechanical ingenuity of the Dutch and French surgeons:—the apparatus of M. de la Faye and Verduin appear to have been merely clumsy and unscientific contrivances for the suppres- sion of hemorrhage. Garengeot's operation had also for its object to supersede the use of the ligature, which, however, after twelve years' practice, he was obliged to give up, and tie the vessel before he laid down the flap (the particulars of all these methods the reader will presently meet with). Opinions, therefore, founded upon the practice of these gentlemen, I conceive, can- not fairly be admitted as evidence against the flap-ope- ration of Lowdham, which nevertheless appears sinking in the estimation of the best modern surgeons; perhaps no material advantage is gained by it over the common mode of operating in the lower extremities, as now practised—but even here cases may occur where we are glad to resort to it: a few years since, I attended a patient in consultation with a friend at Dunmow, in Essex, where we thought it necessary to* remove a man's leg for a caries of the tibia. An ulceration in front extended so high, that no integument could be saved, and the limb would have been removed above the knee, if I had not suggested the propriety of making. a flap from the calfof the leg. The tibia was obliged to be sawed as high as possible, but the flap was left sufficiently long to cover the surface, and that most important object, the bend of the knee, was preserved, to bear the pressure of a wooden leg. In the removal of the arm at the shoulder-joint, doubtless the advan- tages of making a flap from the deltoid, &c. are suffi- ciently established; but in the mode of dressing, I pre- sume that no English surgeon will admit, that the practice of M. Larrey (perhaps the most eminent sur- geon that has been formed by the wars of Buonaparte, and whose practice will be hereafter noticed) can super- sede the method of Yonge (or Lowdham), who wrote 140 years before him! Larrey introduces charpie beneath the flap to prevent union by the first intention! Lowdham's object is simply to lay the flap over the wound to prevent exfoliation, and to heal the surface ' per symphysin' in three weeks."—To the correctness of these sentiments of Mr. Carwardine, I believe that every impartial surgeon will bear witness; and it merely remains for me to thank him for his obliging communication, and say, that I have recently looked over the copy of the Currus Triumphalis e Terebintho, preserved in the valuable library of the Medical and Chirurgical Society, and find, that what he had stated ia fully confirmed by the contents of that ancient work. At the same time, I retain the belief, that the example set by Mr. Alanson, with respect to the proper method of dressing stumps and obtaining a speedy union of the wound, is entitled to the praise of posterity; because his advice was so well enforced that it soon produced a revolution in practice, while the correct suggestions of Lowdham and Yonge, liie the hint in Celsus, of the double incision, had sunk into oblivion, or were only known to a few admirers of surgical antiquities. As Sprengel remarks, Purmann, Dionis (Coura d'Oper. de Chir. p. 611), De la Vauguyon (Traite Compel, des Op6r. de Chir. p. 531), and most other surgeons of the seventeenth century, continued the method of first drawing up the integuments, and then 54 AMPUTATION. applying a band round the member. Dionis also took particular pains to recommend the ligature of the ves- sels, and expresses a strong aversion to the actual cau- tery. Neither did he approve of amputation at the knee-joint, because he thought that the patella, which must be left behind, would impede the healing of the stump, and he was apprehensive of the articular sur- face of the femur becoming diseased. De la Vauguyon relied upon the styptic properties of vitriol, and he praised drawing back the muscles by means of the kind of bag invented by Fabricius HUdanus. Taking off the limbs at the joints was first com- mended again in modern times by J. Munnicks, who was more partial to styptics than the ligature; and for dressing the wound employed compresses and sticking- plaster.— (Chirurgia, p. 101.) Mauquest de la Mothe adopted the plan of operating recommended by Dionis; he was also one of the first who made common use of the tourniquet in amputa- tions, afterward drawing out the vessels with the forceps and tying them.—(Traite Compl. de Chir. vol. 3, p. 171.) Lowdham's original suggestion of amputating with a flap has been briefly noticed. About eighteen years after Yonge's publication, Peter Verduin, an emi- nent surgeon at Amsterdam, submitted to the judg- ment of the profession a new kind of flap-amputation, which he had put in practice.—(See Dis. Epistolica de Nova Artuum decurtandorum ratione,8vo. Amst. 1696.) The following are the chief particulars of Verduin's flap-operation. Two compresses were applied, one under the ham, and the other on the course of the large vessels. The thigh was wrapped in a fine linen cloth, which was sustained by some funis of a roller. This apparatus was covered with a piece of leather, six inches broad, furnished with three straps with buckles, to secure it round the part. The tourniquet was placed in the usual manner. The part above the place intended to be amputated was surrounded with a leather strap. The point of a crooked knife, which was made to pass as near to the back part of the bones as possible, was thrust in on one side of the leg, and made to come out on the other. The knife was then carried down nearly to the tendo achillis, and thus it separated almost the whole calf of the leg. The flap being formed, the operation was finished in the ordi- nary manner. The wound was then washed with a wet sponge, in order to clear it from the fragments of sawed bone. The leather strap, which served to secure the flesh, was next loosened, and the flap laid over the stump. The wound was dressed with lyco- perdon, lint, and tow, over which was put a bladder, sustained by strips of sticking-plaster. Upon this bladder was placed an instrument, called a retinacu- lum, consisting of a compress, and a concave plate, which were made to press upon the stump, by means of two straps, which crossed each other and were at- tached to the broad leather strap surrounding the thigh. In 1702, Sabourin, an able surgeon at Geneva, gave an account of Verduin's practice to the Royal Academy of Sciences, which, however, declined to pronounce any judgment about it, without farther experience. Though this method of amputation was objected to by Conerding, in a tract published at Amsterdam in 1705, it was afterward highly extolled by P. Mas- suet, on account of the quickness with which the stump healed, the safety with which the flap served for the stoppage of the hemorrhage, and the avoidance of exfoliation by the non-exposure of the bone. He also dwelt upon the excellency of the stump for the application of an artificial foot.—(De l'Amputation a lambeau, 8vo. Paris, 1756.) Heister disapproved of the flap-amputation, because it appeared to him, that the irritation of the flesh by the projecting bones was apt to cause pain and inflammation: he operated himself after the manner of Dionis, and was strongly in favour of the use of ligatures. Some exceUent precepts were delivered by J. L. Petit concerning amputation. He improved the tour- niquet ; and, instead of the large crooked amputating knife formerly employed, first brought into use the straight more moderate-sized knives with sharp backs, now seen in the hands of the best surgeons, because much better calculated than crooked knives for divi- ding the flesh by a sawing movement, which is the only right and surgical way of attempting to cut any part of the human body. He proved that making the division in the mortified parts was frequently followed by hemorrhage; and for the suppression of bleeding he thought it the best principle to promote the forma- tion of a coagulum.—(Mem. de l'Acad. des Sciences, an 1732, p. 285. See Hemorrhage.) For compressing the vessels, he employed an instrument which covered the stump, like Verduin's retinaculum, and made pressure by means of a screw. His only objection to Verduin's method was, that the extension of gangrene up the limb frequently hindered the formation of so large a flap. He laid down the valuable general maxim of al- ways removing as much bone, and as little flesh, as possible; for which purpose he invented what is termed the double incision, or dividing the business of cutting through the soft parts into two stages. About an inch higher than the place where he meant to saw through the bones, he first made the circular cut through the integuments down to the muscles; the skin was then pulled up so as to leave the flesh unco- vered to the extent of an inch, and the muscles were now divided at the highest point of their exposure. Lastly, the flesh was held out of the way with a retractor, and the bone was sawed through high enough up to allow of its extremity being well covered with flesh and in- teguments. The greatest defect in the doctrine of Petit, relative to amputation, was the confidence he put in pressure, instead of the ligature.—(Traite des Malad. Chir. vol. 3, p. 126.) The first performance of amputation at the shoulder-joint, by Le Dran, and the improvements and alterations of that operation sug- gested by Garengeot, De la Faye, Desault, &c. I shall notice in a future section. In chronological order, the next event claiming no- tice in the history of amputation, was the promulga- tion of an opinion by T. R. Gagnier, that Verduin's flap-amputation might be traced back to times of great antiquity, the method described by Celsus being very similar.—(Haller, Diss. Chir. vol. 6, p. 161.) On this point, with reference to Lowdham, the true inventor of the flap-operation, I have already delivered my own sentiments. The flap-amputation of the leg, after Verduin's man- ner, was tried by De la Faye, who found that the pres- sure of the flap was not enough to check bleeding from all the vessels, as it only operated on the anterior tibial artery, and by pressing the flesh more firmly against the end of the bones, he thought the risk of mortification would be occasioned. Verduin and Sabourin, as we have seen, made only one flap. Two French surgeons, Ravaton and Ver- male, afterward thought that it would be better to save a flap from each side of the limb. They were also ad- vocates for tying the vessels, and bringing the two flaps into contact, so as to procure their speedy union, and hinder exfoliations and profuse suppuration. However, there is some difference in their methods of forming the flaps. Ravaton, who submitted his plan to the French Academy in 1739, made three deep incisions down to the bone; first, a circular one, with a crooked knife, within four finger-breadths of the bone intended to be sawed; and then with a somewhat larger knife, the two others perpendicularly to the first, one at the fore part, and the other at the back of the limb; and, taking care not to touch the principal vessels, he detached the two flaps from the bone. Vermale formed the separate flaps by two incisions. After applying the tourniquet, he surrounded the part with two red threads, at the distance of four finger- breadths from each other; one at the place where the bone was to be sawed, the other at the place where the incision of the flaps was to terminate. He after- ward thrust a long bistoury down to the bone, at the fore part of the limb; turned it round the circumfe- rence, so that it might come out at the "opposite part ■ then, directing the edge of the knife along the bone he cut down to the inferior thread, where he separated the first flap, which, as the author says, was of a round or conical figure at its extremity. The second flap was made in a similar way on the interior side of the mem- ber—(Traite des Playes d'Armes A feu, par Ravaton £?■ ^S'i7,5n° DeJa Faye' in M6m- de l'Acad. de Chir. t. 5, ed. 12mo. Vermale, Obs. de Chir. 8vo. Man- heim, 1767.) In presence of M. Quesnay, Garengeot performed the flap-amputation according to the method of Ver- duin and Sabourin. We know that they made no liga. ture on the vessels, and that their intention was thai the AMPUTATION. 55 (lap, when applied to the stump, and sustained by a par- ticular apparatus, should reunite, and stop all bleeding. Garengeot's patient died on the third day after the operation ; hemorrhage having had a considerable share in producing death. The multiplicity of machines described by Verduin, La Faye, Sec. had no other end but that of keepjng the flap near the orifices of the vessels, so as to compress and close them. In consequence of the difficulty of making this compression precisely as required, the most considerable vessels being situated between the two bones, and when cut, generally becoming retracted, Garengeot determined in future to employ ligatures. With these views, twelve years after the foregoing case, Garengeot performed a flap-amputation of the arm, preserving two flaps, according to the method communicated to the Academy by Ravaton. The bra- chial artery was tied, and the patient was cured, with- out any exfoliations. Garengeot made a third trial of this operation on a soldier dangerously wounded in the right foot by the bursting of a bomb, which firaciured the interior part of the two bones of the leg, and several of the loot: the patient recovered in twenty-seven days. In this operation one single flap was made. Garen- goet was fearful, however, that the quick union might create some difficulty in withdrawing the ligatures, and he therefore took a means of hindering adhesion where they were situated; but of this objectionable plan I shall not speak. He rightly preferred dressing and bandaging the stump to the use of the compressing machines invented by Verduin and La Faye; and his choice of a straight knife, instead of a crooked one, was equally judicious. The preceding case dictated a truth, which will last as long as surgery itself, viz. that it is advantageous to apply the ligatures in such manner as to embrace no more than the vessel, so that they may fall off the sooner, and the parts more quickly unite.—(M. de Ga- rengeot, in Memoiresde l'Acad. de Chir. t. 5, 12mo.) At one time, an objection frequently urged against the foregoing methods was, that when the fresh cut flap was immediately laid over the stump, inflamma- tion and abscesses were apt to ensue. Hence, in 1765, Sylvester O'Halloran, a surgeon at Limerick, was led to make the experiment of deferring laying down the flap tUl the end of the first eight or twelve days after the operation, when it was conjectured that the risk of inflammation and abscesses would be diminished. The tenor of O'Halloran's book is apparently corroborated by the facts brought forward. Here we see one of the grand points, insisted upon by our worthy countryman James Yonge, viz. the chance of an immediate union of the wound from laying down the flap without deiay, suddenly given up, and because the wound could not always be healed without suppuration, it was deter- mined that it never should do so. However, it is con- solatory to find, that O'Halloran's suggestion now exists only in the history, and not in the practice, of surgery. Alexander Monro, senior, was a great opposer of cer- tain methods which originated among the French sur- geons, and, in particular, he disapproved of the tourni- quet : he secured the vessels with needles and liga- tures ; and was the inventor of a "bandage, which has been extensively approved of-under the name of Monro's roller.—(Medical Essays of Edinb. vol. 4, p. 257.) Bromfield, like Le Dran, restricted amputation to a few cases; and he did not acknowledge its necessity, as a matter of course, in every case of gangrene, much less in every instance of white swelling or caries. From a passage which I have cited from Dr. Rees's Cyclopae- dia, it would seem that the tenaculum was known to the ancients; yet, according to general opinion (and I cannot affirm that it is incorrect from any passage in my recollection), Bromfield is allowed to be the first modern surgeon who employed this very useful instru- ment.—(Chir. Cases and Obs. vol. 1, p. 41, 8vo. Lond. 1773.) About the year 1742, the removal of thighs without bloodshed was a subject a good deal broached. A sin- gle case recorded by Schaarschmid, where a mortified thigh separated without hemorrhage, was the founda- tion of the scheme. The arteries were completely blocked up, and the parts insensible.—(Haller, Diss. Chir. vol. 5, p. 155.) A similar occurrence was related by Acrel (Chir. handels. p. 557); and Lalouette pro- fessed himself a believer in the security from hemor- rhage, on account of the vessels being filled with coa- gula, and therefore he also approved of letting dead parts be removed, or rather fall off, without bloodshed.— (Haller, Diss. Chir. vol. 5, p. 273.) In cases where the projecting bone of the stump was affected with necrosis, Bagieu, an experienced military surgeon, ventured to amputate a second time, and urged a variety of arguments in defence of the practice.—(Mem. de l'Acad. de Chir. t. 2, p. 274.) He coincided with Le Dran and Bromfield, however, about the propriety of restricting amputation to few cases, and has related numerous examples of limbs being saved, which, according to the doctrines then in vogue, ought to have been cut off—(Deux Lettres d'un Chir. de l'Armee, 12mo. Paris, 1750.) M. Louis, a French surgeon of extraordinary talents, introduced the plan of dividing the loose muscles first, and lastly those which are closely connected with the bone. He noticed that the muscles of the thigh, after being divided, were retracted in an unequal degree. He observed that the superficial ones extending along the limb, more or less obliquely, without being attached to the bone, were- drawn up with greater force, and in a greater degree than others, which are deeply situa- ted, in some measure, parallel to the axis of the femur, and fixed to this bone throughout their whole length. The retraction begins the very instant when the mus- cles are cut, and is not completed till a short time has elapsed. Hence, the effect should be promoted, and be -as perfect as possible, before the bone is sawed. In the amputation of the thigh, Mr. Louis was always desirous of letting the muscles contract as far as they could, and for this reason he was rather averse to using the tourniquet, as the circular pressure of this instrument in some measure counteracted what he wished to take place; and hence, at one time he preferred letting an assistant make pressure on the artery, though he subsequently expressed his approbation of the tourniquet proposed by M. Pipelet for compressing the femoral artery.—(Mem. de l'Acad. de Chir. vol. 4, p. 60, 4to.) Actuated by such principles, Louis practised a kind of double incision different from that of Cheselden and Petit, and different also from Alanson's method, which I shall hereafter notice. By the first stroke he cut, af the same time, both the integuments and the loose su- perficial muscles; by the second, he divided those muscles which are deep and closely adherent to the fe- mur. On the first deep circular cut being completed, Louis used to remove a band which was placed round the limb, above the track of the knife. This was taken off in order to allow the divided muscles to become retracted without any impediment. He next cut the deep adherent muscles on a level with the surfaces of those loose ones which had been divided in the first in- cisiou, and which had now attained their utmost state of retraction. In this way he could evidently saw the bone very high up, and the painful dissection of the skin from the muscles was avoided. Louis was conscious that there was more necessity for saving muscle than skin; and he knew that when an incision was made at once down to the bone, the retraction of the divided muscles always left the edge of the skin projecting a considerable way beyond them. Hence he deemed the plan of first saving a portion of skin by dissecting it from the muscles and turning it up, quite unnecessary. As the bone should always be sawed rather higher than the division of the soft parts, Louis, like J. L. Petit, and most other judicious surgeons, highly approved of the employment of a retractor. He was likewise the author of some valuable instructions for preventing the protrusion of the bone after the operation.—(See Mem. de l'Acad. de Chir. t. 2, p. 268—410, uch opinion would be doing a serious ope- ration, and one which probably would not succeed ; for the anastomosing branches would restore the circula- tion in the stump in a short time, and again establish the bleeding. If it is the femoral artery that bleeds, and the ligature is applied high, it is very liable to a return of hemorrhage. To obviate these difficulties, the part from which the bleeding comes should be well studied, and the shortest distance from the stump care- fully noted, at which compression on the artery com- mands the bleeding; and at this spot the ligature should be applied, provided it is not within the sphere of the inflammation of the stump."—(On Gun-shot Wounds, p. 105, 106.) Thus far the advice seems to me correct and valuable; but where the hemorrhage could be re- strained by taking up the artery in the groin, though not lower down, I doubt the propriety of preferring ampu- tation to this other less severe operation, provided the efficiency of a ligature above the profunda be proved in the manner judiciously recommended by Mr. Guth- rie, viz. by means of pressure. The following is the counsel offered by Mr. Hey: " When we are under the necessity of amputating a limb that has suffered great contusion, though the ope- ration is performed upon a part apparently sound, the wound sometimes becomes sloughy and Ul-conditioned No good granulations arise to cover the extremities of the arteries ; but the ligatures cut through these ves- sels, or becoming loose, cease to make a sufficient pres- sure upon them, and hence repeated hemorrhages ensue. This is a dangerous state for a patient; for if the vessels are taken up afresh with the needle, the he- morrhage will now and then return in the course of two or three days. In such cases, the application of dry sponge cut transversely, as directed by Mr. White (Cases in Surgery), has been found singularly useful, and has saved the life of the patient. But a constant pressure must be kept upon the pieces of sponge by the fingers of a succession of assistants, till granulations begin to arise upon the stump, and the prospect of fu- ture hemorrhage disappears. This method is of the greatest importance after amputation on the thigh or leg, where the great vessels are deeply seated. In the arm, above the elbow, where the vessels are more su- perficial, the great artery may be taken up with a por- tion of muscular flesh above the surface of the stump, by making first an incision through the integuments. My colleague, Mr. Logan, has done this twice within the last year with complete success, when repeated ligatures, applied in the usual way, had failed. •' In the morbid sloughy state of the stump above-mentioned, the application of lint, soaked in a liquid composed of equal 'quantities of lemon- juice and rectified spirit of wine, has been found very advantageous, and has caused it to put on soon a healthy aspect."— (P. 536, 537, edit. 2.) [When this operation is necessary in crowded hos- pitals, where hospital gangrene is prevailing, Delpech recommends the practice of-cutting off the ligatures close to the knots on the vessels, so that the lips of the wound may be more completely and accurately brought together. By this means, as his experience has taught him, the risk of the wound being affected is materially les- sened. The small particles of the ligatures enclosed in the stump, he says, are discharged at a period when the patient has regained strength enough to be moved •into a healthy atmosphere, little openings being pro- duced for their escape, and healing up again within twenty-four hours. He assures us that he has never seen the practice give rise to an abscess. Delpech is led by the view he takes of the consequences of suppu ration, and the contraction of cicatrices, to prefer ■ bringing the sides of the wound together after ampu- tation of the thigh, so that the line of the cicatrix may be transverse and not perpendicular. His reason is, that most of the ligatures which unavoidably produce suppuration are placed on branches of the profunda in the posterior part of the limb, consequently here the greatest contraction follows cicatrization, and the ante- rior flap is- thereby drawn over the extremity of the bone in the most advantageous manner.—(Chirurg. Clinique, t. 2, p. 395.) The same author gives an in- stance of the failure of a seton to unite a broken thigh- bone, where no union had followed a long trial of com- mon means ; and he was in the end compelled to 68 AMPUTATION. amputate the limb at the hip joint; the second example of his performing this severe operation.—(P. 466.) Under certain circumstances he is an advocate for the excision of diseased joints in preference to amputa- tion ; and refers the union of the bones in this case, not to the same process by which fractures are united, but to the production of a fibrous substance analo- gous to that of a cicatrix. Several successful ex- amples of the practice are recorded.—(P. 472.) With respect to uncured fractures, I have now one under my care in the King's Bench. The accident happened two years and a half ago, and I have recommended the trial of a seton.—Pref.] ON PROTRUSION OF THE BONE. It is clearly proved by the observations of M. Louis, that this disagreeable consequence may be generally prevented by taking care to divide the loose muscles first, and (after their complete retraction, which will be favoured by no band or tourniquet being applied round the limb,) by observing to divide with a bistoury the muscles which adhere to the bone; for instance, the crural muscle, and the adhesion of the vasti and triceps to the spine of the femur. By this method, the bone may be sawn three finger-breadths higher than it could be if no attention were paid to beginning with the division of the loose muscles, and concluding with that of others attached to the bone. The protrusion of the bones will never take place so long as they are immediately encontpassed with the fleshy substance of the muscles: this proposition is incontestable. The state of the skin, whether longer or shorter, conduces nothing to this protrusion; nor wUl the inconvenience be prevented by drawing the Bkin upwards and preserving as much of it as possible. —(See Mem. sur la Saille de 1'Os apres l'amputation, in Mem. de l'Acad. de Chirurgie, torn. 5, p. 273, edit, in 12mo.) As Mr. Guthrie has observed, a protrusion of the bone, after sloughing of the stump, or other accidental circumstances, will sometimes happen without any fault on the part of the operator; but he thinks it may almost always be prevented by attention to the following rules:—l.To leave the integuments attached to the muscles, instead of turning them back. 2. When the muscles are cut through in a slanting direction, upwards and inwards, or even directly downwards, to separate them from the bone, so that it may appear at the bottom of the cone as a depressed point. 3. To cut the bone short, and to keep the thigh constantly bandaged from the trunk during the cure, so as to prevent the retraction of the muscles. If, says Mr. Guthrie, a surgeon find, directly after the operation, that the bone cannot be well covered, he should imme- diately saw off as much more of it as will reduce it to its proper length. The error may be remedied at this moment with very little inconvenience in com- parison with what must afterward be encountered if the opportunity be neglected.—(On Gun-shot Wounds, p. 109.) For some very useful directions how to ban- dage and support the soft parts with adhesive plasters, with the view of counteracting the tendency of the bone to protrude, I refer to some observations by Mr. Wright.—(See Bromfield's Chir. Cases, Sec. vol.1, p. 177.) Having explained, that the surest way of preventing the evU is to save a sufficiency of muscle, especially of that muscular substance which is naturally most near and adherent to the bone, we shall next speak of the mode of relief. When the end of the thigh-bone protrudes, it of course hinders cicatrization and becomes itself affected with necrosis. By the process of exfoliation, the dead portion of bone is sometimes thrown off, and a cure follows. But, in general, this desirable change is ex- tremely tedious, and the result uncertain, because it frequently happens that, after the piece of bone has separated, the rest yet projects too much, and the stump still continues too conical to heal firmly enough to be capable of bearing the pressure of a wooden leg. When, however, the end of the bone forms only a slight projection, and the stump is not too conical, it is always best to leave nature to throw off the redundant exfo- liating portion. In the opposite circumstances, the re- moval of all such part of it as cannot be covered by the integuments is the best" practice, and, if well executed, will effect a cure. Tins second operation is exceedingly unpleasant to the surgeon, because patients are apt to suspect, and not without reason, that the first was not properly managed. Let me therefore repeat, that the surest way of avoiding the evil is to cut the deep muscles rather higher than the superficial ones, as inculcated by M. Louis, by which means the bone wUl certainly lie within the level of the surface of the divided flesh. The advice delivered by my friend, Mr. Guthrie, I also consider valuable. - The second performance of amputation is a still more severe and unpleasant operation; yet, as Dr. Hennen has explained, it sometimes becomes neces- sary for osteosarcoma, extensive necrosis, abscesses of the medulla, unsuspected fissure, phagedena, or great protrusion of bone, with an extensively diseased peri- osteum, where the powers of nature are inadequate to the cure. " If the general health is not impaired, and the flesh does not peel off from the bone, as if it were boiled, the efforts of nature may be trusted to, aided by proper bandaging, and, in some cases, by the employ- ment of the saw; but when restless nights, intense pain, flushings, and irregular bowels, with great tume- faction and hardness of the stump take place, indi- cating approaching hectic, and there is evidence of an irregular action of the parts, osseous matter becoming deposited, and forming a distinct tumour around the stump, our best plan will be to operate again near the trunk."—(Principles of MUitary Surgery, p. 266, ed. 2.) Sometimes amputation has been considered necessary a second time, in consequence of a morbid protube- rance of the nerves of the stump, a change noticed by Molinelli, Morgagni, Lower, Arnemann, and Prochaska, and always attended with excruciating pain and great irritability of the part, and sometimes with retraction of the skin, and protrusion of the bone. Sir Astley Cooper, in his Lectures, relates one instance of such a stump high up the arm, where, upon examination of the part near the axilla, a tumour was felt, which, when touched, made the patient jump as if he had been elec- trified. In this case, as the bone protruded, amputa- tion at the shoulder was performed. In another ex- ample, where a leg-stump was in a painful irritable state from a similar cause, Sir Astley Cooper effectu- ally relieved the patient by removing the diseased end of the posterior tibial nerve. In a third instance, am- putation was repeated at the patient's desire, and the nerves were found enlarged, forming a ganglion which partly rested upon the extremity of the bone. Such a degree of irritation had been produced by it, that no part of the stump could be touched without exciting a kind of electric shock. In a case that occurred in the Middlesex Hospital, amputation of the thigh was per- formed a second time, in consequence of the first stump being thus diseased. A complete ganglion, or plexus of nerves, was found closely adhering to the removed portion of bone, having almost the appearance of cartilage. The os femoris was of an unusually small size, but the linea aspera larger than natural. —(See Lancet, vol. 1, p. 115; vol. 2, p. 192.) The following works may be consulted for informa- tion on diseases of the bones of stumps: Bonn, The- saurus Ossium Morborum, Amst. 1788; Weidmann de Necrosi Ossium, Francof. 1798 ; Macdonald, de Necrosi ac Callo, Edinb. 1799; the above-mentioned Essays of M. Louis; Leveille sur les Mai. des Os apres PAmputation, Mem. de la Societe d'Emulation, t. 1, p. 148 ; Von Hoorn De iis, quae in partibus membri, prae- sertim osseis amputatione vulneratis, notanda sunt; Lugd. 1803. Roux, de la resection des Os Malades, Paris, 1812; Mem. de Physiologie, &c. par Scarpa, et LeveiUe, Paris, 1804.) SPASMS OF THE STUMP. Spasmodic contractions of the muscles of the stump is another very afflicting occurrence. Such spasms put the patient to the greatest agony, tend to cause a protrusion of the bone or sugar-loaf stump, and in some cases increase, affect the whole body, and ulti- mately prove fatal. But this unfortunate affection which was rather frequent after amputations per- formed in the ancient manner, is infinitely less so after the modern improved plans of operating, tyine the vessels, and dressing the wound. When, how- ever, it does occur, the stump must be kept from start- ing, by fastening it to the pillow and bedding on which it lies, the flesh is to be properly supported with a bandage applied from the pelvis downwards, and opium and the camphor mixture should be liberally exhibited.—(Encyclopedic Methodique, Partie Chir. 1.1, p. 93. Latta's Surgery, vol. 3, Sec.) FLAP-AMPUTATION OF THE THIGH. Although I concur with the majority of surgeons in regarding the operation by a circular incision the most eligible under ordinary circumstances, no doubt can exist about the preference which should be given to amputating with a flap in particular examples. The choice, as Dr. Bushe has well remarked, ought to de- pend on the state of the limb and nature of the malady requiring amputation. " One surgeon is so devoted to the double circular incision, that he performs no other (method), though his coadjutor in the same hospital is bigoted to the double flap-operation, and never ampu- tates but after this manner. But the unprejudiced practitioner will look to the nature of the case, and adjust means accordingly."—(Lancet, No. 246, p. 204.) Notwithstanding this good doctrine, however, Dr. Bushe is in reality very partial to flap-amputations, affirming, that there is only one part, viz. the upper third of the leg, where he would recommend the double circular incision to be preferred.—(Op. cit. p. 207.) At the same time, he confesses, that when the arm is much emaciated and flaccid, Dupuytren's mode, with a sin- gle circular incision, is that to which he has himself given the preference. He admits, also, the frequency of tedious suppuration and sinuses after flap-amputa- tions, which evils, however, he ascribes to the fault of making the flaps too long.—(P. 206.) Flap-ampu- tation of the thigh, I believe, has the important advan- tage of being least exposed to the danger of a protrusion of the bone, and, hence, I think it may be advisable, whenever any reasons exist in the state of the parts, or the constitution, for apprehending that disagreeable occurrence. An experienced military surgeon informs us, that, in the first years of his practice, he performed several amputations by the double incision, strictly according to the precepts of Sabatier, Desault, Pelletan, and Pott, but had the mortification to have three cases in which the bone protruded, though the greatest cir- cumspection was used in the operation and after- treatment. Hence he was induced to make trial of the flap-amputation, and although he imitates O'Hal- loran in not attempting to bring the flaps close together for the first six or eight days, he reports that the stump is generally healed in twenty or thirty days, and exfoliations rarely happen, on account of the bone being so well covered. In short, he says, that this method is to be preferred to all others.—(J. B. Paroisse. Opusc. de Chir. p. 185—203. Paris, 1806.) Mr. Syme also informs us, that though the flap- amputations seen by him have been very numerous, lie has never met with an instance of the bone pro- truding or exfoliating after them.—(Ed. Journ. vol. 14, p. 38.) A description of Desault's or rather Vermale's mode of operating, being given in the First Lines of the Practice of Surgery, I need not here repeat it, nor say by how many respectable names the practice is sanc- tioned. In Guy's Hospital, flap-amputation of the thigh seems now to be mostly preferred. The operation is also sometimes adopted by my friend Mr. Vincent in St. Bartholomew's- Hospital, who showed me, some time ago, a capital stump which he had made in this manner, and which healed with great expedition. By Mr. Guthrie the flap-operation is considered pre- ferable to the circular incision at the upper part of the thigh, " as it permits the head of the bone to be re- moved if found necessary, allows it to be examined and cut shorter with greater ease, and makes a much better covering afterward.—(On Gun-shot Wounds, p. 200.) In military surgery, flap-amputation of the thigh is often advantageous, because all the flesh on one side of the limb is frequently torn away, or left in so terri- bly a mangled state as to be unfit for making a cover- ing for the end of the bone. Here a flap, sufficient to cover .'he whole face of the stump, should be saved from the sound flesh on the other side of the limb. When the surgeon chooses the flap-amputation, not from necessity, as under these last circumstances, and the flesh is sound all round the member, the best way is to save a flap on each side of the limb, by making two semicircular cuts, the convexities of which extend in a parallel manner forwards, and the terminations of nATION. 69 which meet at the upper and lower surfaces of the limb. The skin is not to be at all dissected from the muscles, which are to be obliquely divided as high as the base of the flap on each side. However, though this is the best plan, particular cases may require a flap to be made from the anterior, or even the posterior side of the thigh. The latter method should never be followed but from necessity.—(See Hey's Pract. Obs. in Surgery, p. 531. ed. 2.) According to Mr. Guthrie, the difference between the flap-operation at the upper part of the thigh and that at the hip consists jn its being done lower down, and in the flaps being saved more immediately from the ex- ternal and internal sides of the thigh, the inner flap be- ing the largest, in order to prevent the inconvenience which might arise from the external one being tightly stretched over the end of the bone. For the same rea- son Mr. Guthrie also recommends the bone to be sawed off close tothe lesser trochanter, even when the nature of the injury would allow of its being left an inch longer.—(On Gun-shot Wounds, p. 200.) Flap-amputation of the thigh, after the manner of Vermale, is now preferred by Klein, one of the best operating surgeons in Germany, and by Messrs. Liston and Syme, two surgeons of great merit in Edinburgh. —^See Edinb. Med. and Surg. Journ. vol. 14, p. 36—46, &c.) It is also sometimes practised in several of the metropolitan hospitals. Of seven cases in which Klein adopted this method, the greater number were healed in ten days, and the rest in three weeks; and this suc- cess determined him in future always to practise it. After this mode he finds there is no danger of the mus- cles retracting themselves, and leaving the end of the bone protruding, even though the patient be transported from one place to another. With respect to the occa- sional difficulty of taking up the obliquely cut vessels. Klein admits this objection, but thinks that it equally applies to Alanson's method. He lays great stress on the utility of giving due support to the flaps with compresses and a roller.—(See Practische Ansichten der bedeutendsten chirurgischen Operationen, p. 35—38, 4to. Stuttgart, 1816.) In one instance, where a ball had broken the upper part of the femur, and mortification had spread so far towards the great trochanter and buttock, that it was impossible to operate except by the flap-operation, or by taking the head of the bone out of the joint, Klein made a broad flap six inches long at the inner and upper part of the thigh, and then he cut the soft parts straight across just below the great trochanter, so as to make this wound meet the termination of the incisiqn by which the inner flap was formed. This patient got perfectly well in three weeks (Op. cit. p. 39); and so did another very similar case, operated upon by the same gentleman.—(P. 43.) Where the bleeding is con- siderable, the femoral artery and profunda should be tied previously to sawing the bone; but if the vessels are well commanded by the pressure the sawing ought to be first completed. At the middle of the thigh, Lisfranc also prefers am- putating with two lateral flaps; pressure is made on the femoral artery as it passes over the brim of the pelvis; and the vessel is tied immediately the inner flap is formed. Lisfranc makes the flaps with a very long narrow two-edged knife, which he introduces through the limb on each side, and then cuts obliquely outwards, and downwards with it; but I think Mr. Syme is right in recommending the knife used by Mr. Liston, and the back of which is thin and blunt except for an inch from the point.—(Ed. Med. Surg. Journ. vol. 14, p. 37.) Mr. Hey also preferred a knife with a blunt back, lest the vessels should be cut with it in a way that would render the securing of them troublesome. AMPUTATION BELOW THE KNEE. In treating of amputation of the thigh I have remarked that as much of the limb as possible should be preserved. The longer it is after the operation, tbe stronger and more useful will it be found. But when the leg is to be amputated writers commonly advise the operation to be performed a little way below the knee, even though the disease for which the limb is removed may be situated in the foot or ankle, and would allow the operation to be done much farther down. The common practice is to make the incision through the integuments, just low enough to enable the operator to saw the bones, about four inches below the lowest part of the patella. 70 AMPUTATION. About six inches below this point is generally an eligi- ble place for the first circular cut through the skin. This degree of lowness is usually deemed necessary, in order not to deprive the stump of that power of motion which arises from the flexor tendons of the leg continu- ing undivided. It is alleged also as a reason for this mode of proceeding, that it is quite sufficient to pre- serve a few inches of^he leg in order to afford the body a proper surface of support in walking with a wooden leg; whereas, if a larger portion was saved, the super- fluous part would be a great inconvenience both in walking and sitting down, without being of the small- est utility in any respect whatever. However, as I shall presently notice, experience proves that where, according to these maxims, an injury or disease would dictate the performance of amputation above the knee, the practice of amputating below this joint, but much higher than is generally sanctioned, may be followed with advantage. The tourniquet should be applied to the femoral ar- tery about two-thirds of the way down the thigh, just before the vessel perforates the tendon of the triceps muscle. This place is much more convenient than the ham, where it is very difficult to compress the vessel against the bone. The patient is to be placed upon a firm table, as in the amputation of the thigh, and the leg being properly held by one assistant, while the integu- ments are drawn upwards by another, the surgeon with one quick stroke of the knife is to make a circular in- cision through the integuments all round the limb. Some recommend the operator to stand on the inside of the leg, in order that he may be able to saw both bones at once. No reflections could ever make me perceive that any real advantage ought strictly to be imputed to this plan. Many suppose that it diminishes the chance of the fibula being splintered, this bone being com- pletely divided rather sooner than the tibia. But splin- tering the bones generally arises from the assistant de- pressing the limb too much, or else not supporting it enough. If the assistant were to be guilty of this mis- management, it would be difficult to explain why the tibia should not be splintered instead of the fibula, when a certain thickness of it had been sawed through. At the same time it must be admitted, that if the sur- geon prefer standing on the inside of the limb, there is no objection to it at the time of using the saw; but be- fore this period, in amputating the right leg, there is great convenience in having the left hand next to the wound, as is the case when the surgeon stands on the outside of the right limb. Hence I have seen many hospital surgeons, in amputating the right leg, cut the soft parts while they stood on the outside of the limb, and having done this part of the operation they pro- ceeded to the other side of the member for the purpose of applying the saw. I have only to repeat, that I do not think any particular reason exists against saw- ing the two bones together, yet in such manner as to let the fibula be divided entirely through the first; and the advantage of fixing this bone against the tibia by the pressure of the hands of the assistants, while the surgeon is sawing it, is another circumstance which influences a gfeat many writers to commend the latter plan. Graefe, who, as already mentioned, prefers the true flap-operation, does not think it advisable for the surgeon to stand on the inside of the limb in his me- thod of operating, because, when the knife is intro- duced through the muscles of the calf, its point would be apt to go between the two bones.—(Normen for die Abl. grosserer Gliedrn. p. 130.) A circular cut having been made through the integu- ments, about two inches below the place where it is intended to saw the bones, the next object is to pre- serve skin enough to cover the front of the tibia and the part of the stump corresponding to the situa- tion of the tibialis amicus, extensor longus pollicis pe- dis, and other muscles, between the tibia and fibula, and those covering the latter bone. Throughout this extent there are no bulky muscles which can be made very serviceable in covering the end of the stump, and consequently the operator must take care to preserve sufficient skin in this situation by dissecting it from the parts beneath and turning it up. On the back part of the leg, on the contrary, the skin should never be uselessly detached to a great extent from the large gastrocnemius muscle, which, with the soleus, will here form a sufficient mass for covering the stump. However, the experience which I had in the army taught me the truth of a remark made by Graefe, that in forming the posterior flap of muscle it is a mat- ter of the highest importance to let the integuments be somewhat longer than it; for otherwise, when it is turned forwards, as it must be for the purpose of cover- ing the ends of the bones, its front edge will be left un- covered by integuments which, being the outermost, describe a greater circumference than the deeper mus- cular flap.—(Normen for die Abl. grosserer Glied. p. 131.) I was fully convinced of the truth of this ob- servation by two amputations which were done by my- self one in the neighbourhood of Antwerp, in 1814, and the other at Brussels the day after the battle of Water- loo. Yet Graefe, who performs the flap-amputation, strictly so called (that is to say, the operation in which a flap of skin corresponding in shape to the flap of muscle is preserved), does not himself detach the skin from the muscles of the calf at all, but at the time of making the incision in that situation directs one as- sistant to pull up the integuments, while another bends the foot as much as possible, which manoeuvres have the effect of letting the muscles be cut rather shorter than the skin. Unfortunately, however, in many cases, the very nature of the disease or injury for which the operation is performed, would not admit of these pro- ceedings. Nor, in a very muscular limb, would they be likely to suffice, as Graefe himself confesses, since in such cases he recommends the use of a knife bent laterally for the purpose of excavating, as it were, as the incision is made, the thick muscular flap.—"-(Op. cit. p. 134.) In the common method with the circular incision, I am disposed to think it best, therefore, to let a small quantity of skin be detached and saved at the back part of the leg, so that there may be a certainty of having enough to cover well the extremity of the di- vided muscles of the calf. As soon as the skin has been separated in front and on the outside of the leg, the surgeon is to detach the skin from the calf for about an inch, and having reflected or drawn this pre- served portion out of the way, he is to place the edge of the knife close to the edge of the retracted or reflected skin at the back of the limb, and cut obliquely upwards through the muscles of the calf, from the inner edge of the tibia quite across the fibula, supposing the operator to be on the outside of the. right leg, and that it is this member which is undergoing removal. In performing this last incision, as M. Louis well observes, it is es- sential to incliue the edge of the knife obliquely up- wards. In this manner the skin will be longer than the muscles, and the cure considerably accelerated.— (Mem. de l'Acad. de Chir. t. 5, edit, in 12mo.) In the leg, the necessity of dissecting the skin from the subjacent 4>arts is acknowledged to be greater than in the thigh: thus Mr. Guthrie says, " as the attach- ment of the skin to the bone will not readily allow of its retraction, it must be dissected back all round, and separated from the fascia, the division of which in the first incision would avail nothing, from its strong at- tachment to the parts beneath."—(On Gun-shot Wounds, p. 220.) In dissecting the skin, however, a much greater detachment of it should be made at the front and outer part of the limb, than at the opposite points, as already explained. The flap formed of the integuments and muscles of the calf is then to be held back by one of the assist- ants, while the surgeon completes the division of the rest of the muscles, together with that of the interos- seous ligament, by means of the catling, a kind of long, narrow, double-edged knife. In amputating below the knee, very particular care must be taken to cut every fasciculus of muscular fibres before the saw is used. Every part except the bones being divided, the soft parts are next to be protected from the teeth of the saw by a linen retractor, made with two slits to receive the two bones, care being taken to let the unslit part be applied to the muscles of the calf, as particularly advised by Graefe —(On rit p. 136.) v * In tho leg there are only three principal arteries re- quiring ligatures, viz. the anterior and posterior tibial and the peroneal or fibular arteries. In addition to these, however, the surgeon is sometimes obliged to tie large muscular branches. The anterior tibial artery will be found in front of the interosseous membrane and between the extremities of the bones ; tbe fibular artery behind the fibula; and the posterior tibial situ- ated more inwardly than tlie last, among the fibres of AMPUTATION. 71 Oie soleUB, near the tibia.—(C. Bell, Oper. Surgery, vol. I,p. 385.) When the soft parts have been cut in the preceding way, the bones sawed, and the arteries tied, the wound is to be closed by bringing the flap of skin over the front and external parts of the stump, so as to meet the flap composed of the gastrocnemius, soleus, and integuments on the opposite side. This should be done without letting any tight strap of plaster press the skin against the sharp edge of the tibia; a serious and hurtfUl practice, which has often occasioned ulcera- tion and sloughing of the integuments, and protrusion and necrosis of the bone. It is this danger which leads Mr. Guthrie to prefer closing the wound vertically, or nearly so, and applying the adhesive straps from side to side.—(On Gun-shot,Wounds, p. 221.) I think, how- ever, the above mode of operating almost necessarily re- quires the wound to be closed, so as to form a line, extend- ing in a direction from the tibia to the fibula. But where a great deal of skin is saved all round the limb, and the muscles of the calf are not chiefly calculated upon for covering the bones, the perpendicular line of the wound wUl answer very well. Many surgeons, however, operate differently. They first make the circular incision through the skin, two' inches below where they mean to saw the bones. Thoy next detach the skin from the muscles and bones equally all round the limb to the extent of about a couple of inches. The integuments are then turned up, and a division of the muscles made all round down to the bones, on a level with the line where the detach- ment of the skin has terminated. The parts between the bones are afterward cut through, applied, but merely strips of sticking-plaster, perfectly judicious.—(Op. cit. p 33—34.) [For amputation ofthe lower jaw see note on "Jaw- Bone." For amputation or excision of the upper jaw as first performed in this country by Dr. David L. Ro- gers, of this city, see note on " Osteosarcoma •*' or for the details of the case, reference may be had to the N. Y. Med. and Phys. Journal for 1824, vol. 3, p. 301. For amputation or exsection of the clavicle, an opera- tion performed for the first time by Dr. Mott, in 1829, see also note on " Osteosarcoma."—liecsc] The following sources of instruction, on the subject of amputation, are particularly entitled to notice: Cel- sus de Re Medica. LEuores de Pari, livre 12, chap. 30 et 33. James Yonge, Currus Triumphalis i Terebin- tho, bvo. Lond. 1679. R. Wiseman, Chir. Treatises, ■ilo. Lond. 1692. Sharp's Operations of Surgery, chap. 37, and Critical Inquiry into the present slate of Surgery, chap. 8. Raoaton, Traite des Plaies d'Ar- mes a Feu, Paris, 1768. Bertrandi, Traite des epi- lations de Chirurgie, chap. 23. Le Drun's Obs. de Chir. Paris, 1731, and his Traite des Opera- tions de Chirurgie, Parts, 1742, and the English Translation with the additions of Cheselden, by Gata- ker, Lond. 1749-; Heister's Instil, Chirurg. pars 2, scct.l. Nouoelle MiLhode pour faire V Operation de I'Amputation dans ''Articulation du Bras uoec "' Omo- plate, par M. de La Faye. P. H. Dahl, Dis. de Hu- meri Amputatione ex Arliculo. Gott. 1760. His- toire de I'Amputation, suivant la Milhodc de Verduin et Sabourin, avec la Description d'un nouvel instru- ment pour cette Operation, par M. De la Faye. P. H. F. Verduin, Dis. Epislolaris de Nova Artuum de- curtandoruui Rdtione, Vlmo. Amst. 1696. Mo-yens de rendre plus simple et plus sure VAmputation a Lam- beau, par M. de Garengeot. Observation sur la Re- section del'Os, apris I'A imputation de la Cuisse, par M. Vcyret. Mi moire sur la Saillie de V Os aprJs t'Amputation des Membres; uii I'on examine les causes de cet inconvenient, les muyens d'y remedier, et ceax de la prevenir, par M. Louis. Seconde Memoire sur V Amp illation des Grundes F.xtrimitis, par M. Louis. The foregoing Essays are in Mim. de l'Acad. de Chirurgie, I. 5, edit. V2mo. R. de Vermale, Obs. et Rcmarques de Chirurgie pratique, Manlieim, 1767. Essai sur les Amputations dans les Articles, par M. Brasdor, in t. 15 Mini, de l'Acad. de Ctiir. J. U. Bil- guer de Membrorum Amputatione rarissime adminis- tranda aut. quasi abroganda, ito. Hula Magd. 17(51. White's Cases in Surgery, 1770. Bromfield's Chirur- gical Observations and Cases, vol. 1, chap. 2, 8vo. 1773. O'HallorTin's.complete Treatise on Gangrene, <$•<;., with a new Method of Amputation, 8vo. Dublin, 1765. Alanson's Practical Observations on Amputa- tion, ed. 2, 1782. ./. L. Petit, Traiti des Maladies Chir. i. 3, Paris, 1"4, or the later ed. 1790. R. My- nor's Practical Thoughts on Amputation, Birmingh. 1783. T. Kirkland, Thoughts on Amputation, i,c 8va. Lond. 1780 Loder, Comment, de Nova Alan- soni, Ampututiunis Melhodo, Progr. 1,7, Jen. 1784, or Chir. Med. Bcobachtnngen, 8co. Weimar, 1794. J. F. Tschipius, Casus de Amputatione Fcmoris non Cruenta, Halie, 1742. {Haller, Disp. Chir. 5, 239.) Mursinna, Neve Med. Chir. Beobacht. Berlin, 1796; P. F. Walther, Abhandl. aus dem Gebiete der Prakt. Medicin, besonders der £hirurgie and Augenheil- kunde, b. 1, Landshut, 1810; Kern. Ue'oer die Hiaid- lungswcise bey der Absetzung der Glieder. Wien, 1814^ G. Kloss, De Amputatione Humeri ex Articulo, ito. Francof. 1811; W. Eraser, An Essay on the Sliuuldei-joint Operation, 8vo. Lond. 1813. H. Robbi, De Via ac Ratione, qua nlim membrorum Amputalio instituta est, ito. Lips. 1815. J. P. Roux, Miuwire et Obs. sur la Riunion- Immediate de la Plaie apris VAmputation, 8vo. Paris, 1814. J. G. Hause, Ampu- tationis Ossium prweipua qutedam momenta, Lips. 1801. J. F. L>. Evans, Practical Observations on Cur- taract and closed Pupil, and on the Amputation of the Arm at the Shoulder, Src. 8vo. Lond. 1815. H. J. Brunninghausen, Erfahrungen und Bemerkungeniiber die Auputatiunen, 8vo. Bamb. 1818. Langenbeck, Bibl. fur die l-hirurgie, b. 1, p. 502, S,-c. 8eo. Gott. 1816. 'P. G. Van Hoorn, De iis, qua in partibus Membri, prasertim osseis, amputatione vulnei-atis notanda sunt. ito. Lugd. 1803. Graefe, Nurmen fiir die Ab- I6«nng grBsserer Gliedm. ilo. Berlin, 1813. Klein, Fruittscke Ansichten btdeuttiidsten Chir. Up.h.l, 4t "ear, and a>\p, the eye.) Same as ^Egylops. ANCHYLOSIS. (From ayvv~\oc, crooked.) This denotes an intimate union of two bones which were naturally connected by a moveable kind of joint. All joints originally designed for motion may become an- c'hylosed, that is, the heads of the bones forming them may become so consolidated together that no degree of motion whatever can take place. Bernard Conner (De stupendo ossium coalitu) describes an instance of a general anchylosis of all the bones of the human body. A still more curious fact is mentioned in the Hist, of the Acad, of Sciences, 1716, of a chUd 23 months old affected with universal anchylosis. In the ad- vanced periods of life anchylosis more readily occurs than in the earlier parts of it. The author of the ar- ticle Anchylosis in the Encyclopedic Mcthodique, men- tions a preparation in which the femur is so anebylosed with the tibia and patella, that both the compact and spongy substances of these bones appear to be common to them all without the least perceptible line of sepa- ration between them. In old subjects the same kind of union is common between the vertebra? and between these and the heads of the ribs. Anchylosis is dirided into the true and false. In the true, the bones grow together so completely that not the smallest degree of motion can take place, and the caso ANCHYLOSIS. 80 U positively incurable. Th* position in which the joint becomes thus unalterably fixed makes a material difference in the inconvenience resulting from the oc- currence. In false anchylosis the bones have not com- pletely grown together, and their motion is only dimi- nished, not destroyed. True anchylosis is sometimes termed complete ; false, incomplete. In young subjects in particular, anchylosis is seldom an original affection, but generally the consequence of Borne other disease. It very often occurs after frac- tures in the vicinity of joints; after sprains and dislo- cations attended with a great deal of contusion; and after white swellings and abscesses in joints. Aneu- risms, and swellings, and abscesses on the outside of a joint may also induce anchylosis. In short, every thing that keeps a joint for a long timem otionless may give rise to the affection, which is generally the more com- plete the longer the cause has operated. When a bone is fractured near a joint, the limb is kept motionless by the apparatus during the whole time requisite for uniting the bones. The subsequent in- flammation also extends to the articulation, and attacks the ligaments and surrounding parts. Sometimes these only become more thickened and rigid : on other occa- sions, the inflammation produces a mutual adhesion of the articular surfaces. Hence fractures so situated are more serious than when they occur at the middle part of a boue. After the cure of fractures, a certain degree of stiffness generally remains in the adjacent joints, but this is different from true anchylosis; it merely arises from the inactivity in which the muscles have been kept, and their consequent loss of tone. The position of an anchylosed limb is a thing of great importance'. When abscesses form near the joints of the fingers, and the tendons mortify, the fingers should be bent, that they may anchylose in that position, which renders the hand much more useful than if the fingers were permanently extended. On the contrary, when there is danger of anchylosis, the knee should always be kept as straight as possible. The same plan is to be pursued, when the head of the thigh-bone is dislocated in consequence of a diseased hip. When the elbow cannot be prevented from be- coming anchylosed, the joint should always be kept bent. No attempt should ever be made to cure, though every possible exertion should often be made to prevent a true anchylosis. The attempt to prevent, however, is not always proper, for many diseases of joints may be said to terminate when anchylosis occurs. When the false or incomplete anchylosis is appre- hended, measures should be taken to avert it. The limb is to be moved as much as the state of the soft parts will allow. Boyer remarks, that this precaution is much more necessary in affections of the ginglymoid than of the orbicular joints, on account of the "tendency ofthe former to become anchylosed, by reason of the great extent of their surfaces, the number of their ligaments, and the naturally limited degree of their motion. The exercise of the joint promotes the secretion of the synovia, and the grating first perceived in conse- quence ofthe deficiency of this fluid soon ceases. A cer- tain caution is necessary in moving the limb: too violent motion might create pain, swelling, and inflammation, and even caries of the heads of the bones. It is by pro- portioning it to the state of the limb, and increasing its extent dafly, as the soft parts yield and grow supple, that good effects may be derived from it.—(See Boyer, Mai. des Os, t. 2.) The use of embrocations and pump- ing cold water on the joint every morning have great power in removing the stiffness of a limb remaining after the cure of fractures, dislocations, &c. Unreduced dislocations are not always followed by anchylosis. Nature often forms a new joint, especially in persons of the lower order, who are obUged to move their limbs a great deal, in order to obtain a livelihood. The surrounding cellular substance becomes condensed, so as to form around the head of the luxated bone a membrane serving the purpose of a capsular ligament. Tho muscles, at first impeded in their action, become so habituated to their new state, that they resume their functions. This is particularly the case with bones which move in every direction, and have round heads; but in ginglymoid joints, the heads of the bones are onlv imperfectly dislocated, and the motion is greatly restrained by the extent of surface; while some of the BVtneroui ligaments are only sprained, not ruptured. I>»jc causes promote the occurrence of anchylosis. I Anchylosis may follow sprains and contusions ofthe joints, and such shocks as the articular surfaces expe- rience in leaping or falling on the feet from great heights. This is more likely to happen when the in- flammatory symptoms, resulting from such violence, have not been properly counteracted by bleeding and other general remedies, while the plan of beginning to move the joint gently every day, as soon as the case will allow, has been entirely neglected. When certain diseases of joints end in complete an- chylosis, it is sometimes a desirable event. In fact, it is as much a means of cure, as the formation of callus is for the union of broken bones. The disease of tbe ver- tebra?, described by Pott, is cured as soon as the bones anchylose, nor can the patient be considered weU be- fore this event has taken place.— W. H. Miiller, de Anchylosi, Lugd. 1707. VEncyclodedie Melhodique, partie Chir. t. 1, art. Anchylose. ./. L. Petit, Traite des Mai. d' Os, I. 2. J. T. van de Wynpcrsse, de An- chyloscos Pathologia et Curutione ; singulanbus eifig. illustr. ito. Lugd. 1783. Gentleman's Magazine, 1787, universal anchylosis, ligaments ossified. Wurt, Wundarzn. p. 224, following the removal of the patella. Sandifort, Exercit. Acad. p. 1, &-c., anchylosis of the occiput with the atlas, and of the atlas with the denta- tus ; Sandifort, Obs. Pathol, anchylosis of the jaw. Dumas, Recueil Periodique de la Societe de Med. t. 10, p. 30, and 1.13, p. 352. Hennen's Principles of Mili- tary Surgery, p. 161, &c. ed. 2. The examples of gene- ral anchylosis are numerous: Ploucquet refers to Co- lumbus de Re Anatomicd ; Connor de stupendo Ossium coalitu, Oxon. 1695; Deslandes in Mem. de l'Acad. des Sciences, 1716 ; Frank, Rcise nach Paris, London, &-C-, p. 127, anchylosis of all the joints except those of the lower jaw; Olivier, in Journ. de Mid. t. 12, p. 273; Voigt Mag. fur den Neueslen Zustand der Naturkunde, b.4,p. 412; Portal, Cours a"Anal. Med. t. },p. 14; Phil. Trans. No. 461 ; ./. C. Smith, Nat. Hist. Hibernim Comit. 1744. Job a Meckren's Obs. c. 64, p. 297 Callisen's Systema Chir. Hodierna, t.2,p. 699, edit. 1800. Boyer, Mai. des Os, I. 2, et IVaite des Mala- dies Chir. t. 4, p. 553. Verduc, Traite des Bandages, chap. 35, p. 172. Richerand, Nosogr. Chir. t. 3, p. 223, edit. 4. Murray, Diss, de Anchylosi, Upsal. 1797. [A highly interesting operation has been performed by Professor Mott for the cure of permanent anchylosis, or rather " immobility of the lower jaw,'' which had existed for ten years. A report of this case is pub- lished in the American Journal for Nov. 1829; but as the disease and operation are of so novel and interesting a character. Dr. Mott, at my request, has politely fur- nished me with the following description of the case, which cannot be unacceptable to the profession, and I therefore insert it here. "A young man, twenty-one years of age, from North Carolina, called, with the lower jaw almost immoveably fixed to the upper. No motion in a downward direction could be discovered, nor was the most powerful effort with the hand upon the chin able in the slightest de- gree to alter its situation. He had been in this deplora- ble state for ten years. Unable to chew a mouthful of food, or even open the jaws for its reception, his food had to be introduced through a small opening, oc- casioned by an irregularity of the bicuspides teeth on the right side. On the left side, just within the angle ofthe mouth, a very firm band, of more than ligament- ous hardness was to be seen and felt, reaching from this point along the al veolar ridge to the coronoid process. Along the whole course of this adhesion to the gum of the lower jaw, there was not a vestige of a tooth, and he stated that from this part the jaw had been formerly separated, with the teeth attached to it. This morbid adhesion had been several times freely divided; it was cut from within the mouth in different direc- tions, but never permitted the least motion of the jaw. From the circumstance that he could give a little lateral motion to the jaw, I thought that his mouth might yet be opened, and the deformity removed. I then made an incision from the angle of the mouth on the left side through the cheek, nearly to the coro- noid process, dividing the firm cicatrix within com- pletely. The jaws being relieved by dividing all the adhesions between them, a piece of very broad tape was placed between the teeth by a probe and spatula, and tied some distance below the chin. To the loop thus formed I applied all the strength I could Command, but not the least yielding of the jaw could be discovered. 90 ANE I then applied the principle of the screw and lever, by an instrument prepared for the purpose, composed of two steel plates about three inches in length. When applied to each other, they were of a wedge-shape. To the large end was attached a screw, which, when turned, caused the thin extremity of the plates to expand. This instrument'enabled me to open the mouth completely. With considerable difficulty this vice was insinuated between the range of teeth on the left side, resting along their whole course. It was then expanded, by turning the screw, and such was the report that at- tended the yielding of the lower jaw, that several pre- sent thought it was broken, but the noise was like that attending the laceration of ligaments rather than such as attends the fracture of a bone. The mouth was im- mediately opened to a sufficient extent. The wound was closed with the interrupted suture and adhesive plaster; to prevent the adhesion of the cheek to the jaws internally, pieces of sponge were in- terposed. The patient was enabled to chew his food, and to converse and articulate distinctly as the result of the operation, and he entirely recovered." Dr. Mott has since repeated the operation with the same success on a gentleman from Louisiana. In the North Amer. Med. and Surg. Journal for April, 1828, Dr. J. Rhea Barton has published a most success- ful operation performed on a case of anchylosis at the hip-joint, attended with very great deformity, after it had existed for more than eighteen months. The object of the operation was to substitute an artificial joint for the loss of the natural articulation at the hip, and it is most honourable to Dr. Barton, and alike gratifying to the profession and to humanity, to record, that it has been most completely successful. An abridged account of this novel and most interesting exhibition of consum- mate surgical skill is given in the Appendix to the late Philadelphia edition of Cooper's " First Lines," of 1828. It was performed on a sailor at the Pennsylvania Hos- pital in Nov. 1826. In Dr. Francis's edition of Denman's Midwifery is described a peculiar affection of the hip-joint, in some respects novel and important. It is in effect an anchy- losis, and is denominated " a displacement of bone without fracture or dislocation," inducing a morbid change in the form and cavity of the pelvis, such as might wholly defeat the process of natural labour. The patient, an adult subject, fell on the right hip; the injury done to the external parts was comparatively slight; but an inflammatory action took place in the bottom of the acetabulum, which caused total absorption of the bone, and the protrusion of the head of the thigh- bone itself into the cavity of the pelvis. Nor was the diseased action limited to these changes; large deposites of osseous matter were made within the pelvis sur- rounding the absorbed acetabulum; and the head of the thigh-bone was by the same material augmented to more than double its original size. The neck of the bone and also both trochanters were considerably in- creased in bulk. The capacity of the pelvis was dimi- nished about two inches in its superior and lateral portion.—Reese.] ANEURISM, or ANEURYSM. (From avevpvvu, to dilate.) The tumours which are formed by a preterna- tural dilatation of a part of an artery, as well as those swellings which are occasioned by a collection of arte- rial blood, effused in the cellular membrane, in conse- quence of a rupture or wound of the coats of the artery, receive the name of aneurisms. According to these opinions, aneurisms are of two kinds; the first being termed true; the second spurious or false. Some mo- dern writers have ventured to reckon another form of aneurism, which is said to happen when the exter- nal coats of an artery being weakened by mechanical injury or disease, the internal coat protrudes through the breach in the outer coat, so as to form a tumour distended with blood. This case has been denominated the internal mixed aneurism, or aneurisma herniam arterias sistens. The reality of this form of disease was believed by Dr. W. Hunter; and some delicate experiments, instituted by Haller on the mesenteric ar- teries of frogs, appear to have been the first ground of the opinion. Such an aneurism, however, has not been universally admitted, not that any body doubted the correctness of what Haller advanced, but because there might not always be a perfect analogy between the results of an experiment on animals, and those afforded by the observation ofthe diseases ofthe human body. ANE When Haller asserteta) that by separating the mus- cular from the inner coat ofthe arteries he could, when he pleased, produce an aneurism in these animals; and when Hunter declared that such an experiment made the artery firmer than ever, in consequence of the adhesive inflammation taking place; the character and veracity of these eminent men naturally lead to the question, whether the experiments were conducted ex- actly in the same manner. Now, says Mr. Wilson, when we know that Haller did not suffer the surround- ing parts to unite, and that John Hunter did, we can no longer be at a loss to account for the different con- clusions—See Wilson's Anatomy, Pathology, &c. of the Vascular System, p. 378.) However this may be with respect to the experiments made on certain animals, I am disposed to consider it fully proved by Mr. J. Hunter, Sir E. Home, and Pro- fessor Scarpa, that in the human subject an aneurism will not arise from the kind of weakness which is caused by cutting or even stripping off the external coat of a sound artery, whether the wound be closed or not. This fact would at least appear to be well established, with respect to the generality of the arteries; but how far it is so in relation to the aorta, is another question, the inner membrane of which vessel is alleged to be more elastic than that of common arteries. Dubois and Dupuytren in fact are stated to have presented to the Faculty of Medicine at Paris preparations which exhibit the lining of the aorta protruding through the middle coat, in the form of a sac filled with blood.— (See Diet, des Sciences Med. art. Aneurisme, and Bres- chet inTransl. of Mr. Hodgson's work. p. 130.) By the term mixed aneurism. Dr. A. Monro senior implied the state of a true aneurism, when its cyst had burst, and the blood was diffused in the adjacent cellu- lar substance; an event which is frequent. Besides these varieties of aneurism, the aneurismal varix or venous aneurism, and the aneurism by anastomosis, constitute diseases which are usually regarded as cases pertaining to the present subject, though incapable of being comprised under the ordinary definition of an aneurism. Nothing can be more manifest than the fact, that pre- viously to the discovery of the circulation of the blood, no correct nor valuable opinions could have prevailed, respecting the diseases which now go under the name of aneurisms. Indeed, it was not until after the days of Aristotle that any distinction was made between the swellings of veins and those of arteries, such vessels not having been at that early period distinguished from each other. Their differences were first pointed out by Rufus of Ephesus. Down to Galen, however, nothing like consistency was established in the notions respecting aneurism. His opinion was, that all tumours of this nature were produced either by anastomosis or by rupture; and though he has described their symptoms, he has not informed us of the characters by which each of these cases was distinguishable one from the other. Paulus /Egineta divides aneurisms into two sorts, bath of which, he says, are attended with extravasation, and of course with rupture. Vesalius, who first applied anatomy to the investiga- tion of disease, has described an aneurism arising from the rupture of a dilated aorta ; the first specimen, I believe, on record of this form of disease.—(Bonetus Sepulch. Anat. lib. 4, sect. 2.) The combination of rupture with dilatation of the ar- tery was afterward more particularly noticed by Nuck. —;Oper. Chir., &c. Lugd. 1692.) It was Fernelius who first promulgated the doctrine that aneurisms were always dilated arteries.—(Uni- versa Medicina, De Extern. Corp. Affect, lib. 7, cap 3 Venet. 1564.) ' This opniion was espoused by Forrestus, Diemer- broek, and others; but at length the inaccuracy of at- tempting to refer every aneurism solely to dilatation of the coats of the vessel, was established by the obser- vations of Lancisi, Freind, Guattani, and Morgagni. In short, as Mr. Hodgson has stated, these authors proved that aneurism may be produced either by the rupture or the dUatation of the coats of an artery, or by a combination of both circumstances, the dilatvion having preceded the rupture.—(On the Diseases of Ar- teries, Sec 8vo. Lond. 1815.) This admission of aneurism by dUatation, and of ANEURISM. 91 aneurism by rupture of the coats of an artery, together with the frequent combination of both circumstances, was indeed the prevailing undisturbed doctrine of every surgical school, until Professor Scarpa, inclining to the tenets of Sylvaticus (De Aneurysmate. Tract. Venetiis, 1600, 4to.), ventured to question the correctness of the common opinion about the dilatation of all the arterial coats. However, after the very clear and satisfactory elucidation of this disputed point by my friend Mr. Hodgson, the accurate views ofthe subject, first taken by Morgagni, and the other eminent writers specified above, may be regarded as established beyond the pos- sibility of dispute. At the same time, it is not to be supposed that Scarpa means to say, that the arteries are not subject to a morbid dilatation; on the contrary, he gives a particular description of this affection, which he carefully discriminates from aneurism. Previously to offering a more particular account of the doctrine taught by Scarpa respecting the formation of aneurism, as well as of the chief facts which may be adduced against a part of such doctrine, it seems proiicr to make the reader acquainted with the various species of the disease, their ordinary symptoms, and a few other circumstances. When any part of an artery is dilated (attended with particular circumstances marking its difference from another form of dilatation which, as I shall explain, perhaps ought not to be set down as aneurismal), the swelling is commonly named a true or genuine aneu- rism. In such cases the artery is either enlarged at only a small part of its track, and the tumour has a de- terminate border, or the vessel is dilated for a consi- derable length, in which circumstance the swelling is oblong, and loses itself so gradually in the surround- ing parts, that its margin cannot be exactly ascertained. The first case, which is the most common, is termed the circumscribed true aneurism; the last the diffused true aneurism; a case, however, which would be looked upon by Scarpa only as a specimen of dilatation differ- ent in several particulars from aneurism, as will be hereafter noticed. When Wood escapes from a wound or rupture of an artery into the adjoining cellular sub- stance, the swelling is denominated a spurious or false aneurism. In this instance the blood either collects in one mass, distends the cellular substance, and con- denses it into a cyst, so as to form a distinctly circum- scribed tumour; or it is injected into all the cavities of the surrounding cellular substance, and extends along the course of the great vessels, from one end of the limb to the other, thus' producing an irregular oblong swelling. The first case is named a circumscribed false aneurism ; the second a diffused false aneurism. —(Richter's Anfangsgr. b. 4.) These appellations are, in my opinion, preferable to to the term cylindrical, applied by Sauvages to true aneurisms, or sacciform, proposed by Morgagni for false aneurisms.—'Advers. Anat. 2, Aortas Animadv. 38, et Epist. Anat. 17, No. 27.) Because, as we shall see in the course of this article, though true aneurisms (in- cluding dilatations of all the arterial coals of every kind) do mostly affect the whole circumference of the vessel, and must therefore partake of a cylindrical shape, there are exceptions, in which a distinct circum- scribed sac, composed of all the coats of the vessel, projects from one side of an artery, the diameter of which may not be at all increased. Here the disease might rather be named sacciform, the very appellation suggested by Morgagni for false aneurisms, in which the disease generally originates in this shape, from whatever particular side of the vessel the inner coats have given way. We see also that the subject actually demands more numerous distinctions, since aneurisms undergo in their progress various changes, which some- times make an immense, and even a very sudden dif- ference in their shape, cases which were at first cir- cumscribed afterward becoming diffused. The symptoms of a circumscribed true aneurism take place as follows: the first thing which the patient perceives is an extraordinary throbbing in some par- ticular situation, and on paying a little more attention he discovers there a small pulsating tumour which en- tirely disappears when compressed, but returns again as soon as the pressure is removed. It is commonly unattended with pain or change in tbe colour of the skin. When once the tumour has originated, it con- tinually grows larger, and at length attains a very con- sider.: bio size. In proportion as it lecomes larger, its pulsations become weaker, and indeed they are almost quite lost when the disease has acquired much magni- tude. The diminution of the pulsation has been as- cribed to the coats of the artery losing their dilatable and elastic quality in proportion as they are distended and indurated, and, consequently, the aneurismal sac being no longer capable of an alternate diastole and sys- tole from the action of the heart. The fact is also im- puted to the lamellated coagulated blood deposited on the inner surface of the sac, particularly in large aneu- risms, in which the motion of some of the blood is al- ways interrupted. Immediately such coagulated blood lodges in the sac, pressure can only produce a partial disappearance of the swelling. This deposition of lamellated coagulum in the aneurismal sac is a circum- stance of considerable importance ; for it has been well explained by Mr. Hodgson, that it is the mode by which the spontaneous cure of the disease is in most instances effected. " One of the circumstances which, in the most early stage, generally attend the formation of aneurism (says this author), is the establishment of that process which is the basis of its future cure. The blood, which enters the sac soon after its formation, generally leaves upon its internal surface a stratum of coagulum, and successive depositions of the fibrous part of the blood gradually diminish the cavity of the tumour. At length the sac becomes entirely filled with this substance, and the deposition of it generally con- tinues in the artery which supplies the disease, forming a firm plug of coagulum, which extends on both sides of the sac to the next important ramifications that are given off from the artery. The circulation through the vessel is thus prevented, the blood is conveyed by col- lateral channels, and another process is instituted, whereby the bulk of the tumour is removed," &c.— , On the Diseases of Arteries &c. p. 114.) Whether there is any truth in Kreysig's conjecture, that some of the lymph may exude from the inside of the sac itself, I cannet pretend to say: he owns, however, that the inner concentric layers presenting the appearance of being deposited last, is a circumstance rather against his surmise, though he adverts to some other circum- stances which incline him to look upon the opinion as possibly correct.—(German Transl. of Mr. Hodgson's Work, p. 124.) In a preceding paragraph I have spoken of the dias- tole and systole of the aneurismal sac; for it is the general belief that the pulsation of the tumour is pro- duced by the jet of blood into it at each stroke of the heart. This opinion, however, is disputed by an emi- nent writer, who asks, is it true that the pulsation of aneurisms proceeds from the entrance of a more con- siderable stream of blood into the sac, and the dis- tention of the swelling thereby produced ? In aneu- risms, which have only a narrow communication with the arterial tube, or which are filled with laminated coagula, the idea, says he, is quite inadmissible: the aneurism is rather shaken, as it were, like other differ- ent swellings in the vicinity of an artery, by the stroke of the heart occasioning a stretching of the whole ar- terial system, and at the same time communicating an impulse to the column of blood.—(Kr j sig, Germ. Tr. of Mr. Hodgson's Work, p. 143.) Here, however, I am by no means disposed to coincide with this distin- guished physician, whose sentiments appear to me to be refuted by the fact, that whenever any change hap- pens, calculated to lessen or entirely stop the influx of blood into the sue, the pulsation either diminishes or ceases in proportion. Thus, when Kreysig adverted to the pulsation of anejirisms, in which much coagulated blood was deposited, he might at the same time have mentioned the effect which such deposition has in weakening the pulsation, the layers of coagulated blood within the tumour being in the natural mode of cure, as Mr. Hodgson has correctly explained, " the means by which the force of the circulation is removed from the sac, and the fatal termination of the disease by rupture is prevented."—(On Diseases of Art. and Veins, p. 126.) In proportion as the aneurismal sac grows larger, the communicc ion of blood into the artery be- yond the tumour is lessened. Hence, in this state, the pulse below the swelling becomes weak and small, and the limb frequently cold and cedemalous. On dissec- tion, the lower continuation of the artery is found pre- ternaturally small and contracted. The pressure ot the tumour on the adjacent parts may also produce a variet. of s>mptouit, ulceration, absorption of bone. 92 ANEUrtlSM. &c. Sometimes (says Richter) an accidental contu- sion or concussion may detach a piece of coagulum from the inner surface of the cyst, and the circulation through the sac be obstructed by it: nay, he asserts that the coagulum may possibly be impelled quite into the artery below, so as to induce important changes. The danger of an aneurism arrives when it is on the point of bursting, by which occurrence the patient usu- ally bleeds to death, and this sometimes in a few se- conds. The fatal event may generally be foreseen, as the part about to give way becomes particularly tense, elevated, thin, soft, and of a dark purple colour. —(Rich- ter's Anfangsgr. band 1.) A large axillary aneurism, which burst in St. Bar- tholomew's Hospital some years ago, did not burst by ulceration, but by the detachment of a small slough from- a corneal, discoloured part of the tumour; and soon after this case fell under my observation, I had an opportunity of seeing the process by which an inguinal aneurism burst: at a certain point the tumour became more corneal, thin, and inflamed, and here a slough about an inch in width was formed. On the dead part becoming loose, a profuse bleeding began, which was stopped for a short time by pressure, but soon returned with increasing violence, and put an end to the patient's misery. We are then to conclude that external aneu- risms do not burst by ulceration, but by the formation and detachment of aslough. Ibelievethis is afact which was first particularly pointed out in the early editions of my work, and it gives me pleasure to find that it is a statement which entirely coincides with that subse- quently made by several writers of eminence, espe- cially Mr. A. Burns (On Diseases ofthe Heart, p. 225), and Boyer (Traite des Maladies Chirurgicales, t. 2, p. 98.) As far as my information extends, Mr. A. Burns first explained the very different mode of rupture which happens in internal aneurisms: these, he observed, ge- nerally burst by actual laceration, and not by sphace- lation of the cyst.—(On Diseases of the Heart, p. 225.) But a still more particular account of the process by • which external and internal aneurisms burst, is deli- vered by Mr. Hodgson. When the sac points exter- nally (says this gentleman), it rarely or never bursts by laceration, but the extreme distention causes the in- teguments and investing parts to slough, and upon the separation of the eschar, the blood issues from the tumour. A similar process takes place when the dis- ease extends into a cavity which is Uned by a mucous membrane, as the oesophagus, intestines, bladder, &c. In such cases, the cavity of the aneurism is generally exposed by the separation of a slough which has formed .upon its most distended part, and not by laceration. But when the sac projects into a cavity lined by a se- ,rous membrane, as the pleura, the peritoneum, the pe- ricardium, &c, sloughing of these membranes does not .take place, but the parietes of the tumour having be- come extremely thin in consequence of distention, at length burst by a crack or fissure, through which the ,Wood is discharged.—(On the Diseases of Arteries, &c. j>. 85.) When the aneurism is of considerable size, the col- lateral arteries, which originate above the swelling, are manifestly enlarged. Boyer informs us, that in dissect- ing the lower extremity of a patient on whom Desault had operated eight months previously for a popliteal aneurism, he found in the substance of the great sci- ■atic nerve an artery, whose diameter was equal to that of the radial at the wrist. This vessel had its origin from the ischiatic artery, and descended to the back •part of the knee, where it anastomosed with the upper articular arteries. Boyer had also noticed in the same subject before the operation, that one of the branches of the upper internal articular artery was so much en- larged that its pulsation could be plainly felt on the in- ternal condyle of the thigh-bone.—(Op. cit. p. 93.) It is such enlargement of the collateral arteries above the disease, which ensures to the limb below the tumour an adequate supply of blood when the obstruction to its passage tlirough the diseased artery becomes consi- derable, or when this vessel has been rendered totally impervious by a surgical operation performed for the cure of the complaint. In the advanced stage of an aneurism, the skin is found extremely thin, and confounded, as it were, with the aneurismal sac. The cavities of the cellular sub- stance near the disease are either filled with serum or totally obliterated by adhesion. The adjacent muscles, whether they lie over the aneurism or to one side of it, are stretched, displaced, dwindled, and sometimes con- founded with other parts. It is the same with the large nervous cords situated at the circumference of the tumour: they are pushed out of their natural situ- ation, diminished in size, sometimes adherent to the outside of the sac, and so changed as scarcely to admit of being known again. Lastly, the cartilages and the bones themselves are not exempt from the mischief which the aneurismal swelling produces in all the sur- rounding parts : they are gradually destroyed, and at length not the least trace of their substance remains, just in the same way as the bones of the cranium are destroyed by fungous tumours of the dura mater.—(See Dura Mater.) Even the cartilages of the larynx and rings of the trachea are sometimes destroyed; this tube is pierced, and the blood escapes into it, or the aneu- rism bursts into the oesophagus.—(Boyer, Traite des Maladies, Chir. t. 2, p. 99.) As I shall hereafter ex- plain, however, the pressure of an aneurismal tu- mour more quickly produces an absorption of bone than of cartilage. While an aneurism is small and recent, it does not generally cause much pain, nor seriously impede the functions ofthe limb. But when it has increased, se- veral complications are produced. Thus the dragging of the saphenal nerve, by femoral aneurisms, frequently occasions acute pain in the course of this nerve as far as the great toe. The distention of the sciatic nerve by the popliteal aneurism sometimes brings on intole- rable pain, which extends to all the parts to which this nerve is distributed, and which can hardly ever be ap- peased by the topical use of opiate applications. The compression of the veins and lymphatics gives rise to oedema, numbness, and coldness of the limb. And, finally, the long-continued pressure of the aneurism on the neighbouring bones causes their destruction.— (Boyer, t. 2, p. 105.) In true aneurism, the coats of the artery are not always in the same state, the kind of changes observed depending upon the progress of the tumour. In the early stage of the disease, either the whole cylinder of the vessel, or only a part of its circumference, is 'di- lated ; but this period is generally of short duration, especially in arteries of middling size, because their middle coat is capable of less resistance than that of the larger arteries, like the aorta, where this coat is yellowish, firm, and very elastic. As Breschet remarks, this difference of resistance in the middle coat of the aorta and the branches given off from it, accounts for the rarity of true aneurisms either in tbe small arteries or those of middling size, and their greater frequency in the principal trunk of the arterial system. At length, in consequence of the increasing disten- tion, some of the coats of the artery possessing the least elasticity give way, and these are found to be the internal and middle coats, while the external one stUl makes resistance and continues to be more and more dilated by the lateral impulse ofthe blood. The second stage of true aneurism is that which is mostly met with; that in which the tumour increases more rapidly, and therefore begins to excite greater at- tention. The disease when it has attained this form is in point of fact no longer a true aneurism, but a case which Monro distinguished by the name of the consecutive or external mixed false aneurism. In this stage the patient's life is endangered, and death often broughr on by the rupture of the tumour. Examinations of the dead subject under these circumstances have frequently led to mistaken notions, and doubtless if va- rious swellings of this kind had not been found in different degrees or stages in the same individual, one might be disposed to join Scarpa in the belief, that no aneurism consists of a dilatation of all the arterial coats.—(Breschet, Fr. transl. of Mr. Hodgson's work. p. 128, 129.) 6 ^ The false aneurism is always attended with, at least a rupture, or giving way of the inner coat of the vessel and usually with a breach in both this and the muscu- lar coat, the outer elastic tunic forming the pouch in which the blood collects. But after the swelling has attained a certain size, this coat also bursts, and then the blood either becomes diffused, or a large circumscribed space is formed for it by the condensation of the sur- rounding cellular membrane. False aneurisms, when produced by a wound or puncture, are of course from the ANEURISM. 93 Brat attended with a division of all the coats of the Vessel. This form of the disease is often seen at the bend ofthe arm, where the artery is exposed to injury in venesection.—(See Hemorrhage.) In this circum- stance, as soon as the puncture is made, the blood pushes out with unusual force, and in a bright scarlet, irregular, interrupted current; flowing out, however, in an even and less rapid stream when pressure is ap- plied higher up than the wound. These last are the most decisive marks of the artery being opened; for blood may issue from a vein with great rapidity, and in a broken current, when the vessel is turgid and situated immediately over the artery, which imparts its motion to it. The surgeon endeavours precipitately to stop the hemorrhage by pressure, and in general a diffused false aneurism is the result. The external wound in the skin is closed so that the blood cannot escape, but this does not hinder it from passing into the cellular substance. The swelling thus produced is uneven, often knotty, and extends upwards and down- wards along the track of the vessel. The skin is also usually of a dark purple colour. Its size increases as long as the internal hemorrhage continues, and if this should proceed beyond certain bounds, mortification of the limb ensues. Such is the diffused false aneurism from a wound. The circumscribed false aneurism, from a wound or puncture, arises in the following manner. When proper pressure has been made in the first instance, so as to suppress the hemorrhage, but the bandage has afterward been removed too soon, or before the artery has healed, the blood passes through the unclosed wound, or that which it has burst open again, into the cellular substance. As this has now become aggluti- nated by the preceding pressure, the blood cannot dif- fuse itself into its cells, and consequently a mass of it collects in the vicinity of the aperture of the artery, and distends the cellular substance into the form of a sac. Sometimes, though not often, the circumscribed false aneurism originates immediately after the opening is made in the artery. This chiefly happens when the aperture in the vessel is exceedingly small, and conse- quently when the hemorrhage takes place so slowly that the blood, which is first effused, coagulates, and prevents the entrance of that which follows into the cavities of the cellular substance, and of course its diffusion. False aneurisms, proceeding from the rupture ofthe inner coats of an artery, are always at first circumscribed by the resistance of the outer tunic. The circumscribed false aneurism consists of a sac composed ofthe external coat of the artery, or, in case this has given way, it is composed of an artificial pouch formed among whatever parts happen to be in the vicinity of the burst artery. This cavity is filled with blood, and situated close to the artery, with which it has a communication. Hence in false aneurisms a throbbing is always perceptible, and is more manifest the smaller such tumours are. The larger the sac be- comes the less elastic it is, and the greater is the quan- tity of laminated coagula in it; so that in very large aneu- risms of this kind the pulsation is sometimes wholly lost. The tumour is at first small, and on compression en- tirely disappears; but returns as soon as this is re- moved. It also diminishes when the artery above it is compressed; but resumes its wonted magnitude im- mediately such pressure is discontinued. When there is coagulated blood in the sac, pressure is no longer capable of producing a total disappearance of ihe tumour, which is now hard. The swelling is not painful, and the integuments are not changed in colour. It con- tinually increases in size, and at length attains a pro- digious magnitude. The following are generally enumerated as the dis- criminating differences between circumscribed true and false aneurisms: the true aneurism readily yields to pressure, and as readily recurs on its removal; the false one yieldsyery gradually, and returns in the same way; and as it contains laminated coagula, it cannot be reduced in the same degree by compression as an aneurism formed by a dilatation of the arterial coats, where such strata of coagulated blood are usually ab- sent. Frequently a hissing sound is audible when the blood sushes into the sac. The pulsation of the false aneurism is always more feeble, and as the tumour en- larges is sooner lost than that of the true one, which throbs after it has acquired a considerable volume.— i Sco Riehter*s Anfangsgr. b. I. FORMATION OF ANEURISMS. If the doctrines of Scarpa, published in 1804, had proved correct, the grand distinction of aneurism into true and false must have been rejected as erroneous : " for," says he, " after a very considerable number of investigations, instituted on the bodies of those who have died of internal or external aneurisms, I have ascertained, in the most certain and unequivocal man- ner, that there is only one kind or form of this disease, viz. that caused by a solution of continuity or rupture of the proper coats of the artery, with effusion of blood into the surrounding cellular substance; which solu- tion of continuity is occasioned sometimes by a wound, a steatomatous, earthy degeneration, a corroding ulcer, or a rupture of the proper coats of the artery, I mean the internal and muscular, without the concurrence of a preternatural dilatation of these coats being es- sential to the formation of this disease ; and there fore that every aneurism, whether it be internal or external, circumscribed or-diffused, is always formed by effusion."—(On Aneurism ; transl. by Wishart, Prefi) According to Scarpa, it is an error to suppose that the aneurism at the curvature or in the trunk of the aorta, produced by a violent and sudden exertion ofthe whole body, or of the heart in particular, and preceded by a congenital relaxation of a certain portion of this artery, or a morbid weakness of its coats, ought always to be considered as a tumour formed by the distention or dila- tation of the proper coats of the artery itself, that is, of its internal and fibrous coats. Scarpa considers it quite demonstrable, that such aneurisms are produced by a corrosion and rupture of these tunics, and conse- quently, by the effusion of arterial blood under the cellular sheath, or other membrane covering the vessel. If ever there be a certain degree of preceding dUatation, it is not essential to constitute the disease, for it is not a constant occurrence ; most aneurisms are unpre- ceded by it, and in those rare cases in which an aneu- rism is preceded and accompanied by a certain degree of dilatation of the whole diameter of the curvature of the aorta, there is an evident difference between an artery simply enlarged in diameter, and a pouch which forms an aneurismal sac. Careful dissections, says Scarpa, will prove that the aorta contributes nothing to the formation of the aneu- rismal sac, and that this is merely the cellular membrane which, in the sound state, covered the artery, or that soft cellular sheath which the artery received in common with the neighbouring parts. This is raised by the blood into the form of a tu- mour, and is covered in common with the artery by a smooth membrane. This eminent professor does not deny that from con- genital relaxation the proper coats of the aorta may occasionally yield and become disposed to rupture ; but he wUl not admit that dilatation of this artery pre- cedes and accompanies all its aneurisms, or that its proper coats ever yield so much to distention as to form the aneurismal sac. The root of an aneurism of the aorta never includes the whole circumference of the artery; but the aneurismal sac arises from one side in the form of an appendix or tuberosity. On the contrary, the dilatation ofthe artery always extends to its whole circumference, and therefore differs essen- tially from aneurism. Thus, he urges that there is a remarkable difference between a dilated and aneuris- matic artery, although these two affections are some- times found combined together, especially at the origin ofthe aorta. If we also consider that the dilatation of an artery may exist without any organic affection, the blood being always in the cavity of the vessel; that in an artery so affected there is never collected any gru- mous blood or polypous layers ; that the dilatation never forms a tumour of considerable bulk; and that while the continuity of the proper coats remains unin- terrupted, the circulation of the blood is not at all, or rot so sensibly changed; we shall be obliged to allow, that aneurism differs essentially from one kind of di- latation of an artery. Some additional remarks on this topic more re- cently pubUshed by Scarpa will be presently consi- dered. By dissections of arteries both in the sound and mor- bid state, Scarpa endeavours to demonstrate what share the proper and constituent coats of the artery have in the formation of the aneurismal sac, and what belongs 94 ANEURISM. to the cellular covering, and other adventitious mem- branes surrounding the artery. The covering of an. artery is merely an adventitious sheath which the vessel receives in common with the parts in the vicinity of which it runs. On cutting an artery across in its natural situation, the segment of the cut vessel retires and conceals itself in this sheath. This cellular covering is most evident round the cur- vature and trunk of the aorta, the carotid, mesen- teric, and renal arteries: it is less dense round the trunks of the brachial, femoral and popliteal arteries. The nleura lies over the cellular sheath of the arch of the aorta, and over that of the thoracic a rta; while that of the abdominal aorta is covered by the perito- neum. Both these smooth membranes adhere to and surround two-thirds of the circumference of the vessel. The great arteries of the extremities are not covered in addition to the cellular substance by any smooth mem- brane of this sort, hut by a cellular sheath, which is demonstrably distinct from the adipose membrane, and serves to enclose the vessels, and connect them with the contiguous parts. When air or any other fluid is injected by a small hole, made artificially between the cellular covering and the subjacent muscular coat of the artery, the in- jected matter elevates into a tumour the cellular mem- brane, which closely embraces the artery, without pro- perly destroying its cells, which it distends in a re- markable manner. When melted wax is injected and pushed with much force, the cellular sheath of the ar- tery is not only raised over the vessel like a tumour, but the internal cells of that covering are also lacerated, and on examining afterward the capsule of the arti- ficial tumour, it appears as if it were formed of several layers, rough and irregular internally, smooth and po- lished externally. The same thing happens when any injection is pushed with such force into an artery as to rupture the internal and muscular coats at some point of their circumference. Nicholls performed this expe- riment several times before the Royal Society.—(Phi- los. Trans, an 1728.) As soon as the internal coat is ruptured, the muscular one also gives way; but the external cellular sheath being of an interlaced texture, and the thin lamiua? of which it is composed being not simply applied to one another, but reciprocally inter- mixed, is capable of supporting great distention by yielding gradually to the impulse of the blood, without being torn or ruptured. Scarpa is farther of opinion that the same pheno- mena may be observed when the internal coat of the aorta becomes so diseased as to be ruptured by the re- peated jets of blood from the heart. In this circum- stance, the blood, impelled by the heart, begins imme- diately to ooze through the connexions of the fibres of the muscular coat, and gradually to be effused into the interstices of the cellular covering, forming for a certain extent a kind of eechymosis or extravasation of blood, slightly elevated upon the artery. Afterward, the points of contact between the edges of the fibres of the muscular coat being insensibly separated, the ar- terial blood, penetrating between them, fills and ele- vates in a remarkable manner the cellular covering of the artery, and raises it after the manner of an incipi- ent tumour. Thus the fibres and layers of the muscu- lar coat being wasted or lacerated, or simply separated from each other, the arterial blood is carried with great force, and in greater quantity than before, into the cel- lular sheath of the artery, which it forces more out- wards; and finally, the divisions between the inter- stices of the cellular coat being ruptured, it is converted intod sac, which is filled with polypous concretions and fluid blood, and at last forms, strictly speaking, the aneurismal sac. The internal texture, although appa- rently composed of membranes placed one over the other, is, in fact, very different from that of the proper coats of the artery, notwithstanding the injured vessel and aneurismal sac are both covered externally in the thorax and abdomen with a smooth membrane. Scarpa has examined a considerable number of aneu- risms of the arch and of the thoracic and abdominal trunk of the aorta, without finding a single one in which the rupture ofthe proper coats of the artery was not evident, and in which, consequently, the sac was produced by a substance completely different from the internal and muscular coats. The aneurismal sac never comprehends the whole circumference of the vessel. At the place where the tumour joins the side of the tube, the aneurismal sac presents a kind of constriction, beyond which it be- comes more or less expanded. This would never hap- pen, or rather the contrary circumstance would occur, ir the sac were formed by an equable distention of the tube and proper coats of the affected artery. In inci- pient aneurisms, at least, the greatest size of the tu- mour would then be in the artery itself, or root of the swelling, while its fundus would be the least. But whether aneurisms be recent and small, or of long standing and large, the passage from the artery is al- ways narrow, and the fundus of the swelling greater in proportion to its distance from the vessel. The sac is always covered by the same soft dilatable cellular substance which united the artery in a sound state to the circumjacent parts. Such cellular substance in aneurisms ofthe thoracic aorta is covered by the pleura, and in those of the abdominal aorta by the peritoneum, which membranes include the sac and ruptured artery, presenting outwardly a continued smooth surface, just as if the artery itself were dilated. But if the aorta be opened lengthwise on the side opposite the constric- tion or neck of the tumour, the place of the ulceration or rupture of the proper coats of the artery immediately appears within the vessel, on the side opposite to that of the incision. The edge of the fissure which has taken place is sometimes fringed, often callous and hard, and through it the blood formed for itself a passage into the cellular sheath, which is converted into the aneurismal sac. If, as sometimes happens in the arch ofthe aorta near the heart, the artery, before being ruptured, has been somewhat dilated, it seems at first as if there were two aneurisms ; but the constriction which the sac next to the artery presents externally, points out exactly the limits beyond which the internal and muscular coats of the aorta had not been able to resist the distention, and where of course they have been ruptured. The partition which may always be seen dividing the tube of the artery from the aneurismal sac, and which is lacerated in its middle, consists of nothing else than the remains of the internal and muscular coats of the ruptured artery. By carefully dissecting the proper coats of the rup- tured aorta in its situation, and comparing them with the cellular substance forming the sac, Scarpa affirms that the truth of the preceding statement may be in- disputably demonstrated. When an incision is made lengthwise in. the side of the vessel opposite the rupture, its proper coats are found either perfectly sound, or a little weakened and studded with earthy points, but still capable of being separated into distinct layers. On the contrary, in the opposite side of the aorta, where the rupture is, the proper coats are unusually thin, and are only separa- ble from each other with difficulty, or even not at all; they are frequently brittle like an egg-shell, and are disorganized and torn at the place where they form the partition between the ruptured artery and the mouth of the aneurismal sac. Continuing to separate these coals from within outwards, we arrive at the cellular sheath surrounding the aorta. This sheath being much thickened in large aneurisms, and very adherent to the subjacent muscular coat of the artery at the place of the constriction of the sac, is very apt to be mistaken for a dilated portion of tbe vessel itself. But even in such cases we may at last separate it, without lacera- tion, from the tube of the artery above and below the injury, and successively from the muscular coat as far as the neck of the aneurism. Then it is clear the mus- cular coat does not pass beyond the partition separa- ting the cavity of the artery from that of the aneuris- mal sac, over which it is not prolonged, but terminates at the edge of the rupture like a fringe, or in obtuse points. Errors are more apt to occur in consequence of the aorta and sac being both covered by the pleura or peritoneum. The portion of the aorta within the pericardium being only covered by a thin reflected layer of this membrane such layer may also be lacerated when the proper coats give way, and blood be effrised into the cavity of the pericardium. Examples of this kind are related by Walter, Morgagni, and Scarpa himself. In the latter instance, on making an incision into the concave part of-the aorta, opposite the tumour which had formed un- der the layer of the pericardium, which had also burst by a small aperture, its internal coat, corresponding to the base of the swelling, was quite rough, interspersed ANEUi with yellow hard spots, and actually ulcerated for the space of an inch in circumference. The preparation is preserved in the museum at Pavia. But all other parts of the aorta having, between them and the pleura and peritoneum, a cellular sheath of a stronger and more yielding nature, which allows itself to be distended into a sac, and being strengthened in- ternally by polypous layers, and externally by the pleura or peritoneum, oppose for a long while the fatal effusion of blood. Scarpa believes that what he calls the slow, morbid, steatomatous, fungous, squamous degeneration of the internal coat ofthe artery is more frequently the cause of its bursting than violent exertions of the whole body, blows, or an increased impulse of the heart. This kind of diseased change is very common in the curva- ture, and in the thoracic and abdominal trunks of the aorta. In the incipient state of such disease the inter- nal coat of the artery loses, for a certain space, its beautiful smoothness, and becomes irregular and wrinkled. It afterward appears interspersed with yel- low spots, which are converted into grains or earthy si-ales, or into steatomatous and cheese-like concretions, which render the internal coat of the artery brittle, and so slightly united to the adjoining muscular coat, that upon being merely scratched with the knife or point of the nail, pieces are readily detached from it, and on being cut it gives a crackling sound, similar to the breaking of an egg-shell. This ossification cannot be said to be proper to old age, since it is sometimes met with in subjects not much advanced in life. The whole of the side of the artery, in that portion which is occupied by the morbid affection, is, for the most part, hard and rigid, sometimes soft and fungous, and in most cases the canal of the artery is preternaturally consiricted. In the highest degree of this morbid dis- organization true ulcerations are found on the inside of the artery, with hard and fringed edges, fissures, and la- cerations of the internal and fibrous coats ofthe artery. Having presented the reader with an abridged account of the most important remarks made by Scarpa in sup- port of the doctrine he defends, I now annex his con- clusions. 1. That this disease is invariably formed by the rupture of the proper coats of the artery. 2. That the aneurismal sac is never formed by a dilata- tion of tho proper coats of the artery, but undoubtedly by the cellular sheath which the artery receives in com- mon with the parts contiguous to it; over which cellu- lar sheath the pleura is placed in the thorax, and the peritoneum in the abdomen. 3. That if the aorta, im- mediately above the heart, appears sometimes increased beyond its natural diameter, this is not common to all the rest of the artery, and when the aorta in the vici- nity of the heart yields to a dilatation greater than na- tural, this dilatation does not constitute, properly speak- ing, the essence of aneurism. 4. That there are none of those marks regarded by medical men as character- istic of aneurism from dilatation, which may not be met with in aneurism from rupture, including even the circumscribed figure of the tumour. 5. That the dis- tinction of aneurism into true and spurious, adopted in the schools, is only the production of a false theory; since observation shows that there is only one form of the disease, or that caused by a rupture of the proper coats of the artery, and an effusion of the arterial blood info the cellular sheath which surrounds the rup- tured artery.—(See Treatise on Aneurism, by A. Scarpa, transl. by J. H. Wishart, Edin. 1808.) Such were the inferences made by Scarpa, in 1804, one of the most distinguished anatomists and surgeons of the present day upon the continent. It has been al- ready stated, that, great as this authority is, several eminent modern surgeons, as Richerand, Boyer, Du- bois, Dupuytren, Sabatier, Breschet, Sec, did not yieid to it, but still contended that in some aneurisms the coats of the artery were dilated. These professors in France coincided with what has been usually taught upon this subject in the surgical schools of Great Bri- tain. Every lecturer here has been accustomed to de- scribe the distinctions of aneurism into true and false, or into some cases Which are accompanied writh dUata- tion. and into others which are attended with rupture of the arterial coats. A few years ago Mr. Hodgson, of Birmingham, published a valuable treatise on aneu- rism, in which work he differs from Scarpa, and joins those surgical writers who believe in the occa- sional dilatation of the coats of the arteries in this <***■ RISM. 95 ease. He inquires, " Is every aneurism produced by a destruction of the internal and middle coats of the ves- sel, and does not a partial dilatation of these coats oc- casionally precede and give rise to their destruction ? I believe that this is frequently the case. We have seen that the disorganization of the coats of an artery by destroying their natural elasticity, will give rise to permanent dilatation of the whole circumference of the vessel; and there is every reason to expect that a loss of its elasticity in a portion only of the diameter of the vessel, will give rise to a partial dilatation of its coats. Indeed, the proofs of a partial dUatation of the coats of an artery, particulafty of the aorta, are incontestably established by the possibility of tracing the coats of the vessel throughout the whole extent of the expansion, and by the existence of those morbid appearances in the sac which are peculiar to the coats of the arteries. "In the year 1811 (says Mr. Hodgson), I dissected an aneurism of the aorta, which was removed from the body of a young woman by my friend Dr. Farre. The sac was as large as a small melon, and had proved fatal by bursting into the posterior mediastinum, and subsequently into the cavity of the thorax. This aorta exhibited the formation of aneurism by partial dilata- tion in three distinct stages. The internal coat was throughout inflamed, and presented a fleshy and irre- gular appearance. At the arch of the aorta there was a dilatation not larger than the half of a small pea. About two inches lower in the same vessel was a se- cond dilatation, which would have contained a hazel nut, and immediately above the the diaphragm was the large aneurism which had proved fatal. I removed that portion ofthe vessel which contained the smallest dilatation, and macerated it until its coats could be se- parated without violence. I found that the dilatation existed equally in the three coats of the vessel, and, when separated, each presented the appearance of a minute aneurism. The second dilatation exhibited the same circumstances in a more advanced stage. The coats of the vessels were more intimately adherent to each other than in a natural state, but it was evident that the dilatation consisted in a dilatation of the inter- nal, the middle, and the external coats of the aorta. In the large aneurism the disorganized internal and mid- dle coats could be traced for some distance into the sac, when the parts contained in the posterior me- diastinum and the vertebrae formed the remainder of the cyst. There can be little doubt that the sac com- menced in a dilatation of the coats of the vessel, simi- lar to those appearances which existed in the superior portion of the dissection, and the artery appeared to illustrate the formation of aneurism by partial dilatation in three distinct stages."—Hodgson on the Diseases of Arteries and Veins, p. 66. 68.) As far as Kreysig's information extends, nobody before Mr. Hodgson had ex- amined the structure of an aneurismal sac in this accu- rate manner, viz. by maceration ; and the results, he thinks, are not liable to the slightest objections.—(See the German transl. of Mr. Hodgson's work, with notes by Kreysig and Koberwein, p. 109. Hanover, 1817.) Mr. Hodgson has seen this partial dilatation in almost all the arteries, which are subject to aneurism: at the division of the carotids and iliacs; in the arteries ofthe brain, Sec.; and he agrees with Dr. Baillie ' Morbid Ana- tomy, Sec), Laennec (Cerattius, Beschreib. d. Krankh. Preparate d. Anat. Theatres zu Leip. p. 408, 8vo. 1819;, and others, that aneurisms at the origin of the aorta are generally formed by dilatation of the coats of the vessel. " Partial as well as general dilatation (says Mr. Hodgson frequently precedes the formation of aneu- rism in the arteries of the extremities. A gentleman had a large aneurism in the thigh, which had under- gone a spontaneous cure. Upon examining the limb after death, the popliteal artery was found to be thick- ened and covered with calcareous matter. A small pouch, which would have contained tbe seed of nn orange, originated from the side of this artery? This lit- tle sac was evidently formed by a dilatation ofthe coats ofthe vessel. A man died from the sloughing of ar. aneu rism in the ham; in the femoral artery there was a small aneurism "about as large as a walnut. The ex ternal coat was dissected from the surface of the tu mour to a considerable extent. The interna' and mid die coats were evidently dUated, and contri'.uted to the formation of the sac. The dUatation oi these coats was gradual, and they continned for a considerable dis 96 ANEURISM. tance to form the sac, when they were inseparably blended with the surrounding parts."—(Op. cit. p. 70.) When Mr. A. Burns bears testimony to the fidelity and accuracy of Scarpa's general detail, he adds, that perhaps it may not be uniformly found that " the root of an aneurism never includes the whole circum- ference of the tube of an artery." We have, says he, a preparation in which the reverse has taken place. In this case the whole cylinder of the vessel, from the heart to beyond the curvature, is equally dilated; and dilated to such an extent, that the tumour measures no less than ten inches in circumference. Scarpa limits dilatation, says Mr. Burns,*So that state of an ar- tery in which the coats remain in then- natural relation to each other, and in which they were not altered in their texture, nor lined on their inner surface with " polypous layers." " This, however, was not the case in the instance which I have brought forward. In it you have seen that the coats were much' dilated, and also very much altered in their structure. Externally and internally they had assumed the look of the mem- branes of the foetus, only they were thicker and denser, but they were equally gelatinous and nearly as trans- parent; and on their inner surface, they were crusted over with the laminae of coagulated lymph. By peeling off this incrustation, after the sac had been inverted, we saw plainly, that although the internal coats were round the complete cylinder of the vessel much dis- eased, and considerably dilated, yet they were not di- lated in the same degree as the external coverings of the artery. At irregular distances, longitudinal rents were formed in the fibrous coats, and these chasms were filled with coagulating lymph. The internal coats over the whole circumference of the vessel had assumed the diseased condition which in aneurism is generally confined to a part of the cylinder. In this tumour all the coats continued for a time to dilate equally, but at length the internal gave way, forming longitudinal rents, through which the external coats could be seen after the lymphatic coating had been scraped off. In this instance, had the sac been dis- sected in the early stage, it would have presented pre- cisely the same appearances as those described by Dr. Monro, and the one (the aneurism) lately examined by the surgical editor of the London Med. Review." Mr. Burns afterward expresses doubts whether the sac ever acquires a.large size without dilatation. The case reported in the latter periodical work was the largest that he knew of, in which all the coats were found uni- formly dilated. The sac, which was as large as the fist, was lined throughout with flakes of bone, and though the internal coat of the vessel was thus patched, and extremely thin and brittle, it did not, on minute inspection, any where exhibit a solution of continuity. Mr. A. Burns farther states, that the above case, re- ported by himself, was the only one out of fourteen which did not corroborate Scarpa's description.—(On Diseases of the Heart, &c. p. 204.) Mr. Wilson, after mentioning the frequency of aneurism in the aorta, carotid, subclavian, and axillary arteries, and its ra- rity in the brachial, tells us, that he knows of no ex- ample of aneurism below the elbow, where the swell- ing could not he traced to a wound of the coats of the artery. He adds, that true aneurism has not unfre- quently occurred in the internal and external iliac arteries, in the inguinal, femoral, and very frequently in the popliteal. It has taken place in the posterior tibial artery, but he knows of no instance of it in the anterior tibial or peroneal arteries. " I have (says he) met with only one instance of true aneurism affecting any of the branches of the aorta which are distributed to the abdominal viscera. In the year 1809, on inspect- ing the body of a clergyman, in the presence of the late Sir W. Farquahr, a tumour very rpuch resembling the heart in colour, shape, and size, appeared to hang down from the under surface of the left lobe of the liver When this tumour was opened and carefully in- spected, it appeared to have been formed by the left branch ofthe hepatic artery having become very much enlarged and aneurismal. It had burst, and the blood which had escaped was found in an imperfect cyst, partly in a fluid, and party in a coagulated state, forming a large proportion of the tumour." This pre- paration is in Windmill-street.— See Lectures on the Blood, and on the Anatomy, Physiology, and Surgical Pathology of the Vascular System, p. 379, 380, 8vo. Lond. 1819.) The facts adduced by Mr. Hodgson appear sufficiently conclusive, and from them the following doctnne ia clearly deducible. First, That numerous aneurisms are formed by de- struction of the internal and middle coats .of an artery, and the expansion of the external coat into a small cyst, which giving way from distention, the surrounding parts, whatever may be their structure, form the re- mainder ofthe sac. Secondly, That sometimes the disease commences in the dilatation of a portion of the circumference of an artery. This dilatation increases until the coats ofthe vessel give way, when the surrounding parts form the sac, in the same manner as when the disease is in the first instance produced by destruction of the coats of an artery.—(P. 74.) The conclusions of Mr. Hodgson, as he himself ex- plains, are supported by the observations of numerous writers. The learned Sabatier says there can be no doubt that many aneurisms depend upon the dilatation of the arterial coats; but in far more numerous examples the internal tunics are ruptured, and it is the cellular coat alone which separates from them, and enlarges so as to form the aneurismal sac ; " de sorte que les arteres, qui sont dans ce cas, sont diloriquees, suivant l'expres- sion de Lancisi." It is difficult to conceive, he observes, how all the coats of an artery can dilate and yield sufficiently to form the investment of such immense tumours as some aneurisms are. Indeed, that very tunic, which com- poses the greater part of the thickness of the vessel, and which is termed the muscular coat, is known to consist of fibres whose texture is firm, and little capa- ble of bearing extension. However, Haller, in descri- bing a very large aneurism, situated in the aorta, near the heart, relates, that the innermost coat of this vessel was ruptured and torn, the loose jagged edges of the laceration being visible in the aneurismal sac. These were squamous, bony, and of little thickness; while the muscular and cellular coats were quite sound. Donald Monro noticed the same thing in five different aneurisms in the course ofthe femoral and popliteal ar- teries of a man who had been confined a long while to his bed after being operated upon for bubonocele. Monro succeeded in tracing the fibres of the muscular coat over the swellings, so that he had no doubt of this tunic being dilated.—(See Medecine Operatoire, t. 3, p. 160—162.) According to Richerand, when an aneurism is recent and of small size, the dissection of the tumour exhibits a simple dilatation of the arterial coats; while in the other cases, where the aneurism is large, and has existed a considerable time, the internal and middle coats of the vessel are invariably lacerated. In the early stage of the disease, the blood which fills the aneurismal sac is fluid, and, on the contrary, in cases where the internal tunics of the artery are ruptured, the sac contains more or less coagulated lymph. The external or cellu- lar coat composes the greater part of the cyst; and the coagulated lymph, with which it is filled, is arranged in layers, the density of which is described as being greater in proportion to the length of time which they have been deposited. Such as are nearest the sac are, therefore, represented as being most compact, and con- taining the smallest quantity of the colouring matter of the blood; more deeply, the concretions of lymph re- semble simple coagula; and lastly, the blood which is still nearer the arterial tube retains its fluidity. After the aneurismal sac, has been cleansed from the lymph and coagulated blood which it contains, its pa- I rietes wrill appear to be almost entirely formed of the cellular coat of the artery. Towards the bottom may be observed the aperture, arising from the laceration of the internal and middle coats, which, being much less elastic than the external, are ruptured in an early stage of the disease. It is when these two tunics give way, that the aneurismal tumour undergoes a sudden and considerable increase in its size; for then the cel- lular coat alone has to sustain all the pressure of the blood, which now, becoming effused into a more am- ple cyst, loses a great deal of its impetus, coagulates and forms fibrous masses ; circumstances to which maybe ascribed the hardness of the swelling, the weakness of its pulsation, &c—(Nos. Chir. t. 4 n 82. ed. 2.) > * «i 1 But this author seems to venture for beyond the ANEURISM. 97 bounds of accuracy, when he represents every small aneurism as exhibiting a dilatation ofthe arterial coats, unless his meaning refer more particularly to the outer coat alone. The reality of what are called true internal aneurisms was ably urged by C. F. Ludwig, in a programma written expressly on that subject.—(DiagnosticesChir. Fragm. de Aneurysmate Interno; Lips. 1805.) But an inter- esting case, exemplifying an aneurismal dilatation of all the coats of the abdominal aorta, has been published by Professor iSiegele of Heidelberg. The swelling was as large as a man's head, and weighed about five pounds. The aorta began to be dilated at the point where it passes into the cavity of the abdomen between the crura of the diaphragm. This dUatation extended gradually down to a point about four finger-breadths from the bifurcation of the aorta into the iliac arteries, at which point, strictly speaking, the large aneurismal Kac commenced. The length of the whole dilated part of the vessel was eleven inches; that of the sac, six; and its diameter five inches. The artery was not , equally dilated in every direction, the expansion being most considerable laterally and forwards. Professor Naegele and Ackermann found that the three coats of the aorta, the internal, muscular, and cellular, were all equally dilated. These gentlemen traced the mus- cular coat with the scalpel from the top to the bottom of the tumour, and not the slightest doubt could be entertained, that the case was a true aneurism.—(F. C. Naegele, Epistola ad T. F. Baltz, qua Historia et Descriptio Aneurysmatis, quod in aorta abdominali ob- servavit, continetur. Heidelb. 1816.) In the valuable cases collected by H. F. Janin, very convincing evidence will be found of there being two kinds of aneurism; one attended with the rupture of the coats of the artery, the celluiar coat alone forming the aneurismal sac; and the other, consisting in an equal dilatation of all the coats of the artery. Of the latter species of aneurism, Janin relates three very unequivocal cases.— (Sec Annales du Cercle Medical, t. 1, Art. 2, 1S-20.) After the clear demonstration of an aneurismal sac being occasionally composed of all the coats of an ar- tery, as afforded in the dissections and pathological preparations to which a reference has been made, the reader will be better prepared to judge of the differ- ence existing upon this subject between Scarpa and other modern writers ; and, as far as I can judge, the question is now reduced to one, whether any of the di- latations on record, said to comprise all the arterial coats, merit the name of aneurism. We have seen, that he has always unequivocally admitted that the arteries may be dilated, though the kind of dilatation to which he alludes, is thought by him, as well as by A. Burns, and my friend Mr. Hodgson (On Diseases of Arteries, Sec. p. 58), to require discrimination in a pathological point of view. " It is proved (says Scarpa) by dissection, that the morbid dilatation is circum- scribed by the proper coats of the diseased artery; and that the inner surface of the sac, formed by the partial or total protrusion of the arterial tube, is never filled with polypous laminae, or layers of fibrine disposed over each other (a fact particularly dwelt upon by Mr. Hodgson, p. 82); which layers never fail to be formed in greater or smaller quantity in the cavity of an aneurism." The opinion that these layers of coa- gula are not met with in small dilatations of arteries, but are found in large expansions of them, he says, is contradicted by numerous careful observations, and especially by a specimen, actually before him when he was writing, where a morbid dUatation of the arch of the aorta, in the vicinity of its origin from the heart, six inches in length, and five in breadth, was entirely free from any of the lamellated coagula al- ways found in aneurisms. On the contrary, the sac of the aneurism is formed from the parts surrounding tho wounded or ruptured artery, into which pouch, the blood, entering as into a natural receiver, and quite out of the current of the circulation, moves only slowly, and constantly deposites these layers of fibrine, and this sometimes in such quantity as to fill the whole cyst. Scarpa, at the same time, particularly explains, that if accidentally furrows or fissures exist on the inside of the morbid dilatation, the fibrine may be de- posited in these rough places, but only in them. These fissures and inequalities of the internal surface of the inorbidlv dilated arterv, he regards strictly as so many Vol. I— G beginnings of another disease of the vessel, quite dif- ferent from dilatation, that is, of aneurism subsequent to dilatation.— (See MemoriasuUa Legatura delle prin- cipali Arterie degli Arti, con una Appendice all' Opera sulle Aneurisma, fol. Pavia, 1817 ; or the Treatise on Aneurism, transl. by Wishart, ed. 2, p. 119, Edinb 1819.) In this manner, no doubt, Scarpa would account for the presence of lamellated coagula in the case reported by Mr. A. Burns (On Diseases of the Heart, p. 306), though the latter gentleman himself, for reasons al- ready detailed in the foregoing pages, did not regard the expansion of all the coats of the artery, as corres- ponding to the morbid dilatation implied by Scarpa. Thus Scarpa farther agrees with other modern writers, in admitting the possibility of aneurism becoming in- grafted, as it were, on one of these unnatural dilata- tions, more than one example of which combination were indeed recited in his first work. In that treatise he has asserted, that what he calls morbid dilatation, always extends to the whole circumference of the vessel. But this point seems, from the appendix, to be renounced, as he now observes, " Where the mor- bid dilatation is partial, or on one side of the artery like a thimble (for very frequently, even in the arch of the aorta, this partial dilatation does not exceed the size of half a bean), the entrance for the blood into this capsule is as large as the bottom ofthe sac."—(Transl. by Wishart, p. 120, ed. 5.) According to Scarpa, where the morbid dilatation occupies the whole cir- cumference of the arterial tube, the tumour always re- tain sa cylindrical or oval form; and, if situated in such manner that it can be compressed, it yields very readdy to pressure, and almost disappears; and after death is found much smaller than during life. On the contra- ry, aneurism, whether preceded by dilatation or not, constantly originates from one side of the ruptured artery. The entrance for the blood is small, compared with the size of the fundus of the sac; the tumour as- sumes an irregular shape; yields with difficulty to pressure; retains nearly the same size in the dead that it had in the living body; find its sac, instead of becom- ing thinner as the swelling enlarges, as the coats of an artery do when they are simply affected with dilata- tion, attains greater thickness, the larger the aneurism grows. These essential differences between the two diseases are illustrated by an interesting case, met with by Professor Vacca, where a patient died with an aneurism of one subclavian artery, and a simple mor- bid dilatation of the whole circumference of the other. —(See Sprengel, Storia delle Operaz. di Chir. trad. Ital. Parte 2, p. 294.) When these two different affections are situated in the thorax or abdomen, it is impossible to discriminate them from each other before death. The symptoms occasioned by the pressure of the tumour on the vis- cera, must be nearly the same, whether caused by a morbid dilatation or an aneurism. The means for re- tarding their fatal termination is also the same in both forms of the disease. With regard to the possibility of cure, however, Scarpa says, that there is great dif- ference ; for when the case is an internal aneurism, there may be some slight hope of a radical cure by tho efforts of nature and art, which hope can never be en- tertained in a case of morbid dilatation; a fact which is accounted for by no laminated coagula being depo- sited in the latter disease.—(On Aneurism, transl. by Wishart, p. 124, ed. 2.) A great deal of the latter statement coincides with the observations of Mr Hodgson, who particularly notices, that he has never met with lamellated coagula in such sacs, as consist either in a general or partial dilatation of the coats of the vessel.—(On Diseases of Arteries, &c. p. 82.) Whether this ever takes place in such cases may stUl be a question, because, if Professor Nsegele has given a correct description of the aneurism of the abdomi nal aorta already mentioned, which aneurism was of a large size, and consisted of a dilatation of all the coats of the vessel, there was in this rare example a large quantity of these layers of coagulated blood. Yet, whether the Professor actually means the fibrine, arranged in laminae, or only common coagulated blood, which, as every one knows, may be found either in the cysts of dUat'ed or of ruptured arteries, may admit of doubt. The statement, therefore, made by Hodgson and Scarpa, may not be contrary to what was really seen bv Niegele and Ackermann. The following case., 98 ANEURISM. however, observed by Laennec, and quoted by a mo- dern writer, must (if correctly reported) afford not only an unequivocal specimen of aneurism by dilata- tion of all the coats of the aorta, but of laminated co- agula within its cavity. " In homine enim, qui repente sub atrocissimis pectoris doloribus corruit, praeter aortam adscendentem in aneurysma ita expansam, ut neonati infantis caput aequaret, cystidam aneurismati- cam immediate supra arteriae cceliaca? ortam magnitu- dine nusis juglandis invenit, qua? luculenter ostendit sinum communicantem cum arteria? cylindro per fora- men magnitudine amygdala?, diametro totius arteria? Ulo loco non mutato. Saccus hie cultro anatomico ac- curate ac subtilliter subjectus, eamdem structuram, easdem ostendit membranas, quibus gaudebat arteria, e ctrjus latere excreverat: caeterum massis grumosis, sive fibrosis erat impletus. Inde igitur patet, hoc an- eurysma sacciforme et laterali et partiali quidem tuni- carum aorta? dUatatione ortum esse."—(J. H. G. Ehr- hardt, De Aneurysmate Aorta?, p. 13, 4to. Lips. 1820.) From what has been stated, then, it appears, that there is only one principal point of difference between Scarpa and other writers, and this resolves itself into the question, whether a dilatation of an artery, arising at one particular side of the vessel, and Uned by its in- ternal coat, ought not to be regarded as an aneurism, because its communication with the tube of the artery is more capacious than what exists in other aneurisms, where the inner coat has given way, and because it rarely (perhaps never) contains laminated coagula, unless fissures should happen to exist at some points of the inner arterial tunic thus expanded ? The greater number of aneurisms increase gradu- ally, and sooner or later incline to the side on which the least resistance is experienced. De Haen men- tions an aneurism of the aorta, which first made its appearance between the second and third ribs of the left side, and which, instead of growing larger, as is usual, subsided, and could neither be seen nor felt for more than a month before the patient's decease, al- though, on opening the body, a tumour of the arch of ( the aorta was found, three times as large as the first. De Haen imputes the sudden disappearance of the swelling to its weight, the yielding of the parts with which it was connected, and to its gravitating into the chest, when the patient lay on his right side; for the difficulty of breathing, and other complaints, produced by the pressure on the lungs, underwent a material increase as soon as the tumour ceased to protrude. The pulsations which accompany true aneurisms continue to be strong, untU the inner coats of the ves- sel give way, or the layers of coagulated blood, lodged in the sac, are numerous. Hence, when soft swell- ings, situated near any large arteries, lose their pulsa- tory motion, their course, precise situation, and other circumstances, ought to be most carefully investigated, before any decision is made about the mode of treat- ment. A few years ago, I saw a man in St. Bartholomew's Hospital, who had a large swelling of great solidity, occupying the ham, and apparently extending a good way forwards round the condyles of the femur. Ita hard- ness, shape, large size, and entire freedom from pulsa- tion not only then, but at an earlier period, as far as could be collected from the patient's own account, led to the belief, that the case was probably a tumour complir cated with exostosis of the femur, and as this opinion seemed to be confirmed by no fluid escaping from a puncture made with a lancet, amputation was per- formed. To our surprise, however, dissection proved, that the disease was a large diffused popliteal aneu- rism, in which the spontaneous cure by an oblitera- tion of the sac with coagula was taking place.—(See Med. Chir. Trans, vol. 8, p. 497.) In many instances the most fatal accidents have happened, in consequence of incisions having been made in aneurisms, which were mistaken for abscesses because there was no pulsation. Vesalius was con- sulted about a tumour ofthe back, which he pronounced to be an aneurism. Soon afterward an imprudent practitioner made an opening in the swelling, and the patient bled to death in a very short time. Ruysch re- lates that a friend of his opened a tumour near the heel not supposed to be an aneunsm, and the greatest diffi- culty was experienced in suppressing the hemorrhage. De Haen speaks of a patient, who died in consequence of an opening which had been made in a similar swell- ing at the knee, although Boerhaave had given Irk advice against the performance of such an operation. Palfin, Schlitting, Warner, and others, have recorded mistakes of the same kind.—(Sabatier, t. 3, p. 107.) Ferrand, head surgeon ofthe Hdtel Dieu, mistook an axillarv aneurism for an abscess, plunged his bistoury into the swelling, and killed the patient. ' J ai ete temoin d'erreurs semblables, commises par les practi- ciens non moins fameux ; et si des aneunsmes ex- ternes on passe a ceux des arteres placees a 1 mte- rieur, les erreurs ne sont ni moins ordinaires ru de moindre consequence."---(Richerand, Nosogr. Chir. t. 4, p. 75, ed. 2.) Notwithstanding a pulsation is one of the most prominent symptoms of an aneurism, it is not to be inferred, that every swelling which pulsates is un- questionably of this description ; for, as Mr. Warner has explained, it does happen that mere imposthn- mations, or collections of matter, arising from external as well as internal causes, are sometimes so imme- diately situated upon the heart itself, and at other times upon some of the principal arteries, as to par- take in the most regular manner of their contraction and dilatation. He details the particulars of a boy, about thirteen years of age, whose breast-bone had been badly fractured, and who was admitted into Guy's Hospital a fortnight after the accident had happened. The broken parts of the bone were removed some distance from each other. The intermediate space was occupied by a tumour of a considerable size; the in- teguments were of their natural complexion. The swelling had as regular a contraction and dilatation as the heart itself, or the aorta, could be supposed to have. Upon pressure the tumour receded; upon a re- moval of the pressure the tumour immediately resumed its former size; all these are allowed to be distin- guishing signs of a recent true aneurism. The situa- tion and symptoms of this swelling were judged suffi- cient reasons for considering the nature of the disease as uncertain: on which account, it was left to take its own course. " The event was the tumour burst in about three weeks after his admission, discharged a considerable quantity of matter, and the patient did well by very superficial applications."—(Cases in Surgery, edit. 4, p. 155.) An extraordinary form of disease, having very much the appearance of an aneurism, sometimes presents itself. A swelling, attended with considerable pain and a strong pulsation, is gradually produced high up the arm, and at length attains a very large size. The strength of the throbbings at first leads to the suspi- cion that the case must be an aneurism; but on care- ful examination the humerus is found to have given way at a point involved in the disease, and here to be as flexible as if there were a fracture. This circum- stance, and the extension of the swelling too far away from the track of the artery, in time raise doubts about the case being an aneurism. The patient ultimately falls a victim to the effects of the disease on the consti- tution, and when the arm is dissected after death, the tumour is found to consist of a sarcomatous or medul- lary mass, occupying the central portion of the limb, and accompanied with a solution of continuity extend- ing completely through the whole thickness of the bone. Two cases of this description were admitted into St. Bartholomew's Hospital in the course of the year 1820. One of these patients, a woman, I had an opportunity of seeing ; and after her death the real nature of the disease was proved by dissection. My friend Mr. Vincent has seen a similar disease in the leg, resembling aneurism in the circumstance of pulsa tion, but attended with destruction of a part of the tibia, and a moveableness of the separated ends of the bone. A few years ago, I saw a large abscess in the situa- tion of the quadratus lumborum muscle, which pul- sated so strongly that the case was supposed by several experienced men to be an aneurism of the abdominal aorta. The patient was a boy belonging to Christ's Hospital, and under the care of the late Mr. Ramsden, surgeon to that establishment, by whose discernment the real nature of the case was detected. It is curious that, in this instance the pulsations of the swelling suddenly ceased, after having continued in a very strong and manifest way and without interruption for several weeks, during which it was under the observa- tion of the above eminent practitioner. ANEUJ As Mr. Wilson has observed, any encysted or even solid tumour, situated in the neighbourhood of, or upon a large artery, may have a considerable degree of mo- tion communicated to it from the pulsation ofthe artery. The thyroid gland, when a bronchocele is formed, oc- casionally receives a pulsatory motion from the carotid arteries. This may be mistaken for an aneurism, from which disease, however, it can be discriminated by placing our Angers behind the tumour and drawing it forwards, when the pulsation ceases. But there are other criteria for distinguishing a swelling on or near an artery from an aneurism. In such a case the whole tumour moves at once, without any alteration of size. In an aneurism the swelling does not simply move, it expands. A tumour of the thyroid gland, having ap- parently a pulsatory motion, may be known not to be an aneurism of the carotid, by observing that from its connexion with the larynx it follows the movements of the latter in deglutition. Aneurisms, not of very long standing, and not containing a large mass of lami- nated coagula, may also be diminished, or rendered more or less flaccid, by pressing the artery leading to the disease.—(See Wilson on the Blood, Anatomy, Pa- thology, Sec. of the Vascular System, p. 385 ; and Burns on the Heart, p. 257.) In cases of much ambiguity, the stethoscope will sometimes convey the necessary information. In a doubtful instance of aneurism of the groin Mr. Brodie found all obscurity cease on the application of this instrument.—(Sir A. Cooper's Lec- tures, vol. 2, p. 46.) The following case, recorded by Pelletan, shows, that an artery running more superficially than natural, may under particular circumstances give rise to the suspicion of an aneurism. A strong, robust man, about forty years of age, was in the habit of going on foot to dine three leagues from Paris every day, on the completion of his business. One day having been this distance and returned, he felt an acute pain along the leg and in the right ankle. The pain did not subside, and a tumour appeared at the lower third of the leg opposite the space between the two bones. The skin was of a yellowish colour from effused blood, and a pulsation existed by which the hand of an examiner was lifted up. There seemed great reason for con- cluding that the case was an aneurismal swelling. In comparing the affected limb with the sound one, how- ever, Pelletan perceived in the latter a similar kind of throbbing. In short, in both legs the pulsation of an arterial tube could be felt for three inches, and Pelletan distinctly ascertained that in the diseased member the throbbing did not extend to the whole of the tumour, but only lengthwise. By a particular disposition in this individual, the anterior tibial artery, which usually runs along the interosseous ligament, covered by the tibialis amicus and extensor communis digitorum pedis, came out from between these muscles at the middle of the leg, and lay immediately under the skin and the fascia. The swelling and eechymosis gradually dispersed, and the symptoms were supposed to originate from the rupture of some muscular fibres.—(Clinique Chir. t. 1, p. 101, 102.1 Whenever an aneurismal sac of immoderate size beats violently and for a long while against the bones, as the sternum, ribs, clavicle, and vertebrae, they are in the end invariably destroyed, so that the aneurismal sac elevates the integuments of the thorax, or back, and pulsates immediately under the skin. Scarpa, with the best modern writers, attributes the effect to absorption in consequence of the pressure. J. L. Petit saw the condyles of the femur and the upper head of the tibia almost destroyed by an aneu- rism of the popliteal artery; and another case in which the caries and absorption of bone were very extensive, is reported by Rosenmuller.—(Anhang zu Scarpa iib. d. Pulsadergeschwulste, p. 364.) According to Mr. Hodgson, the carious and corroded state of the bones in aneurism is never attended with the formation of pus ; " at least the discovery of pus in its vicinity has not been remarked by those who have examined such cases. In this respect, therefore, it differs essentially from common caries or ulceration of the bones. Ex- foliation also is very rarely attendant upon it; from which circumstance one Important practical observa- tion is deducible, namely, that if the aneurism be cured the bones will recover their healthy state, without un- dergoing those processes which take place in the-cure RISM. 99 of caries or necrosis.*"—(On the Diseases of Arteries and Veins, p. 80.) The same author confirms the remark made by Dr. W. Hunter (Med. Obs. and Inquiries, vol. 1, p. 384), Scarpa (On Aneurism, p. 100, ed. 2), and others, that cartilage is less rapidly destroyed by the pressure of aneurism than bone. This fact is strikingly Ulustrated in a case of aneurism of the thoracic aorta recorded in another modern publication: the bodies of the vertebra? from the fourth down to the ninth were carious; the four lowest in particular: yet the intervertebral car- tilages were not materially affected.—(F. L. Kreysig, Die Krankheiten des Herzens, b. 3, p. 176, 8vo, Berlin, 1817.) A case is related by Pelletan, to which I refer the reader, as exemplifying not oiUy the degree in which internal aneurisms may injure the vertebrae, but also the occasional possibUity of such diseases being mis- taken for rheumatism or a lumbar abscess.—(See Cli- nique Chir. t. 1, p. 97—100.) CAUSES OF ANEURISM. In many instances it is difficult to assign any cause for the commencement ofthe disease. Among the cir- stances which predispose to aneurisms, however, the large size ofthe vessels may undoubtedly be reckoned. Those trunks which are near the heart are said to have much thinner parietes, in relation to the magnitude of the column of blood with which they are filled, th^n the arteries of smaller diameter; and since the lateral pressure of this fluid against the sides of the arteries, is in a' ratio to the magnitude of these vessels, it fol- lows that aneurisms must be much more frequent in the trunks near the heart than in such as are remote from the source of the circulation.—(Richerand, No- sogr. Chir. t. 4, p. 72, edit. 2.) The whole arterial system is liable to aneurisms; but, says Pelletan, ex- perience proves that the internal arteries are much more frequently affected than those which are external. —(Clinique Chir. t. 1, p. 54.) The curvatures of the arteries are another predis- posing cause of the disease; and, according to Riche- rand, such cause has manifest effect in determining the formation of the great sinus of the aorta, the dilata- tion which exists between the cross and the origin of this large artery, and is the more considerable the'older the person is: Monro even thought that one-half of old persons have an aneurism at the beginning of the aorta. And with respect to aneurisms in general, which are preceded by calcareous depositions, thicken- ing, and disease of the coats of the vessel, they are most frequently met with in persons of advanced age. Aneurisms from wounds are of course often seen in individuals of every age. In old people the coats of the arteries are subject to a disease which renders them incapable of making due resistance to the lateral impulse of the blood. The disease here alluded to is what is described in a foregoing part of this article, one common effect of which is the deposition of calca- reous matter between the inner and muscular coats of the arteries. " People in the early part of life," says Mr. Wilson, " are not very subject to these calcareous depositions; but I have occasionally met with them in the arteries of very young people. I have seen a well- marked deposition of the phosphate of lime in the arte- ries of a child under three years of age." He adds, that few persons above the age of sixty are free from these ossifications.—(On the Blood, and on the Anato- my, Pathology, &c. of the Vascular System, p. 375, Lond. 1819.) Though spontaneous aneurisms are most common in old persons, the disease is not absolutely confined to them; for I assisted Mr. Docker at Canterbury in an operation for the cure of a popliteal aneurism in a pos- tillion, whose age must have been under thirty; and Mr. Wilson says that he has met with several instances of the disease in the aorta and other vessels, where the patients were not more than forty years of age.—(Op. cit. p. 376.) According to Sir Astley Cooper, the time of life when aneurism generally occurs, is between the ages of thirty and fifty; an age when exercise is consider- able and strength on the decline. In very old age the disease is not so common. However, he operated suc- cessfully on a case of popliteal aneurism where the pa- tieni was eighty four or eighty-five years old. He ope- rated with success on another man sixty-nine years of 100 ANEURISM. age. He has also seen a boy only eleven years old with aneurism of the anterior tibial artery. The man of more than eighty is the oldest, and the boy of eleven the youngest, aneurismal patients he has ever seen.— (See Lectures, vol. 2, p. 40.) Richerand affirms, that out of twelve popliteal aneu- risms which he has seen in hospital or private prac- tice, ten were caused by a violent extension of the leg. This statement, he says, wUl derive confirmation from the following experiment. Place the knee of a dead subject on the edge of a firm table, and press on the heel so as forcibly to extend the leg far enough to make the ligaments of the ham snap. Now dissect the parts, cut out the artery, and examine its parietes in a good light, when the lace- rations of the middle coat will be observable and ren- dered manifest by the circumstance of those places ap- pearing semitransparent where the fibres are separated, the parietes at such points merelv consisting of the in- ternal and external tunics.—(Nologr. Chir. t. 4, p. 73, 74, edit. 2.) But the insufficiency of this explanation is clear enough from the fact that such violence as is requisite to break the ligaments of the knee, cannot be imagined to happen in the accidents which ordinarily bring on aneurism in the ham. The implicit belief also which Richerand seems to place in the idea that the laceration of the middle coat of an artery wUl bring on an aneurism, whUe the inner coat is perfect, will appear to be unfounded, when it is remembered that Hunter, Home, and Scarpa even dis- sected off the external and middle coats of arteries, without being able in this manner to cause an aneu- rism. Nay, where the experiment has been made of applying a tight ligature to an artery, and immediately removing it again in order to determine whether the di- vision of both the inner coats of the vessel would terminate in an obliteration of the tube of the vessel, no aneurism has been the consequence. Pelletan accounts for the frequency of popliteal aneurisms somewhat differently from Richerand: speaking of the two principal motions of the knee, viz: extension and flexion, he remarks, that the first of these is so limited that it is actually an incipient flexion ne- cessarily produced by the curvature backward both of the condyles of the femur and those of the tibia. This curvature, which would seem to protect the popliteal artery against any dangerous elongation that might otherwise be caused by a forcible extension of the joint, becomes the very source of such an elongation in persons who are accustomed to keep their limbs bent, or who from this state proceed hastily and vio- lently to extend the leg. The arterial tubes are really- shortened when the limbs are in the state of flexion, and lengthened when the extension ofthe members renders it riecessary. Hence, says Pelletan, it is manifest that an habitually shortened state of these vessels, and their sudden elongation, must be attended with hazard of rupturing their parietes.—(Clinique Chirurgicale, t. 1, p. 112.) The opinion of Pelletan, however, is quite untenable; because Mr. Hodgson has several times repeated the experiment mentioned by Richerand, and found, as that gentleman did, that the coats of the artery were never lacerated unless the degree of violence had been such as to rupture the ligaments of the knee.—(On Diseases of Arteries, Sea. p. 64.) Aneurisms are exceedingly common in the aorta, and they are particularly often met with in the popliteal ar- tery. The vessels which are next to these the most usually affected, are the crural, common carotid, sub- clavian, and brachial arteries. The temporal and occi- pital arteries, and those of the leg, foot, fore-arm, and hand, are far less frequently the situations of the pre- sent disease. But although it is true that the larger ar- teries are the most subject to the ordinary species of aneurisms, the smaller arteries seem to be more immediately concerned in the formation of one pe- culiar aneurismal disease, now weU known by the name of the aneurism by anastomosis, of which I shall hereafter speak. According to surgical writers, the causes of aneu- risms operate either by weakening the arterial parietes or by increasing the lateral impulse of the blood against the Bides of these vessels. It is said to be in both these ways that the disease is occasioned by violent contu- sions of the arteries, the abuse of spirituous drinks, frequent mercurial courses, fits of anger, rough exer- cise, exertions in lifting heavy burdens, &c. In certain persons aneurisms appear to depend upon a particular organic disposition. Of this description was the sub- ject whose arteries, on examination after death, were found by Lancisi affected with several aneurisms of various sizes. I have known a person have an aneu- rism of one axillary artery, which disease got sponta- neously well, but was soon afterward followed by a similar swelling of the opposite axUlary artery, which last affliction proved fatal. I have seen another instance in which an aneurism of the popliteal artery was ac- companied with one of the femoral in the other limb. Boyer mentions a patient who died of femoral aneurism in La Charite, at Paris, and who had also another aneu- rism of the popliteal artery equal in size to a walnut. —(Traite des Maladies Chir. &c. p. 102, t. 2.) The greatest number of aneurisms that Sir Astley Cooper has seen in one patient is seven ; and it is a remark made by this eminent surgeon, that when an aneurism occurs in the ham, the disease is frequently of a local nature; but that when it is between the groin and ham, disease of other arteries is very commonly met with.— (See Lectures, vol. 2, p. 37.) The most remarkable case, however, proving the existence of a disposition to aneurisms in the whole arterial system, is mentioned by Pelletan : " J'ai pourtant vu plusieurs fois ces nom- breux aneurismes occupant indistinctement les grosses ou les petites arteres, mais surtout celles des capacites: j'en ai comte soixante-trois sur un seui homme, depuis le volume d'une aveline jusqu'a celui de la moitie d'un oeuf de poule."—(Clinique Chir. t. 2, p. 1.) Aneurisms, and those diseases of the coats of arte- ries which precede the formation of aneurism, are much less frequently met with in women than men.—(Las- sus, Pathologie Chir. t. 1, p. 348.) A few years before John Hunter died, Mr. Wilson heard him remark, that he had only met with one woman affected with true aneurism.—(Anatomy, Pathology, &c. of the Vascu- lar System, p. 376.) Mr. Hodgson drew up the follow- ing table, exhibiting the comparative frequency of aneurisms in the two sexes, in different cases of this disease, and also in the different arteries of the body, as deduced from examples either seen by himself, during the lives of the patients, or soon after their death. H o £ 3 5? s 21 16 5 8 7 1 2 2 5 5 12 12 15 14 1 63 56 7 Of the ascending aorta, the arteria in nominata, and arch of the aorta . Descending aorta...... Carotid artery . «....... Subclavian and axillary .... Inguinal artery....... Femoral and popliteal . . . . This table does not include aneurisms arising from wounded arteries, nor aneurisms from anastomosis.— (On the Diseases of Arteries and Veins, p. 87.) Sir Astley Cooper confirms the fact of the much greater frequency of aneurism in the male than the fe- male sex. Women, he says, rarely have aneurism in the limbs. In forty years' experience, he has seen only eight cases of popliteal aneurism in women, but an immense number in men. Most of the aneurisms which he has seen in females have been in the ascending aorta, orthe carotids.—(Lectures, vol. 2, p. 41.) It was observed by Morgagni, and it has been noticed in this country, that popliteal aneurisms occur with particular frequency in postillions and coachmen; whose employments oblige them to sit a good deal with their knees bent. In France, the men who clean out the dissecting rooms and procure dead bodies for anato- mists, are said almost all of them to die with aneuris- mal diseases. Richerand remarks, that he never knew any of these persons who were not addicted to drink ing, and he comments on the debUity which their in- temperance and disgusting business together must tend to produce.—(Nosogr. Chir. t. 4, p. 74, edit 2 ) Aneurisms are supposed by Roux to be'rriuch more frequent in England than France; a circumstance which, before he proves it to be a fact, he vaguely re- fers to the mode of life and kind of labour to which a ANEURISM. 101 large portion of the population of England is subjected Indeed, he connects this surmise with a reason for the very cultivated state of this part of knowledge in Eng- land: thinks that we have been placed in favourable circumstances for perfecting the treatment of aneu- risms, and acknowledges that we have contributed more than his countrymen both in the last and present century to the improvement of this branch of surgery. —.Roux, Paralfele de la Chirurgie Angloise avec la Chirurgie Frangoise, &c. p. 249.) But ere M Roux ventured into such conjectures, he ought at least to have specified what particular occupations and kind of labour are known by Englishmen themselves to be fre- quently conducive to aneurism; for, with the excep- tion of postillions and coachmen, of whom there is also abundance in France, I am not aware that any determi- nate class of persons is found in this country to be af- fected with particular frequency. In some instances aneurisms of the axillary artery appear to have arisen from violent extension of the limb.—(See the cases recorded by Pelletan in Clinique Chir. t. 2, p. 49 and 83.) In other examples related by the some practical writer, aneurism arose from reite- rated contusions and rough pressure on parts.—(Op. cit. p. 10 and 14.) The extremity of a fractured bone may injure an ar- tery and give rise to an aneurism, instances of which are recorded by Pelletan (Op. cit. t. 1, p. 178) and Durver- ney (Traite des Mai. des Os, t. 1). In Pelletan's case, the disease followed a fracture of the lower third of the leg. An aneurism of the anterior tibial artery from such a cause, is also described by Mr. C. White.— (Cases in Surgery, p. 141.) The following case of an aneurism of the humeral artery after amputation is recorded by Warner: C. D. was afflicted with a caries of the joint of the elbow, which was attended with such circumstances as ren- dered the amputation ofthe limb necessary. The ope- ration was performed at a proper distance above the diseased part, and the vessels were taken up with needles and ligatures. In a few days the humeral artery became so dilated above the ligature upon it as to be in danger of burst- ing. Hence it was judged necessary to perform the operation for the aneurism, which was done, and the vessel secured by ligature above the upper extremity of its distended coats. Every thing now went on for some time exceedingly well, when suddenly the artery again dilated, and was in danger of bursting above the second ligature. These circumstances made it necessary to repeat the operation for the aneurism. From this time every thing went on successfully tiU the stump was on the point of being healed; when, quite unexpectedly, the artery appeared a third time diseased in the same manner as it had been previously, for which reason a third operation for aneurism was determined on and performed. The last operation was near the axilla, and was not followed by any relapse. Could the several aneurisms of the humeral artery (says Mr. Warner) be attributed to the sudden check alone which the blood met with from the extremity of the vessel being secured by ligature; or is it not more reasonable to suppose that the coats of the artery nearly as high as the axilla were originally diseased and weakened ! The latter, in the opinion of this judicibus writer, seems the most probable way of accounting for the successive returns of the disease of the vessel; since it is found from experience that such accidents have been very rarely known to occur after amputa- tion, either ofthe arm or thigh, where nearly the same resistance must be made to the circulation in every subject of an equal age and vigour, who has undergone such operation. If it should be supposed that the several dilatations ofthe coats ofthe vessel, continues Mr. Warner, arose merely from the check in the circulation, it will not be easy to account for the final success of this operation; and especially when we reflect that the force of the blood is increased in proportion to its nearness to the heart.— Sec Cases in Surgery, p. 139, 140, edit. 4.) Ruvsch has related an observation somewhat similar. —(Obs. Anat. Chir. t. 1, p. 4.) Aneurisms sometimes follow the injury of a large artery by a gun-shot wound. The passage of a bullet through the thigh, in one example, gave rise to a femoral aneurism.—(See Parisian Chirurgical Journal, vol. 2, p. 109.) The same cause produced an aneurism high up the thigh of a soldier who was under the care of my friend Mr. Collier, at Brussels, after the battle of Waterloo. PROGNOSIS. In cases of aneurism the prognosis varies according to a variety of important circumstances. The disease may generally be considered as exceedingly dangerous; for, if left to itself, it almost always terminates in rup- ture, and the patient dies of hemorrhage. There are some examples, however, in which a spontaneous cure took place, and aneurismal swellings have been known to lose their pulsation, become hard, smaller, and gradually reduced .to an indolent tubercle, which has entirely disappeared. After death the artery in such instances has been found obliterated, and con- verted into a ligamentous cord, without any vestige of the aneurism being felt. Aneurisms are also some- times attacked with mortification; the sac and adjacent parts slough away; the artery is closed with coagu- lum; and thus a cure is effected. Lastly, tumours having all the character of aneurisms have been known to disappear under the employment of such pressure as was certainly too feeble to intercept entirely the course of the blood. Such examples of success, how- ever, are not common, and whenever they happen, it is because the entrance of blood into the sac is prevented by the coagulation of that already contained in it, and because the artery above the swelling is filled with coagulum. They must, in fact, have been cured on the very same principle which renders the surgical operation successful. Nothing is subject to more variety, than the duration of an aneurism previously to its rupture; the tumour bursting sooner or later, according as the patient hap- pens to lead a life of labour, or ease, temperance, or moderation. Even the bursting of an internal aneu- rism'may not immediately kill the patient: a stone- cutter died in the hospital Saint Louis with an enor- mous aneurism, situated on the left side of the lumbar vertebrae. The body was opened by Richerand, who found that the external tumour consisted of blood, which, after making its way through the muscles, had been effused into a cyst formed in the midst of the cellular substance of the loins. The track through which it came led into another aneurismal sac con- tained in the abdomen, and situated behind the peri- toneum, on the left side of the lumbar vertebrae. In endeavouring to discover whence the extravasated blood proceeded, Richerand found that the abdominal aorta was entire, though in contact with the swelling. The original affection consisted of an aneurismal dila- tation of the interior portion of the thoracic aorta, which had burst at the point where it lies between the crura of the diaphram. The blood had probably escaped very slowly, and it had accumulated in the cellular sub- stance round the kidney, so that three cysts had burst successively before the patient died.—(Nosogr. Chir. t. 4, p. 82, edit. 2.) Every aneurism, so situated that it can neither be compressed nor tied above the swelling, has generally been considered absolutely incurable, except by a natu- ral process, the establishment of which is not suffi- ciently often the case to raise much expectation of a recovery on this principle. But it should be recollected that sometimes the size of the swelling appears to leave no room for the application of a ligature above it, whUe things are in reality otherwise, in consequence of the communication between the sac and the ar- tery bearing no proportion to the magnitude of the tumour itself. At the present day, also, enlightened by anatomical knowledge, and encouraged by successful experience, surgeons boldly follow the largest arteries, even within the boundaries of the chest and abdomen, as we shall presently relate, and numerous facts have now proved that few external aneurisms are beyond the reach of modern surgery. It being certain that aneurisms cannot commonly be cured, except by an obliteration of the affected artery, it follows that the circulation must be carried on by the superior and infe- rior collateral branches, or else the limb would mortify. Experience proves that the impediment to the passage of the blood through the diseased artery obliges this fluid to pass through the collateral branches, which gradually acquire an increase of size. It is therefore a common notion that it must be in favour of the success of the operation, if the disease be of a certain standing; 102 ANEURISM. and in direct opposition to the sentiments of Kirkland, Boyer even asserts that the most successful operations have been those performed on persons who have had the diseasea long while.—(Maladies Chirurg. t. 2, p. 116.) There is this objection to delay, however, that the tumour becomes so large, and the effects of its pres- sure so extensive and injurious, that after the artery is tied, great inflammation, suppuration, and sloughing often attack the swelling itself, and the patient falls a victim to what would not have occurred had the opera- tion been done sooner. The large size of an aneurism, as Mr. Hodgson has rightly observed, is a circumstance which materially prevents the establishment of. a collateral circulation. When the tumour has acquired an immense bulk, it has probably destroyed the parts in which some of the principal anastomosing branches are situated; or by its pressure it may prevent their dilatation.—(On the Dis- eases of Arteries and Veins, p. 259.) The practice of permitting an aneurism to increase, that the collateral branches may become enlarged (says this gentleman), is not only unnecessary but injurious, inasmuch as the increase of the tumour must be attended with a de- struction of the surrounding parts, which will render the cure of the disease more tedious and uncertain.— (P. 266.) The most successful operations which I have seen were performed before the aneurismal swellings were very large. However, notwithstanding the great dis- advantages of letting the swelling become bulky before the operation, the fact appears scarcely yet to have made due impression, and surgeons are yet blinded with the plausible scheme of giving time for the col- lateral vessels to enlarge; at least, I infer that things are so, from having lately seen a patient who has been advised to let the operation be postponed on such a ground, though the swelling in the ham was already as large as an egg. The surgeon should not be afraid of operating, al- though appearances of gangrene may have taken place on the tumour; for, as Mr. Hodgson remarks, should it burst afterward, it is probable that both extremities of the artery in the sac will be closed with coagulum. —(Hodgson, p. 305.) Sir Astley Cooper tied the exter- nal Uiac artery in two cases of inguinal aneurism, when gangrene existed, and though the tumours burst no hemorrhage ensued. The coagulum was discharged; the sac granulated; and the sores gradually healed.— (Medico-Chir. Trans, vol. 4, p. 431.) The effects of the pressure of aneurisms upon the bones are justly regarded as an unpleasant complica- tion, when they take place in an extensive degree, and, according to writers, they may sometimes induce a ne- cessity for amputation.—(Boyer, Traite des Mai. Chir. t. 2, p. 117.) However, I have never seen a case of this description; and Mr. Hodgson, as toe have already ex- plained, informs us that the affection of the bones is hardly ever attended with exfoliations, or the forma- tion of pus, so that if the aneurism can be cured, the bones will generally recover their healthy state, with- out undergoing those processes which take place in the cure of caries or necrosis.—(On Diseases of Arte- ries and Veins, p. 80.) At the same time there can be no doubt, that where the tumour has been allowed to attain a large size before an attempt is made to cure it, and where from this cause both the neighbouring soft parts and the bones have suffered considerably, the completion of a cure, that is to say, the full restoration of the use of the limb, must be for more distant than in other cases where the cure is attempted in an earlier stage. Here then we see another reason against the pernicious doctrine of waiting for the enlargement of the anastomising vessels in addition to that which has been urged above. The age, constitution, and state of the patient's health are also to be considered in the prognosis; for they undoubtedly make a great difference in the chance of success after the operation. The operation, however, should not be rejected on account of the age of the patient, if the circumstances of the case in other respects appear to demand it: for it has often succeeded at very advanced periods of life. " I have seen several aneurisms cured by the modern operation in patients above sixty years of age."— (Hodgson, p. 304.) Similar cases have fallen under my own notice. Sir Astley Cooper, already noticed, has operated with success for a popliteal aneurism on one patient aged 85, and on another 69 years old, with the same favourable result. When an aneurism exists in the course of the aorta, the violent action of the heart, excited by an operation in the extremities, may cause it to burst, and prove in- stantaneously fatal. Two cases occurred a few years ago in this metropolis, in which the patients died from such a cause during operations for popliteal aneurisms. — (See Hodgson on Diseases of Arteries, p. 306 ; Lon- don Med. Review, vol. 2, p. 240 ; and Burns on Dis- eases of the Heart, p. 226.) Were the co-existence of the internal aneurism known, the operation for the other tumour would be improper, and the surgeon should limit the treatment to palliative means. Experience proves, however, that the circumstance of there being two aneurisms in the limb should not prevent the operation, which is to be practised at sepa- rate periods. Facts in support of this statement are quoted by Mr. Hodgson.—(P. 310.) OF THE SPONTANEOUS CURE AND GENERAL TREATMENT OF ANEURISMS. The obliteration of the sac in consequence of a depo- sition of lamellated coagulum in its cavity, as Mr. Hodgson has well described, is the mode by which the spontaneous cure of aneurism is in most instances ef- fected. The blood soon deposites upon the inner sur- face ofthe sac a stratum of coagulum; and successive depositions of the fibrous part of the blood by degrees lessen the cavity of the tumour. At length, the sac be- comes entirely filled with this substance, and the de- position of it generally continues in the artery on both sides of the sac as far as the giving off of the next large branches. The circulation through the vessel is thus prevented ; the blood is conveyed by collateral channels; and another process is instituted whereby the bulk of the tumour is removed.—(On the Diseases of Arteries, &c. p. 114.) Such desirable increase of the coagulated blood in the sac is indicated by the tu- mour becoming more solid, and its pulsation weak or ceasing altogether. Another mode, in which the disease is spontaneously cured, happens as follows: an aneurism is sometimes deeply attacked with inflammation and gangrene; a dense, compact, bloody coagulum is formed within the vessel, shutting up its canal, and completely interrupt- ing the course of the blood into the sac. Hence, the ensuing sphacelation and the bursting of the integu- ments and aneurismal sac are never accompanied by a fatal hemorrhage; and the patient is cured of the gangrene and aneurism if he has strength sufficient to bear the derangement of the health necessarily at- tendant on so considerable an attack of inflammation and gangrene. When a patient dies of hemorrhage, after the morti- fication of an aneurism, it is because only a portion of the integuments and sac has sloughed, without the root of the aneurism, and especially the arterial trunk, being similarly affected. For cases illustrative of this statement, refer to Hodgson on Diseases of Arte- teries, p. 103, Sec. A third way, in which an aneurism may be sponta- neously cured, is by the tumour compressing the ar- tery above, so as to produce adhesion of its sides, and obliteration of its cavity. This mode of cure must be uncommon : it has been adverted to by Sir E. Home, Scarpa, Dr. John Thomson, and others ; but some facts, tending to prove it, have been collected by Mr. Hodgson, and are published in his useful work.—(See p. 107, the crural arch downwards. The sloughs were thrown -off, however, and the ulcer had in a great measure 'healed, when the patient fell a victim to debility.— (Hist. 17.) Here it is to be remarked, that during the Jive weeks this man lived after the obliteration of the femoral artery above the origin of the profunda, not .only the circulation and life of the whole limb were preserved, but the auxiliary arteries, coming from within the pelvis, proved capable of limiting the progress of the mortification of the parts round the aneurism, and of commencing the healing process in a manner which raised great hopes of a cure. A similar fact is also recorded by Dr. Clarke.—(Duncan's Med. Com- ment, vol. 3.) [In cases of aneurism in the thigh, it is not always practicable to decide with absolute certainty whether the disease is situated in the femoral artery, or in the profunda; and even when it obviously originates with the former, the latter is often deeply involved, particu- larly when the disease has been of long standing. Many unsuccessful cases have been reported and I know of one which has failed m the hands of a distin- guished surgeon, the aneurismal tumour still remain- ing, although the femoral artery was tied above the tumour. In this case the disease is no doubt seated in tho profunda. „ , , Many surgical writers and teachers have inculcated the doctrine, that when the aneurism is situated in the thigh, the ligature must always be applied below the bifurcation, lest the circulation of the Umb should suf- fer. A distinguished surgeon of Philadelphia, prefer- red opening the sac of a femoral aneurism, and apply- ing his Ugature below the profunda, rather than ven- ture to tie the artery higher up. The operation failed, however, and the tumour still remains. That such fears are wholly, groundless, may be confidently as- serted from analogy, furnished as we are with the knowledge that the innominata, the common iliac, and even the aorta itself, may be obliterated, and yet the anastomosing vessels continue the circulation. But Dr. Whitridge, an accomplished surgeon of Charles- ton, S. C, has afforded a demonstration in a case of aneurism in the thigh from a gun-shot wound, in which he tied the femoral artery just below Poupart's ligament, and of course above the point at which the profunda goes off. This case has been completely suc- cessful, and the patient recovered without any sensible interruption in the circulation, and without any unto- ward symptom. The cases in which the femoral artery divides high up, whioh Professor Godman has shown are by no means unfrequent, may account for the occasional failures of this operation, and should not be lost sight of by the judicious surgeon. As a general rule, how- ever, applicable to all other cases, when the aneurism is situated immediately below the bifurcation, and in tbe vicinity of the profunda, it is safer, and also better surgery, to apply the ligature above. The action ofthe profunda may endanger the success of the operation, and the most profound surgeon may sometimes mis- take the seat ofthe disease.—JReese.] These and other cases which might be quoted, ftir- nished ample proof of the efficiency of the anasto- mosing vessels in the support of the limb, though the femoral artery had been tied, or obUterated in a very high situation. Besides these facts, surgeons derived every encou- ragement to attempt the cure of popliteal aneurism, by the ligature of the artery above the tumour, from the elucidations given by Winslow and Haller concerning the numberless inosculations which exist between the upper and lower articular arteries. Haller even drew the conclusion, that if the course of the blood were in- tercepted in the popUteal artery, between the origins of the two orders of articular branches, such anasto- moses would suffice for carrying on the circulation in the leg. And at length, Heister, weighing the ana tomical observations of Winslow and Haller, and the facts recorded by Severinus and Saviard, first proposed applying to popliteal aneurisms an operation, which, with the exception of those two cases, had until his time been restricted chiefly to aneurisms of the bra- chial artery.—(Dis. de Genuum Structurd eorumque Morbis. Disp. Chir. Halleri, t. 4.) It was in Italy that the earliest operations were un- dertaken for the cure of popliteal aneurisms, by Guat- tani, or rather by a German surgeon named Keysler, as would appear from a letter written by Testa to Cotunni.—(See Pelletan, Clinique Chir. t. 1.) The success obtained by those surgeons soon led others to imitate them, and by degrees, the practice of tying the femoral artery became common both in cases of aneu- rism and wounds; and from the observations of Heis- ter (Haller Disp. Chir. t. 5), Acrell (Murray de Aneu- rysm. Femoris), LesUe (Edin. Med. Comment.), Ham- Uton (B. Bell's Surgery, vol. 1), Burschall (Med. Obs. and Inq. vol. 3), Leber (Dehaen, Ratio Medendi, t. 7), and Jussy (Ancien Journ. de Med. t. 42), it waa proved beyond the shadow of a doubt, that the circu- lation might continue in the limb after the obliteration of the femoral artery, whether such obliteration were effected by direct pressure or the ligature. The exact period when the first operation of laying open the tumour and tying the popliteal artery waa performed in England, is not, as far as I know, particu- larly specified. However, judging from the observa- tions mage on this practice in the writings of Pott ANEURISM. 125 (Remarks on Palsy, tc. Even Boyer avers his relinquish- ment of what he calls Anel's plan.—(Traiti des Mai. Chir. t. 2, p. 1 IS.) But we shall not be surprised at their iU success, when we hear that they neglect the right principles on which ligatures ought to be applied to arteries, as explained by Dr. Jones in his work on hemorrhage. Even Baron Dupuytren adtiereB to the use of ligatures of reserve; and Boyer applies foui loose ligatures round the artery, besides two tight ones; and consequently, a large portion of the vessel lies separated from its natural connexions, and irritated by these extraneous substances. Hunter's first operation nearly failed also on account of so many ligatures, none of which were tightened so as to cut through the inner coats of the artery, and thus promote its closure. —(See Hemorrhage.) With reference to the operation of popliteal aneurism, Rosenmuller's Chir. Anat. Plates deserve to be consulted, Part 3, Tab. 8*9. Scarpa's and Tiedemann's matchless engravings, and Haller's Icones should likewise be examined. ANEURISMS OF THE LEO, FOOT, FOREARM, AND HAND. Doubts were not long ago entertained respecting the possibility of curing an aneurism at the upper part of the calf of the leg by tying the femoral artery in the middle of the thigh.—(Instituto di Ital. Scienze ed Arti, vol. 1,parte 2, p. 266.) The author here referred to was led by this uncertainty to have recourse in one instance to the severe method of laying open the tu- mour, in order to get at the vessel lower down. On this case, Scarpa makes some correct reflections: the operator (says he) assured himself, that, on compress- ing the femoral artery at the upper part of the thigh, the tumour at the top of the calf ceased to pul- sate ; and that, when the compression was continued for some time, the swelling partly disappeared, and became softer. It ought to have been evident, there- fore, that the aneurism might have been cured by tying the trunk of the femoral artery, as described in the foregoing section. In Scarpa's work is a case in which an aneurism at the bifurcation of the popliteal artery was cured by the ligature of the femoral artery. —(See p. 451, ed. 2.) Mr. Hodgson has seen three an- eurisms situated at the commencement of the tibial arteries, cured by the same operation.—(On Diseases of Arteries, &c. p. 437.) But, as Scarpa remarks, though the Hunterian operation answers in the cure of aneurism in the bend of the arm, and at the upper part of the calf of the leg, it is not so effectual for aneurisms situated on the back or palm of the hand, or the dorsum or sole of the foot. The free communi- cation which the ulnar and radial arteries keep up with each other in the hand, and the tibial arteries have have in the foot, prevent the operation from succeeding whether the brachial or femoral artery, or one ofthe two large arteries of the forearm or leg, be tied. In proof of this statement, Scarpa cites two cases of aneurism seen by himself; one on the instep, the other in the sole of the font; and a third case of the same dis- ease in the latter situation; all of which were found to be incurable by the ligature ofthe anterior tibial artery. —(P- 311.) He thinks, however, that the operation of tying this vessel where it passes over the dorsum of the foot might succeed, if aided by compression, applied so as to stop the current through the other main chan- nel ; and he seems to approve of this practice, be- cause the plan of tying the artery above and below the disease (which is the most certain means of cure) could not be done, without extensive incisions in the sole of the foot. In an aneurism at the lower part of the leg, Mr. Hodgson judiciously insists upon the prudence of tying the artery, as near as possible to the tumour, because tbe recurrent circulation through the large inosculations in the foot might stiU cause the swelling to enlarge, in consequence of the blood sent into the sac from the lower extremity of the vessel, passing through the aneurismal cavity into bran ches arising from the artery between the aneurism and the Ugature.—(P. 438.) However, in one case of aneurism of the ante- rior tibial artery, Mr. H. Cline applied a ligature just above the tumour without success, and Sir Astley Cooper expressly recommends making an incision in the sac, and applying a ligature both above and below the swelling.—(Lectures, S-c vol. 2, p. 63.) When an aneu- rism arises from the radial, ulnar, or interrosseous ar- teries near the elbow, tying the brachial wUl suffice; but if the disease be lower down, the vessel from which it proceeds must be taken up near the swelling.—(Hodg- son, p. 393.) A case, strikingly ulustrative of this truth is recorded by Mr.Liston. J. M. P., aged 19, ap- plied to him on the 28th of July, on account of an an- eurism of the left radial artery, about the middle of tha forearm, occasioned by a wound. The tumour was as laree as a walnut, and so compressible, that it could 126 ANEURISM. easily be made to disappear. Pressure was tried at first, with apparent benefit; but as it did not succeed, the humeral artery was tied on the 8th of August, and with the effect of completely removing the tumour. On the eighteenth day afterward, however, a small slough was detached from the cicatrix, and about three o'clock next morning, a violent hemorrhage took place. Mr. Liston then deemed it necessary to lay open the sac, and tie the artery above and below the wound in it.—(See Edinb. Med. Journ. No. 90, p. 4.) Scarpa mentions a case, where the dorsal artery of the thumb was wounded; but as the hemorrhage re- turned several times, and pressure failed in suppress- ing it, the surgeon took up the radial artery at the wrist. After cutting off this direct current of blood towards the injured vessel, pressure on the wound proved effectual. Three months afterward, the pa- tient having died, the radial artery was found impervi- ous for three fingers' breadth below where the ligature had been applied, and the dorsal artery was likewise obUterated from the root of the thumb to the begin- ning of the palmar arch. Mr. Todd has published a case in which he cured a large aneurismal swelling of the posterior side of the forearm, by tying the brachial artery. From the de- scription, I conclude that the disease was an aneurism by anastomosis, as it is termed; but the particulars given by the author leave us in doubt on this point.— (See Dublin Hospital Reports, vol. 3, p. 135.) The manner of exposing and tying the principal ar- teries of the leg and forearm, wiU be described under the term Arteries. OF ANEURISMS HIGH UP THE FEMORAL ARTERV. Several facts already specified in the preceding co- lumns as having occurred many years before the ope- ration of tying the external iliac artery was attempted, amounted to a full proof, that the circulation might go on in the lower extremity notwithstanding the artery in the groin were tied or obliterated. On this point, some of Guattani's cases were most decisive. The ligature of tbe external iliac artery, for aneu- risms of the femoral artery in the bend of the groin, has now been practised so frequently, and the instances of success are so numerous, that all doubt concerning the propriety and utUity of the attempt has entirely ceased. The French, who have evinced great back- wardness in espousing the Hunterian method of ope- rating for aneurisms, though it is decidedly one of the greatest improvements in modern surgery, have also shown great reluctance even to believe, much less to practice, the operation of tying the external iliac artery. A Parisian surgeon, however, who was in London a few years ago, saw the thing done, and the eyes of his brethren in the capital of France have since been a little more open. Still, as Roux remarks, " We can- not but blame the indifference with which the opera- tion is mentioned in some of the latest French'surgical publications. At this moment (1815) we can reckon twenty-three facts relative to tying the external iliac artery, and on fifteen ofthe patients it has perfectl y suc- ceeded. In these twenty-three operations, I compre- hend the two which were done in France; one at Brest, by Delaporte, and the other at Lyons, by Bouchet; cases, the authenticity of which cannot be doubted. In the number of successful cases, is to be comprised Bouchet's operation, since the patient lived more than a year afterward, and then died of the, con- sequences of an inguinal aneurism of the opposite side. Of the other twenty-one operations, fifteen were performed in London only, in the several hospitals of this metropolis, by Abernethy, Ramsden, A. Cooper, Brodie, and Lawrence; gentlemen who would never publish forged cases. " Sir A. Cooper alone had tied the external Uiac ar- ery six times before my journey to London, and dur- ing my stay there, I saw him perform the operation once. Four of his patients were entirely well; one of the three others died, the thirteenth week after the operation, of the bursting of an aneurism ofthe aorta. At this period, the circulation in the limb had been re- established. I saw the limb after it had been injected among Sir A. Cooper's anatomical preparations. Large and beautiful anastomoses existed round the pelvis, between the dilated branches of the internal Uiac and femoral arteries. With respect to the sixth patient, the leg mortified, and the thigh was amputated with- out success. The seventh died of hemorrhage, which took place the fourteenth or fifteenth day after the ope- ration »—(Para*M/< de la Chir. Angloise avec la Chir. Francoisl, p. 275, 276.) Sir Astley Cooper has now tied the external iliac artery in nine cases.—(See Lan- The many facts already published, exemplifying the propriety of this operation, must be highly gratifying to Mr. Abernethy, by whose judgment it was first sug- gested, and by whose enterprising hand it was first practised. , Mr. Abernethy has been called upon in several cases to take up the external iliac artery, and they all prove that the anastomosing vessels were fully capable of conveying blood enough into the limb below, and that a vessel even of this size could become permanently closed after being tied. Three of the operations done by this gentleman, I was an eye-witness of, and it is therefore with confidence that I can speak of the ease and simplicity of the requisite measures for securing the external iliac artery.—(See Abernethy's Surg, and Physiol. Essays; and Surgical Observations, 1804; Edin. Med. and Surg. Journal for January, 1807 ) In Mr. Abernethy's first operation, performed in 1796, an incision, about three inches in length, was made through the integuments of the abdomen, in the direc- tion of the artery, and thus the aponeurosis of the ex- ternal oblique muscle was laid bare. This was next divided from its connexion with Poupart's ligament, in the direction of the external wound, for the extent of about two inches. The margins of the internal ob- lique and transverse muscles being thus exposed, Mr. Abernethy introduced his fingers beneath them to pro- tect the peritoneum, and then divided them. Next he pushed this membrane, with its contents, upwards and inwards, and took hold of the external iliac artery with his finger and thumb. It now only remained to pass a ligature round the artery, and tie it; but this required caution, on account of the contiguity of the vein to the artery. These Mr. A. separated with his fingers, and introducing a ligature under the artery with a common surgical needle, tied it about an inch and a half above Poupart's ligament.—(Surg. Essays.) The following was the method which Mr. Aber- nethy adopted, the second time of tying the external iliac artery. An incision three inches in length was made through the integuments of the abdomen, beginning a little above Poupart's ligament, and extending upwards; it was more than half an inch on the outside of the up- per part of the abdominal ring, to avoid the epigastric artery. The aponeurosis of the external oblique mus- cle being exposed, was next divided in the direction of the external wound. The lower part of the internal oblique muscle was thus uncovered, and the finger being introduced below the inferior margin of it and of the transversalis muscle, they were divided with the crooked bistoury for about one inch and a half. Mr. Abernethy now introduced his finger beneath the bag of the peritoneum, and carried it upwards by the side of the psoas muscle, so as to touch the artery about two inches above Poupart's ligament. He took care to disturb the peritoneum as little as possible, detach- ing it to no greater extent than was requisite to admit his two fingers to touch the vessel. The pulsations of the artery made it clearly distinguishable, but Mr. Abernethy could not put his finger round it with fa- cility. In order to be able to do so, he was obliged to make a sUght incision on each side of it. Mr. A. now drew the artery gently down, so as to see it behind the peritoneum. By means of an eye-probe, two ligatures were conveyed under the vessel; one of these was carried upwards as far as the artery had been detached, and the other downwards; they were firmly tied and the vessel was divided in the interspace between them. —(Surg. Observ. 1804.) In a third instance of tying this vessel, Mr. Aber- nethy operated exactly as in the foregoing case, and with complete success.—(See Edin. Surg. Journ. Jan. 1807.) Mr. Freer, of Birmingham, who may be said to claim the honour of having seconded Mr. Abernethy in this new practice, made an incision about one inch and a half from the spine of the Ueum, beginning about an inch above it, and extending it downwards about three inches and a half, so as to form altogether an incision four inches aridahalf long, extending to the base of the tumour. The tendon of the external ob- ANEURISM. 127 lique being exposed, was carefully opened, and also the internal oblique, when the finger being introduced between the peritoneum and transversalis, served as a director for tbe crooked bistoury, which divided the muscle. Avoiding all unnecessary disturbance, Mr. Freer separated the peritoneum with his finger, till he could feel the artery beating, which was so firmly bound down, that he could not get his finger under it without dividing its fascia. The vessel having been separated from the surrounding parts, a curved blunt needle, armed with a strong ligature, was put under it, and tied very tight, with the intention of.dividing the internal coats of the vessel. The operation led to a perfect cure.—(Freer on Aneurism, p. 83, ito. 1807.) Mr. Tomlinson, of the same town, was also an early performer of the operation : he applied only one liga- ture, and, of course, left the artery undivided: the event was attended with perfect success. The following is Sir Astley Cooper's mode of ope- rating as described by Mr. Hodgson:—A semilunar in- cision is made " through the integuments in the direction of the fibres of the aponeurosis of the external oblique muscle. One extremity of this incision will be situated near the spine of the ileum : the other will terminate a little above the inner margin of the abdominal ring. The aponeurosis of the external oblique muscle will be exposed, and is to be divided throughout the extent and in the direction of the external wound. The flap which is thus formed being raised, the spermatic cord will be seen passing under the margin of the internal oblique and transverse muscles. The opening in the fascia which lines the transverse muscle through which the spermatic cord passes, is situated in the midspace between the anterior superior spine of the ileum and the symphysis pubis. The epigastric artery runs precisely along the inner margin of this opening, beneath which the external iliac artery is situated. If the finger, therefore, be passed under the spermatic cord, through this opening in the fascia, it will come into immediate contact with the artery which lies on the outside of the external iliac vein. The artery and vein are con- nected together by dense cellular membrane, which must be separated to enable the operator to pass a ligature by meads of an aneurism-needle round the former."— (On Diseases of Arteries, p. 421, 422.) The foregoing incision, the convexity of which is turned outwards and downwards, extends from within and a little above the anterior superior spinous process of the ileum, to above and a little within the middle part of Poupart's ligament. As soon as the tendon of the external oblique muscle has been divided, the knife may be put down, and the internal oblique and trans- verse muscles raised from Poupart's ligament by intro- ducing the finger behind them. Care must be taken to avoid the epigastric artery which runs from the pubis side of the external iliac to the inner side of the inci- sion. Baron Dupuytren, when performing the opera- tion at the Hdtel-Dieu in Paris, in the autumn of 1821, wounded the epigastric artery.—(See Averill's Opera- tive Surgery, p. 37.) The hemorrhage was so copious that two ligatures were required. The patient after- ward died of peritonitis, which, in all probabUity, was brought on by the disturbance of the parts in the pro- ceedings requisite for securing the ends of the wounded vessel. The external iliac vein must also not be in- cluded in the ligature, as such a proceeding would cause a dangerous interruption to the return ofthe blood. When little of the artery is exposed, one liga- ture will suffice; in the contrary circumstance it is best to apply two.—(See Lancet, vol. 2, p. 44, 45.) Mr. Norman, of Bath, who has tried both modes of operating, found that proposed by Sir A. Cooper a more easy way of finding the external iUac artery than the longitudinal incision practised by Mr. Abernethy. " The objection (says Mr. Norman) to sir A. Cooper's mode of operating in cases where the tumour extends high up, is by no means well founded; for the lower part of the bag of the peritoneum lying on the edge of Pou- part's ligament, must in every case be exposed and de- tached, in order to get at the artery which Ues behind the posterior pan, of that membrane, and this is most easily effected by an incision in the direction of Poupart's ligament; while two-thirds of the longitudinal incision are made on a part of the peritoneum, which lines the abdominal muscles, and the lower portion only of the incision reaches that part of the membrane which is vo be separated. The consequences of this are, that the peritoneum is in much greater danger of being wounded, and that the probability of a hernia forming after the cure is much increased by the extensive divi- sion of the oblique muscles."—(See Med. Chir. Trans. vol. 10, p. 101.) As far as I am able to judge, these re- marks are well founded, and they coincide with some observations which were made some years ago by Roux, who, while he inclined to Mr. Abernethy's method, saw the disadvantage of letting the direction of the wound in this instance correspond to the course of the artery. Hence, after many trials on the dead subject, he laid down the rule that the beginning of the wound should never be farther than half an inch from, and a very little higher than, the anterior superior spine of the ileum, and that it should be carried very obliquely down- wards to the middle of Poupart's ligament—(See Nou- veaux Elemens de Med. Op. t. 1, p. 747, 6 c.) Mr. Todd, also, after repeated trials of Mr. .Aberne- thy's and Sir Astley Cooper's methods on the dead sub- ject, concluded that the plan recommended by the lat- ter afforded the greatest facUity of applying the ligature to the artery, because more room was obtained by it, and with less disturbance of the peritoneum, than in the other way. Where, however, it becomes necessary to apply a ligature to a higher part of the artery, in consequence of secondary hemorrhage, Mr. Todd con- ceives that Mr. Abernethy's method should be adopted —(See Dublin Hospital Reports, vol. 3, p. 92.) In a case operated upon by Mr Kirby, a hernia fol- lowed in the situation where the abdominal muscles had been divided.—(Sec Cases with Observations, p. 109, 8vo. Lond. 1819.) In one case, Dr. Post found the peritoneum so thickened and diseased that he could not raise it from the subjacent parts, and he was obliged to make an opening in it. The protruding viscera were then pushed back, and with a needle a ligature was introduced un- der the artery, the peritoneum being also included in the ligature. Notwithstanding the disadvantageous method of operating, and the return of pulsation in the swelling, the patient had so far recovered in three months that he had regained the use of the limb.—(See American Med. and Phil. Reg. vol. 4, p. 443.) In one remarkable case, Mr. Newbiggin, by tymg the external iliac artery, cured both an inguinal and a popUteal aneurism together.—(See Edin. Med. and Surg. Journal, for Jan. 1816, p. 71, Src.) The many operations which have now been done on the external Uiac artery have impressed me with a con- viction that in subjects under a certain age there is no reason to fear that the anastomoses will not generaUy suffice for the supply of the lower extremity. Out of twenty-five cases I only know of three in which the limb was attacked with gangrene. These three were patients of Sir A. Cooper, Bouchet of Lyons, and Mr. Collier. The proportion is not so much as one in eight. The three instances ef gangrene were not all in the circumstances which permitted the event to be imputed to the anastomoses not having had sufficient time to enlarge, though perhaps Mr. Collier's case was such. On .the other hand, we are to notice that Dr. Cole's patient was operated upon a few days after the wound, and yet the limb was duly supplied with blood, and did not become gangrenous. It appears, therefore, to me, that the occasional occurrence of gangrene cannot be admitted as a just reason for delay, until the collate- ral vessels have had time to enlarge. I believe that in all aneurismal diseases, early operating is the best and most judicious practice. This was one principal cause, as Kirkland observes, which occasioned the bad suc- cess of the old surgeons in the treatment of popliteal aneurisms, and he foretold, many years ago, that ope- rations for the cure of aneurisms would answer bet- ter if not deferred so long as formerly.—(See Thoughts on Amputation, 4-c. 8vo. Lond. 1780.) I join Kirkland in this sentiment, not without recollecting that all aneurisms are attended with a chance of getting well spontaneously in the course of time. In saw the in- guinal aneurism which did so under Dr. Albert in the York Hospital; but as this also is a rare incident, I do not believe that it ought to influence us against having speedy recourse to an operation. Besides, the cure by inflammation and sloughing appears to me to be at- tended in reality with more peril than a well-executed operation, and consequently has less recommendations than many may imagine. Had not Dr. Albert's patient been a very strongman, he would certainly have faUen 128 ANEURISM. a victim to the extensive disease which the bursting and sloughing of the tumour created. Thus Dela- porte*s patient died of the mass of disease which the tumour itself made; for it had been suffered to attain too large a size, so that when it inflamed the effects were fetal.—(See Richerand, Nosogr. Chir. t. 4, p. 113, edit. 4.) I believe Dr. Wilmot's observation is perfectly cor- rect, that if a comparison were made between the ope- ration of tying the external iliac artery and that of ty- ing the artery in the thigh, we should find the reco- veries after the first more frequent in proportion to the number of times it has been done, than after common operations lower down.*—(See Dublin Hospital Rep. 6-c. vol. 2, p. 214.) The greatest artery that conveys blood into the lower extremity, after the external Uiac has been tied, is the gluteal;, but, besides it, the ischiatic, the obturator, and the external pudic, which anastomoses freely with the internal pudic, are important vessels in keeping up the circulation. I subjoin a list of some of the successful examples of this operation. Mr. Abernethy, 2 cases (Surgical. Works, vol. 1); Freer and Tomlinson, 2 (Freer on Aneu- rism, 1807); Sir A. Cooper, 4 (Hodgson on Diseases of Arteries, p. 417); Goodlad, 1 (Edin. Med. and Surg. Journ. vol. 8, p. 32); Brodie, 1 (Hodgson, op. cit. p. 419); Lawrence, 1 (Med. Chir. Trans, vol. 6, p. 205); J. S. Soden, 1 (Same work, vol. 7, p. 536): G. Nor- man, 1 (Same work, vol. 10, p. 95, <$c.); E. Salmon, 1 (Same work, vol. 12); Bouchet, 1 (Roux, Med. Ope- ratoire, t. I, p. 744); J. S. Dorsey, 1 (Elements of Surgery, vol. 2, p. 180, Philadelphia, 1813); Mouland, 1 (Bulletin de la Faculte de Mcdecine de Paris, t. 5, p. 535); Dupuytren, 1 (French Transl. of Mr. Hodg- son's work, t. 2, p. 215); Dr. Cole, 1 (Rapport des Travaux de la Societe d'Emulation de la Ville de Cam- brai, 1817, or Lond. Med. Repository); Dr. WUmot, 1 (Dublin Hospital Reports, vol. 2, p. 208, frc.); Kirby, 1 (Cases with Observations, <$-c. 8vo. Lond. 1819); Dr. Post, 1 (American Med. and Philos. Register, vol. 4); Newbiggin, 1 (Edin. Med. and Surg. Journ. Jan. 1, 1816); J. C. Warren, 1 (New-England Journal, or Anderson's Quarterly Journal, vol. I, p. 136). In this case the epigastric artery arose from the anterior and inner part of the sac, and gave origin to the obturator, while the circumflex iln originated from the outer part of the sac. All these vessels were greatly enlarged, and the epigastric rendered the necessary detachment of the external Uiac troublesome. Some particulars of the case of ruptured inguinal aneurism, in which Sir A. Cooper tied the aorta, will be hereafter noticed.—(See Aorta.) Rosenmuller's Chir. Anat., Tiedemann's and Scarpa's Plates, in Ulustration of the operation of tying the ex- ternal Uiac artery, merit notice. CASES OF GLUTEAL ANEURISM CURED BY TYING THE INTERNAL ILIAC ARTERY. Tne gluteal artery is large; from its situation liable to wounds; from its size subject to aneurism. Dr. Jeffrey, of Glasgow, was consulted in a case where the gluteal artery had been wounded. He urged the propriety of tying the vessel where it had been in- jured. This sensible advice was at first rejected, and when the friends at last consented, the operation was too late, as, while preparation was making for it, the tumour burst, and the patient expired in a few moments. Thenden also mentions an instance in which the gluteal artery was wounded in the dilatation of a gun- shot wound, and the patient lost his life.—(See Scarpa * on Aneurism, p. 407, ed. 2.) Mr. John Bell, however, tied the gluteal artery in a case where it was wounded, and the patient was saved. [The late Dr. Cocke and Davidge, professors in the University of Maryland, tied the gluteal artery for an aneurism of immense size, with entire success. The patient was one whose gluteal muscles were exceed- ingly large, and the extent and boldness of the incision rivalled the herculean case reported by Mr. Bell. It will presently be seen that even when the extent of the disease forbids this attempt, the ligature of the in- ternal iliac wiU afford a means of relief.—Reese.] Mr. Stevens, surgeon in Santa Cruz, the gentleman [* Dr. Mott has tied the external Uiac four times with complete success.—Reese.] who has proved the practicableness of putting a liga- ture round the internal iliac artery, informs us that " one of the first surgeons in London had a patient with gluteal aneurism. The tumour was large; al- lowed to burst; and the person bled to death. " I sincerely trust," says he," that the following case may be the means of preventing such an occurrence in future. " Maila, a negro woman from the Bambara country in Africa, was imported as a slave into the West In- dies in the year 1790. She was purchased for the es- tate of Enfield Green; now the property of the heirs of P. Ferrall, Esq. I saw her first in the beginning of December, 1812. She had a tumour on the left hip, over the sciatic notch. It was nearly as large as a chUd's head, and pulsated very strongly. She could assign no cause for the disease. It had commenced, about nine months before, with slight pain in the part; and had gradually increased to its present size. She was now much reduced, in great misery, and ready to submit to any operation.—(See Medico-Chir. Trans. vol. 5, p. 425.) Mr. Stevens had tied the internal iliac on the dead body, and believed that it might be done with safety on the living. The following is some ac- count of the operation: " On the 27th of December, 1812 (says Mr. Stevens), I tied the artery in the pre- sence of Dr. Lang, Dr. Van Brackle, Mr. Nelthropp, and Mr. Ford, the manager of the estate. An incision, about five inches in length, was made on the left side, in the lower and lateral part of the abdomen, parallel with the epigastric artery, and nearly half an inch on the outer side of it. The skin, the superficial fascia, and the three thin abdominal muscles, were successively di- vided ; the peritoneum was separated from its loose connexion with the Uiacus internus and psoas magnus; it was then turned almost directly inwards, in a di- rection from the anterior superior spinous process of the ileum, to the division of the common iliac artery. In the cavity which I had now made, I felt for the in- ternal iliac, insinuated the point of my fore-finger be- hind it, and then pressed the artery between my finger and thumb. Dr. Lang now felt the aneurism behind; the pulsation had entirely ceased, and the tumour was disappearing. I examined the vessel in the pelvis; it was healthy and free from its neighbouring connex- ions. I then passed a ligature behind the artery and tied it about half an inch from its origin. The tumour disappeared almost immediately after the operation, and the wound healed kindly. About the end of the third week the ligature came away, and in six weeks the woman was perfectly well. This is the first example in which the internal iliac was tied. The operation was not attended with much difficulty or pain, and not an ounce of blood was lost. Mr. Stevens had no difficulty in avoiding the ureter, which, when the peritoneum was turned inwards, fol- lowed ^it. Had it remained over the artery, Mr. Ste- vens s'ays that he could easily nave turned it aside with his finger.—(See a particular history of this case in Medico-Chirurg. Trans, vol. 5, p. 422, &c.) A second instance, in which the internal iliac artery was tied, was some time ago communicated to the pub- lic. The operation was performed by Mr. Atkinson, of York, on account of a gluteal aneurism. The follow- ing are a few ofthe particulars, as related by this gen- tleman :—Thomas Cost, aged 29, presented himself at the York County Hospital, April 29th, 1817. He was a tall, strong, active bargeman, not corpulent, but very muscular. He was enduring great pain from a large, renitent, pulsating tumour, situated under the gluteus ofthe right side; an obvious aneurism. It had existed about nine months, and was the consequence of a blow from a stone. In a consultation with Dr. Lanson and Dr. Wake, the necessity of the operation was deter- mined upon, and it was performed on the 12th of May without any material difficulty or interruption, except such as was the consequence of the division of, and bleeding from, the small muscular arteries. Halving got command of the internal iliac artery within the pelvis, which, says Mr. Atkinson, required the complete length of the fingers to accomplish, it was tied Suf- ficient proof of its being the identical artery was re- peatedly obtained by the pressure upon it stopping the pulsation and causing a subsidence of the tumour. Dr. Wake, Mr. Ward, and all the pupils were quite as- sured of the circumstance. The artery being then tied, the pulsation of the sweUing entirely ceased. Some ANEURISM. 129 delay in placing the ligature arose from the needle not being sufficiently pliable ; but for future operations of this kind Mr. Atkinson very properly recommends the ligature to be put round the artery by means of an in- strument resembling a catheter, the wire of which has a little ring at its extremity, and can be pushed out some way beyond the end of the tube. The patient went on tolerably well for some time after the operation; the pulse never exceeded 130, and after a time sunk to 85 or 90. He became exhausted, how- ever, partly by the discharge, and partly by hemor- rhage, and died on the 31st of May, about nineteen days after the operation. In the dissection, the cavity on the external part of the peritoneum, in the situation of the incision, was completely filled with coagulated blood. " The ligature, on moviug a part of this (blood) with a sponge, readily followed it, and without doubt had been disengaged for some days." The internal iliac, which appeared to have been tied, had separated about an inch and a half from the bifurcation with the ixlernal iliac. By " separated" I conclude Mr. Atkin- son means, that the upper part of the internal iliac was separated from the continuation of the same vessel.— (See Medical and Phys. Journ. vol. 38, p. 267, <$-c.) Although this gentleman has not given a very clear tccount of some part of the dissection, and he has also tmitted to describe the place of his external incision, »r the exact parts which he divided in the operation, yet I think that all the circumstances of the case taken 'ogether leave not the smallest doubt of the internal Uiac artery having been actually tied. The complete stoppage of the pulsation as soon as the ligature was tpplied, and the testimony of several respectable prac- .41, Svo. Dub. 1817.) From the very imperfect account here given of the tumour, it is impossible to form any con- clusion respecting its nature. Sandifort has recorded an instance of an aneurism ofthe internal iUac artery itself.—(See Tabula Ana- tomiciB, A-c. Prcecedit Obs. de Aneurismate Arteriae lliaca internee, rariore ischiadic Nervosa causa, fol. Lugd. 1H04.) The common iliac has never been tied in any case of aneurism of the external or internal iliac ; but Pro- fessor Gibson had occasion to put a ligature round it in an example of gun-shot wound. " The patient lived fifteen days after the operation, and then died from peri- toneal inflammation, and from ulceration of the artery. The circulation in the limb of the injured side was re- established about tin: seventh day after the artery was tied."—(See American Med. Recorder, vol. 3, p. 185; and Gibson's Institutes of Surgery, vol. 2, p. 145. Philadelphia, 1825.) [As an act of justice to my distinguished friend Professor Mott, I here insert a detailed account of this Herculean operation, which Dr. Cooper admits has never before been performed. It is alike honourable to him, to the profession, and to our country. It is introduced Vol. I—1 entire, as communicated to me by the doctor at my soli- citation. A detailed account of the first operation ever per- formed upon the arteria iliaea communis for the cure of aneurism, and especially of the first attempt to apply the ligature to so great a vessel, without dividing the peritoneum, may prove interesting to the profession generally, and must be immediately serviceable to practitioners of surgery. " On the 15th of March, 1827,1 was requested to visit a patient with Dr. Osborn (of Westfield, New-Jersey, about twenty-five miles distant from New-York), whom we found labouring under a large aneurism of the right external iliac artery. Israel Crane, aged thirty-three years, by occupation a farmer, of temperate and regular habits, having gene- rally enjoyed excellent health, says, about the middle of January he felt some pain about the lower part of the belly, which he attributed to a fall received during the winter. He is in the habit of using great efforts in lifting heavy logs of wood, as his employment at this season consists in carrying wood to market. It, however, was not untU a fortnight since that he per- ceived any tumour about the lower part of the abdomen. Upon examination, the abdomen on the right side was considerably enlarged from about the crural arch, as high as the umbilicus. When the hand was applied to the parietes of the abdomen, a pulsation was felt and rendered visible to some distance. To the touch the tumour beat violently, and appeared to contain only fluid blood. It commenced a little above Pou- part's ligament, and reached, judging by the touch, from without near the navel, inwards almost to the linea alba, outwards and backwards filling up all the concavity ofthe ileum, and reaching beyond the poste- rior spinous process of that bone. The rapid increase of this aneurismal tumour occa- sioned, as the countenance of our patient indicated, the most extreme agony. His sufferings at times were so great that his screams could be heard at a distance from the house. He had been bled several times, taken light food, and was kept constantly under the effect of opium. He was now informed of the serious nature of his case, and that without an operation very little chance of his life remained; with great composure he immediately consented to whatever would give him the best prospect of saving his life. From the extent and situation of the tumour he was apprized of the uncertain nature of the operation, as well as the difficulty of performing it, and indeed that it would require an artery to be tied, which never had been before operated upon for aneurism. With these views of his situation, he cheerfully submitted to be placed upon a table of suitable height, in a room which was well lighted. Then, in the presence of Dr. Osborn, Dr. Liddle, and Dr. Cross, the following operation was performed:— The pubes and groin of the right side being shaved, an incision was commenced just above the external abdominal ring, and carried in a semicircular direction half an inch above Poupart's ligament, until it termi- nated a little beyond the anterior spinous process of the ileum, making it in extent about five inches. The integuments and superficial fascia were now divided, which exposed the tendinous part of the external ob- lique muscle ; upon cutting which in the whole course of the incision, the muscular fibres of the internal ob- lique were exposed; the fibres of which were cau- tiously raised with the forceps and cut from the upper edge of Poupart's ligament. ^This exposed the sper- matic cord, the cellular covering of which was now raised with the forceps, and uivided to an extent suffi- cient to admit the fore-finger of the left hand to pass upon the cord into the internal abdominal ring. The finger serving now as a director, enabled me to divide the internal oblique and transversalis muscles to the extent of the external incision, while it protected the peritoneum. In the division of the last-mentioned muscles outwardly, the circumflex ilU artery was cut through, and it yielded for a few minutes a smart bleed- ing. This, with a smaller artery upon the surface of the internal oblique muscle between the rings, and one in the integuments were all that required ligatures. With the tumour beating furiously underneath, I now attempted to raise the peritoneum from it, which we found difficult and dangerous, as it was adherent to it in every direction. By degrees we separated it with 130 ANEURISM. great caution from the aneurismal tumour, which had now bulged up very much into the incision. But we soon found that the external incision did not enable us to arrive to more than half tbe extent of the tumour upwards. It was therefore extended upwards and backwards about half am inch within the ileum, to the distance of three inches, making a wound in all about eight inches in length. The separation of the peritoneum was now continued, untU the fingers arrived at the upper part of the tu- mour, which was found to terminate at the going off of the internal Uiac artery. The common Uiac was next examined by passing the fingers upon the pro- montory of the sacrum, and to the touch appearing to be sound, we determined to place our ligature upon it, about half way between the aneurism and the aorta, with a view to aUow length of vessel enough on each side of it to be united by the adhesive process. The great current of blood through the aorta made it necessary to allow as much of the primitive iliac to remain between it and the ligature as possible, and the probable disease of the artery higher than the aneurism required that it should not be too low down. The depth of this wound, the size of the aneurism, and the pressure of the intestines downwards by the efforts to bear pain, made it almost impossible to see the vessel we wished to tie. By the aid of curved spatulas, such as I used in my operation upon the innominata, toge- ther with a thin, smooth piece of board, about three inches wide, prepared at the time, we succeeded in keeping up the peritoneal mass, and getting a distinct view of the arteria iliaca communis, on the side of the sacro-vertebral promontory. This required great effort on our part, and could only be continued for a few se- conds. The difficulty was greatly augmented by the elevation of the aneurismal tumour, and the intercep- tion it gave to the admission of light. When we elevated the pelvis, the tumour obstructed our sight; when we depressed it, the crowding down of the intestines presented another difficulty. In this part of the operation I was greatly assisted by Dr. Os- born and my enterprising pupil, Adrian A. Kissam. Introducing my right hand now behind the perito- neum, the artery was denuded with the nail of the fore- finger, and the needle conveying the ligature was in- troduced from within outwards, guided by the fore-finger of the left hand in order to avoid injuring the vein. The ligature was very readily passed underneath the artery, but considerable difficulty was experienced in hooking the eye of the needle, from the great depth of the wound and the impossibility of seeing it. The distance of the artery from the wound was the whole length of my aneurismal needle. After drawing the ligature under the artery, we suc- ceeded by the aid of our spatulas and board in getting a fair view of it, and were satisfied that it was fairly under the primitiv 3 iliac, a little below the bifurcation ofthe aorta. It was now tied ; the knots were readUy conveyed up to the artery by the fore-fingers; all pulsa- tion in the tumour instantly ceased. The ligature upon the artery was very Uttle below a point opposite the ombUicus. The wound was now dressed with five interrupted sutures, passing them not only through the integu- ments, but the fibres of the cut muscles, so as to bring their divided edges together at all parts of the incision which was muscular. Adhesive plaster to assist the stitches, lint and straps to retain it, completed the dressing. The operation lasted rather less than one hour. He was removed from the table, and put into bed upon his back, with the knee a little elevated upon pillows to relax the limb as much as possible, and to avoid pressure upon it. It was considerably cooler than the opposite leg, and flannels were appUed all over it, and a bottle of warm water to the foot. From the habit he had been in of taking largely of anodynes, a tea-spoonful of the'tinct. opii was administered, with directions to repeat it in an hour if the pain should be severe. In less than one hour from the operation, considerable reaction of the heart and arteries took place; he felt, as he stated, altogether reUeved from the excruciating agony he had suffered since the aneurism commenced. The whole limb had now recovered its natural tempe- rature. March 16th. The day after tie operation, pulse eighty; skin moist; limb warm as the other; com- plains of some pain at the ligature; ordered a purgative of neutral salts. 17th. Pulse eighty, and fuller than yesterday ; took. "* x. of blood from his arm; skin moist; tongue brown; considerable uneasiness in the limb; no pain at the Ugature; leg of natural heat; salts had a good effect. 18th. Pulse seventy-five; skin moist; tongue white; pain in the limb considerable; no pain at the ligature or in the wound; limb warm. 19th. Bled him to-day ten ounces, the pulse being tense, and beating eighty strokes in a minute ; repeated the cathartic: suppuration appearing to have taken place, the dressings were removed. 20th. Pulse seventy and soft; skin moist; wound looks well; pain in the limb continues; leg warm as the other; cathartic operated well. 21st. Pulse seventy and soft; wound looks well; repeated the laxative; pain in the leg rather less; con tinues warm. There has been at no time tension of the abdomen or any particular uneasiness in that part. The patient thus far has been altogether more comfort- able than could have been imagined. He takes more or less opium daily, from the long habit he has been in of taking anodynes. 26th. No unpleasant symptom; wound looks well; bled again to \ xij., as there was a Uttle tumefaction and inflammation about the wound. 30th. Our patient continues to do well; wound dressed daUy. April 3d. Not being able to leave the city, I requested Dr. Proudfoot, my late pupil, and a most promising young surgeon, to visit the patient. He reports that he was free of fever; wound all healed but where the large ligature was passing. The ligature appearing to be detached, the Dr. took hold of it and removed it: this was on the eighteenth day from the time of its application. Limb of the natural temperature; en- joined upon him to keep very quiet and in bed. 8th. There are no disagreeable appearances what- ever ; he appears to be doing remarkably well; has been bled once since the last report; takes a purgative every other day, and an opiate every night; pulse as in health; no pain; says he is entirely comfortable; wound is dressed with dry lint. 16th. Has improved rapidly since the last report. Two days after the ligature came away he very im- prudently got out of bed, without experiencing any dif- ficulty except weakness. Rode out to-day; wound perfectly healed. April 26th. He has been using crutches for a few days to favour the lame leg, which as yet feels rather weak. General health greatly improved. 30th. Is perfectly restored in health; has a little stoop in his walk, which he says is occasioned by the external cicatrix. Leg is not yet of its full size, nor quite so strong as the other. From the period of the operation to the recovery of our patient, he did not ap- pear to suffer more pain, or have more unpleasant symptoms, than would ordinarily take place in a flesh wound of equal extent. Much of this, in my opinion, is to be attributed to the prompt and judicious antiphlo- gistic treatment pursued by Dr. Osborn, to whom I am indebted for the daily reports of the case. May 2Qth. My patient visited me to-day, having come twenty-five miles; he was so much improved in health that I did not recognise him. Examined the cicatrix, and found it perfectly sound; could not dis- cover any remains of an aneurismal tumour; felt the epigastric artery much enlarged and beating strongly, and a feeble, though distinct pulsation in the femoral artery immediately below the crural arch. The leg has its natural temperature and feeling, and he says it is as strong as the other. Much credit is due the patient for his firmness on the occasion ; although apprized ofthe great danger attend- ing so formidable an experiment, and the uncertainty of its result; yet with a fortitude unshaken, and a fuU con- viction that it was the only chance of prolonging his life, he cheerfully and resolutely submitted to the operation The gratification his visit afforded me is not to be imagined, save by those who have been placed under similar circumstances. The perfect success of so im- portant and novel an operation, with the entire restora- tion of the patient's health, was a rich reward for tbe anxiety I experienced in the case, and in a measure compensated for the unexpected failure of my opera- ton on the arteria innominata." ANEURISM. 131 Professor Bushe has lately tied the common iliac in a child less than two months old for a congenital aneu- rism of one of the labia?, she recovered from the ope- ration, but perished a few weeks afterward from abscess of the knee-joint.—Reese.] ANEURISMS OF THE BRACHIAL ARTERY. Surgical writings contain many histories of aneu- risms in the bend of the arm, produced by the punc- ture of the brachial artery in venesection, or caused by a deep wound inflicted at the bend of the arm along the inner side of the humerus or in the axUla. Such cases must indisputably be formed by effusion. Although Morand and others have found, that, along with aneu- risms caused by a wound of the brachial artery, the diameter of the vessel is sometimes unusually enlarged through its whole length above the seat of the tumour, this enlargement, which is very rare, might have ex- isted naturally before the puncture occurred. Even were it frequent, such an equable longitudinal expan- sion of the tube of the artery could not explain the form- ation of the aneurismal sac in the bend of the arm, along the inner side of the humerus, or in the axilla, after wounds.—(Scarpa, p. 160.) The proximate cause of these cases may invariably be traced to the solution of continuity in the two pro- per coats of the artery, and the consequent effusion of blood into the cellular substance. The effect is the same, whether from an internal morbid affection, ca- pable of ulcerating the internal and fibrous coats ofthe artery, the blood be effused into the neighbouring cel- lular sheath surrounding the artery, which it raises after the manner of an aneurismal sac; or the wound of the integuments having closed, the blood issue from the artery, and be diffused in the surrounding parts. The cellular substance on the outside of the wounded vessel is first injected, as in ecchymosis; the blood then distends it, and elevates it in the form of a tumour, and, the cellular divisions being destroyed, converts it at last into a firm capsule or aneurismal sac.—(Scar- pa, p. 167.) The circumscribed or the diffused nature of the aneu- rism, and the rapidity or slowness of its formation, de- pend on the greater or less resistance to the impetus of the blood, during the time of its effusion, by the in- terstices of the cellular substance surrounding the ar- tery, and by the ligamentous fasciae and aponeuroses, lying over the sac. The aponeurosis of the biceps muscle being only half an inch broad, and situated lower than the common place for bleeding, cannot, at least in most cases, materially strengthen the cellular substance surrounding the artery, as is commonly sup- posed.—(Scarpa, p. 168—170.) This author refers the greatest resistance to the intermuscular ligament, which, after having covered the body of the biceps muscle, extends over the whole course of the humeral artery, and is implanted into the internal condyle. This ligamentous expansion has a triangular shape, the base of which extends from the tendon of the biceps to the internal condyle, while the apex reaches upwards along the inner side of the humerus towards the axilla, in the course of the artery. The humeral artery and median nerve, kept in their situation by the cellular sheath and this ligamentous expansion, run in the furrow formed between it and the internal margin of the biceps.— (Scarpa,p. 171.) This author anatomically explains many circumstances relative to the diffusion, circum- scription, shape, f an assistant, I divided it from within outwards and upwards, in the line ofthe outward edge of the sterno-cleido-mastoideus muscle to the extent of two inches. My object in pinching up the skin for the second ineision, was to expose at once the superficial veins, and by dissecting them carefully from the cellular mem- brane, to place them out of my way without wounding them. This provision proved to be useful, for it ren- dered the flow of blood during the operation very tri- fling, comparatively with what might otherwise have been expected ; and thereby enabled me with the great- est facUity to bring into view those parts which were to direct me to the artery. My assistant having now lowered the shoulder, for the purpose of placing the first incision above the clavicle (which I had designedly made along and upon that bone), I continued the dissection with my scalpel, nntU I had distinctly brought into sight the edge of the anterior scalenus muscle, immediately Delow the angle which is formed by the traversing belly of the omo-hyoideus and the edge of the sterno-cleido-mastoi- deus ; and having placed my finger on the artery at the point where it presents itself between the scaleni, I found no difficulty in tracing it, without touching any of the nerves, to the lower edge of the upper rib, at which part I detached it with my finger nail, for the purpose of applying the ligature. Here, however, arose an embarrassment which (al- though I was not unprepared for it) greatly exceeded my expectation. I had learned, from repeatedly per- forming this operation many years since, on the dead subject, that to pass the ligature under the subclavian artery with the needle commonly used in aneurisms would be impracticable; I had, therefore, provided my- self with instruments of various forms and curvatures to meet the difficulty, each of which most readily con- veyed the ligature underneath the artery, but would serve me no farther; for being made of soUd materials and fixed into handles, they would not allow of their points being brought up again at the very short curva- ture, which the narrowness of the space between the rib and the clavicle afforded, and which, in this parti- cular case, was rendered of unusual depth by the pre- vious elevation ofthe shoulder by the tumour. After trying various means to overcome this diffi- culty, a probe of ductile metal was at length handed me, which I passed under the artery, and bringing up its point with a pair of small forceps, I succeeded in passing on the ligature, and then tied the subclavian artery at the part where I had previously detached it for that purpose. The drawing of the knot was unat- tended with pain; the wound was closed by the dry suture, and the patient was then returned to his bed." —(See Practical Observations on the Sclerocele, $-c, to which are added four cases of operations for Aneu risms, p. 276, &rc.) .____ It only seems necessary for me to add, that imme- diately the artery was tied the pulsation of the swelling ceased; that the arm of the same side continued to be freely supplied with blood, and was even rather warmer than tbe opposite arm ; that the operation, which was severe from the length of time it took up, was after a time followed by considerable indisposition ; that the patient died about five days after its performance; that after the artery had been tied, the oedema of the arm and the aneurismal tumour partly subsided; and that, on examination after death, nothing but the vessel was found included in the ligature. In this publication are descriptions of instruments which will be of great service to any future performer of this operation. The chief one is a needle, resembling that which was invented and used by Desault, and of which I have already endeavoured to give an idea. Py means of this instrument, I conceive that the main dif- ficulty of the operation will in future be avoided. Had Mr. Ramsden had its assistance, his patient would have been detained a very little time in the operating theatre, and the event of the case might have been completely successful. Having witnessed all the cir- cumstances ofthe case, the inference that I drew from them was, that if the operation could have been done in a moderate time, which now seems practicable with the aid of the aiguille a. ressort, or the instrument sold by Mr. Weiss, the case in all probability would have ended well. The preceding case is particularly me- morable, as being the first instance in which the sub- clavian artery was scientifically tied, without any ran- dom thrust of a needle, and without the inclusion of any part besides the artery in the ligature. It fur- nished encouragement to repeat the experiment; held out the hope, that axillary aneurisms might be cured as well as inguinal ones ; and confirmed the compe- tency of the anastomosing arteries to nourish the whole upper extremity, when the subclavian is tied where it emerges from behind the anterior scalenus muscle. In the year 1811, the subclavian artery was tied in the London Hospital, in a case of axillary aneurism, by Sir W. Blizard, who found no difficulty in getting the ligature under the artery, with a common aneurism- needle. A single ligature was applied. At first hopes of recovery were entertained; but the patient, who was old and debilitated, afterward sunk and died on the fourth day.—(See Hodgsun's Treatise, p. 375.) In the year 1815, Mr. Thomas Blizard tied the sub- clavian artery in the same hospital. The case was an aneurism in the left axilla, and, like all the other ex- amples of this kind upon record, was attended with great pain in the tumour and limb. There was no pulse in the left radial artery, though there was scarce- ly any difference in the temperature of both arms. " An incision about three inches in length was made through the integuments at the root of the neck, on the acromial side, and parallel with the external jugu- lar vein. The platysma myoides being divided, the cellular membrane was separated with the finger, untU the pulsation of the subclavian artery was felt where the vessel passes over the first rib. The finger being pressed upon this part of the artery, the cellular sheath investing it was carefully opened with the point of a knife. A ligature was then conveyed underneath the artery, by means of a common aneurism-needle, with the greatest facility." As soon as the ligature was tied, the pulsation in the tumour ceased. On the second day after the operation the left arm began to have more feeling, and was as warm as the right. However, difficulty of breathing, twitchings, delirium, &c. afterward ensued, and the patient died on the evening of the eighth day, previously to which event the ring and middle fingers turned black. On opening the body, the pericardium exhibited the- effects of a high degree of inflammation, and the heart was covered with flakes of lymph, its posterior surface being of a deep red colour. The inner membrane of the ascend- ing aorta was of a bright scarlet hue, much diseased, and studded with white patches. A reddish appear ance was also noticed in the lining ofthe right carotid, left subclavian, and even the abdominal aorta. The boundaries of the aneurismal tumour were in a state of sphacelation. These are all the circumstances which I wish here to notice; but more particulars may be pe- rused in Mr. Hodgson's work, p. 602. ft Is remarkable, that in the cases operated upon in the London Hospital, and some others on record, no difficulty was experienced in passing the ligature under the artery with a common aneurism-needle; a circum- stance which must have depended upon the space be- tween the clavicle and the first rib having been less deep in these instances than the two which fell under my own observation, or in others which occurred in the practice of Dr. Col les, Sir Astley Cooper, and Mr. Liston.—(See Lond. Med. Review, vol. 2, p. 200 ; and Edin. Med. and Surg. Journal, January, 1815, No. 64.) In Mr. Key's case, "the dipth of the angle in which the artery was enclosed rendering it impossible to pass a ligature under it, about three-quarters of an inch of the clavicular portion of the sterno-mastoid was divided, which afforded sufficient room, and rendered the concluding part of the operation easy ; the artery became readily exposed to view, and an armed aneu- rismal needle was passed with facility under it"— (Med. Chir. Trans, vol. 13, p. 5.) In Dr. Colles's first case, the artery was tied before it reached the scaleni muscles, as the tumour, which was in the right subclavian artery, extended from the sternal origin of the sterno-mastoid muscle along the clavicle, a little beyond the arch of that bone, and rose nearly two inches above it, in a conical form, the apex of the cone being situated at the outer edge of the fore- going muscle. After a tedious dissection, it was found that only a quarter of an inch of the artery was sound, and on this portion the ligature was placed. Great difficulty was encountered in passing it round the artery, and the pleura was supposed to have been slightly wounded. Before tightening the ligature the breathing became laborious, and the patient complained of oppression about the heart. These symptoms, in- deed, were so violent, that it was judged prudent not immediately to tighten the ligature. On the fourth day, however, the artery was constricted, when the pulse at the wrist ceased, the patient not seeming to suffer much from what had been done. The patient then went on pretty well till the ninth day, when he was seized with a sense of strangling, and pain about his heart, and, becoming delirious, died nine hours after the beginning of this attack. On dissection the aorta was found diseased, and the disease extended into the subclavian artery. In another instance, Dr. Colles tied this vessel at the point where it emerges from between the scaleni muscles, without any particular difficulty. The ope- ration, however, was soon followed by a train of severe symptoms, delirium, and mortification, and the patient died on the firth day.—(See Edin. Med. and Surg. Journ. January, 1815.) The first case in which complete success attended the operation of tying the subclavian artery, where it first comes from behind the anterior scalenus muscle, was that under the care of Dr. Post, of New-York. The patient was a gentleman, with an aneurism in the left axilla. Dr. Post performed the operation on the 8th of September, 1817, in the following manner. "An incision, commencing at the outer edge of the tendon ofthe mastoid muscle, was carried through the integu- ments about three inches in length, in a direction de- viating a little from a parallel line with the clavicle. This divided the external jugular vein, the bleeding from which required a ligature for its suppression ; and in proceeding with the operation, three or four arterial branches were cut, which it was also neces- sary to secure. The subclavian artery was then sought immediately on the outside of the scaleni muscles, and was easily laid bare. Passing over the artery at this place, in contact with it, were three considerable branches of nerves, running downwards towards the chest from the plexus above. These were separated, and a ligature passed under the artery with great facility, by the instrument well adapted to this purpose invented hy Drs. Parish, Hartshorn, and Hewson, of Philadelphia. On tying the ligature, all pulsation ceased in the limb." In the afternoon, the temperature of the limb was observed to be rather higher than that of the other arm. On the 17th of September, the aneu- rismal tumour burst, and about three ounces of dark coagulated blood were discharged. On the 26th, the ligature came away from tbe subclavian artery. Oct. IIth, the wound was entirely healed ; and on the 16th af the same month, the patient required no farther at- tendance, his only complaints being now a little occa- RISM. 135 sional pain in the fingers, and a superficial sinus at the part where the tumour burst.—(See Med. Chir. Trans, vol. 9, p. 185, &c.) Mr. Liston, of Edinburgh, has the honour of being the surgeon that first succeeded, in Europe, in curing an axillary aneurism, by taking up the subclavian artery from above the clavicle, on the 3d of April, 1820 The particulars of the case are very instructing. They prove the risk there always is of tying one of the axillary nerves instead of the artery, unless great caution be employed; and, in fact, Mr. Liston himself first passed his ligature under a nerve, and would have tied it, had he not wisely tried what effect con- stricting the included part would have upon the pulsa- tion of the tumour. As the subclavian artery seemed diseased at the point where it emerged from behind the anterior scalenus, Mr. Liston cautiously divided this muscle to about its middle, so as not to injure the phrenic nerve. At length, with the aid of an aneurism- needle, he passed a strong round silk ligature under the artery, and laying hold of the loop with a small hook withdrew the needle. In consequence of the great depth of the artery, the knot could not be made with the fingers; but with the assistance of a kind of forceps, each extremity of which had a little notch in it, the business was accomplished.—(See Edin. Med. and Surgical Journ. No. 64.) Several other successful operations of this kind have subsequently been done by English surgeons. One by Dr. Gibbs, in the General Naval Hospital of St. Peters- burgh (see Med. Chir. Trans, vol. 12, p. 531); another by Mr. Bullen, in the Lynn Dispensary' (see London Med. Repository for Sept. 1823); a third by Mr.Wishart at Edinburgh (see Edin. Med. and Surg. Journ. No. 78); a fourth by Mr. Key, in Guy's Hospital (see Med. Chir. Trans, vol. 13, p. 1); and a fifth by Mr. B Cooper, in the same establishment. [ Professor Gibson, of the University of Pennsylvania, has cured a case of axillary aneurism occasioned by the reduction of an old luxation of the humerus, by tying the subclavian artery.—(See American Journal, vol. 2, p. 136.)—Reese.] The instructions delivered by Mr. Hodgson for the performance of this operation, are the best with which I am acquainted. When the subclavian artery (says this gentleman) has emerged from behind the anterior scalenus muscle, it passes obliquely over the flat sur- face ofthe first rib, with which it is in immediate con- tact. The cervical nerves are situated above and.a little behind the artery; the subclavian vein passes before it, and underneath the clavicle. If the finger be passed down the acromial margin of the anterior sca- lenus muscle, the artery will be found in the angle formed by the origin of that muscle from the first rib. The shoulder being drawn down as much as possible, the skin is to be divided immediately above the,cla\ricle, from the external margin of the clavicular portion of the mastoid muscle, to the margin of the clavicular in- sertion of the trapezius. No advantage whatever, says Mr. Hodgson, is gained by cutting the clavicular at- tachment of the sterno-cleido-mastoideus. On this point, however, there is some difference of opinion: Mr. Key having found, in his operation, that the division of the clavicular portion of that muscle greatly facili- tated the introduction of the ligature under the artery. —(See Mod. Chir. Trans, vol. 13, p. 5 and 10.) The exposed fibres of the platysma myoides are now to be carefully divided, without wounding the external jugu- lar vein, which lies immediately under them, near the middle of the incision, and should be detached, and drawn towards the shoulder with a blunt hook. The cellular membrane, in the middle of the incision, is then to be cut, or separated with the finger, until the surgeon arrives at the acromial edge of the anterior scalenus. He passes his finger down the margin of this muscle, until he reaches the part where it arises from the first rib, and in the angle formed by the origin of the muscle from the rib he will feel the artery. The ligature is now to be conveyed under the vessel with an aneurism-needle, or that recommended by Desault. —{Hodgson on Diseases of Arteries, Src. p. 376, Src.) Breschet thinks that the safest and easiest method is that adopted by Dupuytren. An incision, three or four inches long, is to be made at the lower and outer part of the neck, and extended to the clavicle. This first incision, situated behind the external edge of the sterno-mastoid muscle, should go through the skin, 136 ANEURISM. the cellular membrane, and platysma myoides. Some venous branches, running into the jugulars, will then be met with, which should be surrounded by a double ligature, and divided in the interspace. A director is then to be introduced under the omo-hyoideus muscle, in order to facilitate its division, and the surgeon will at length reach the external edge of the anterior sca- lenus. A curved probe-pointed bistoury is then to be gradually and cautiously passed behind that muscle, with the flat surface of the blade against it, and deeply enough to divide the external third, or half of the fibres ofthe same muscle, or even all of them if requisite. The insulated artery wiU then be felt at the bottom of the wound, situated in the area of a triangle, the upper side of which is formed by the brachial plexus, the lower by the subclavian vein, and the inner by the scalenus. A ligature is then to be conveyed under the artery by means of the needle invented by Deschamps. —(See French transl. of Mr. Hodgson's work, t. 2, p. 126.) Whether cutting the anterior scalenus and omo-hyoideus wUl facUitate the operation is question- able ; but the assertion that these measures Increase its safety, is what I cannot understand. With respect to tying the subclavian artery on the tracheal side of the scalenus, we have seen, that it was performed by Dr. Colles, and the event was fatal. Descriptions of the operation may be found in Mr. Hodgson's work, p. 382. When I consider the man- ner in which the subclavian artery, before it passes behind the anterior scalenus, is surrounded by parts of great importance, I can scarcely bring my mind to think, that the measures requisite for taking up the vessel in this situation, wUl ever leave the patient much chance of recovery. " Between the aorta and scaleni muscles (says Mr. A. Burns) the subclavian arteries are connected with several important vessels and nerves. They are in the vicinity of the nervus vagus, of the recurrent laryngeal nerve, of the sympa- thetic nerve, of the phrenic nerve, and the subclavian vein; and, on the left side, the subclavian artery is in- timately connected with the termination of the tho- racic duct. These parts are all grouped together in a very narrow space, and the perplexity of their dissec- tion is farther increased by the interlacement of the different nerves with one another. The natural con- nexions of these parts are best shown by merely rais- ing the external extremity of the sterno-mastoid mus- cle. If this be done, the nervus vagus will be brought into view, lying on the forepart of the subclavian ar- tery, almost directly behind the sternal end of the cla- vicle ; and exactly opposite to the nervus vagus, but behind the artery, the lower cervical ganglion of the sympathetic nerve will be brought into view. The re- current nerve, on the right side, hooks round the sub- clavian anery, and, in its course towards the larynx, ascends along the tracheal side of the sympathetic nerve. On the left side, it twines round the arch of the aorta, and in moifnting upwards, is interposed be- tween the subclavian artery and oesophagus. The subclavian vein lies anterior to the artery, and in the collapsed state, sinks nearer to the thorax;" but, when distended in the Uving body, it overlaps the artery. The thoracic duct enters the subclavian vein, about the eight of an inch nearer to the acromion than the point where the internal jugular vein empties itself into the subclavian vein. The termination of the tho- racic duct is situated between the sternal and clavicu- lar portions of the sterno-mastoid muscle.—(A. Burns, on the Surgical Anatomy of the Head and Neck, p. 28.) A case in which an axillary aneurism, unattended with pulsation, was punctured, and the child bled to death, is noticed in a modern periodical work.—(See Med. Chir. Journ. vol. 4, p. 78.) For anatomical views of the parts concerned in the operation of taking up the subclavian artery, consult Rosenmuller's Chir. Anat. Plates, part 2, tab. 8 and 9; Tiedemann's and Scarpa's beautiful engravings. Some valuable anatomical remarks, in relation to the operation, are given by Mr. A. Bums,—(Surgical Anatomy of the Head and Neck, p. 28, ij c) In certain cases of subclavian aneurism, it has been proposed to tie the arteria innominata. In the dead subject, Mr. Allan Burns applied two ligatures to it, and after cutting through the vessel in the interspace, he injected the aorta, when the injection was found to pervade the anastomosing vessels of the right arm, and aU those of the head. But notwithstanding this fact, and others noticed by Mr. Hodgson, tending to show the probability that a ligature upon the arteria innominata would not prevent the arm and head from .receiving an adequate supply of blood, other objec- tions were made to the practice. The principal of these were founded upon the difficulty of the opera- tion in the living body; the inflammation, likely to be excited by it in neighbouring important organs ; the danger of hemorrhage from the adhesion of the vessel being likely to be broken by the force of the circula- tion ; and the equal practicableness, in most cases, of tying the subclavian artery on the tracheal side of the scalenus. Dr. Mott, an eminent surgeon at New-York, im- pressed with the value of Mr. Allan Burns's remarks upon this subject, has, ever since he became acquainted with them, maintained in his lectures the propriety of attempting to tie the arteria innominata, under particu- lar circumstances of subclavian aneurism. At length, Dr. Mott put this new operation to the test of experi- ence in the New-York Hospital, on the 11th of June, 1818. The case was a subclavian aneurism on the right side, and the patient, a sailor, aged fifty-seven, to whom seventy drops of tinct. opii were first given. Dr. Mott began the first incision directly over the swelling above the clavicle, extended it along this bone and ended it at the trachea, just above the upper por- tion of the sternum. Here he commenced the second incision, of about the same length as the first, and reaching along the inner margin of the sterno-cleido- mastoideus. Dr. Mott next detached the skin from the subjacent platysma myoides, cut through the lat- ter, and cautiously divided the sternal portion of the mastoid muscle, in the direction of the first incision. The internal jugular vein now presented itself close to the swelling, and adherent to it; a circumstance that rendered the subsequent part ofthe operation very difficult. After detaching a portion of the latter vein from its connexion, Dr. Mott cut through the sterno- hyoideus and sterno-thyroideus, and turned them back over the trachea. The carotid was now exposed a few lines above the sternum, and after he had sepa- rated the par vagnm and internal jugular vein from it, they were drawn towards the outer side of the neck. Dr. Mott then laid bare the subclavian artery, which part of the operation he chiefly accomplished with the handle of the scalpel, as there was nothing to be sepa- rated but cellular membrane. The subclavian artery was found to be very much enlarged and diseased, and as Dr. Mott recollected that this state of the vessel had seemingly hindered its successful closure in the example operated upon by Dr. Colles, of Dublin, he decided to take up the arteria innominata itself. In detaching the cellular membrane from the lower sur- face of the subclavian artery, a small branch, situated about half an inch from the innominata, was injured, and the wound was six or eight times filled with blood from it. The hemorrhage was soon suppressed, how- ever, by means of a little pressure. Had not the bleeding been so easily stopped, Dr. Mott would have concluded, from the situation of the vessel, that it was the internal mammary; but if it were not this branch, he conceives it must have been an artery not regu- larly originating in this situation; perhaps the supe- rior intercostal. Dr. Mott continued the operation with a small, round- ended, sharp scalpel, until he came to the division of the arteria innominata, which great vessel he traced below the sternum, and after freeing it from all the cel- lular membrane with the handle of the scalpel, and drawing aside the recurrent and phrenic nerves, he tied it with a round sUk ligature, about half an inch from its bifurcation. Most surgeons, says Dr. Mott, complain of the diffi- culty of tying large arteries in a deep small wound, Hence, he recommends a set of instruments, invented for the purpose, in Philadelphia, by Drs. Parish, Hartshorn, and Hewson; consisting, 1st. Of several blunt-pointed needles, of various sizes and curvatures, furnished with an eye at each end, and calculated at one- end to screw into a strong handle. 2dly. Two strong instruments, with handles, having at one end an eye or hole; they resemble those sometimes used for ap- plying a ligature to the tonsils. 3dlv. A small round pointed scalpel. 4thly. A small hook, fixed in a very strong handle.—(Parish, in Eclectic Rep. vol. 3, p. 229.) After Dr. Mott had introduced the ligature into the ANEURISM. 137 eye of one of the above-described needles, and screwed the needle into a handle, he pressed with its convexity the cellular membrane and pleura carefully down- wards, while he carried it from below upwards round the artery. As the point now appeared on the other side ofthe vessel, the above-mentioned hook was passed into its eye, and the handle unscrewed from the other end of it, when it was easily drawn out from under the artery, and the ligature left under the vessel. In this part of the operation, Dr. Mott urges the ne- cessity of being particularly attentive to two impor- tant circumstances; one is, to convey the ligature round the artery from below upwards, as the only way to prevent injury of the pleura; and the other is, to fix the hook in the eye of the needle, before the handle is unscrewed from its other end, because, after this has been done, the needle loses all steadiness, and it is then difficult to get the hook into the eye. With respect to the foregoing instruments, I may ob- serve, that they are superseded by the needle lately constructed by Mr. Weiss. Dr. Mott now made a noose, pressed it with the fore-finger down to the artery, and- tightened it very gradually, in order not to stop the flow of blood through the vessel all at once. A moderate constric- tion was kept up some seconds, so that the effect of the ligature upon the heart and lungs might be ob- served; and as no disturbance was produced in the functions of these organs, Dr. Mott tightened the liga- ture, and stopped the current of blood through the vessel. At this instant, the pulsation of the right tem- poral and radial arteries ceased. The noose was tightened still more with the above-mentioned ligature irons, and then a second knot was made. Dr. Mott was greatly pleased at finding his patient's counte- nance remain perfectly unchanged, and no complaint made of pain in any other part. Immediately after the ligature had been applied, the aneurismal swell- ing lost one-third of its size, and the clavicle could be felt through its whole extent. The divided muscles and detached skin were now brought into their natu- ral situation, the wound closed with three sutures and adhesive plaster, and a compress applied. In the ope- ration three small arteries were tied: the first lay under the sternum, and seemed to be a branch of the internal mammary; the second was a descending branch of the superior thyroideal; and the third a branch of the inferior thyroideal. From two to four ounces of blood were lost, most of which came from an injured small branch of the subclavian. The ope- ration took up about an hour. The curved spatula? recommended by Dr. Colles, were found very useful for holding the carotid and par vagum aside, while, by their uniform pressure, they materially assisted in re- straining the effusion of blood from small vessels, and as taking up little room, were infinitely more conve- nient in a deep narrow wound, than the fingers of an assistant. The day after the operation, the veins of the right forearm and hand had a turgid appearance. When the circulation in them was promoted by pressure, they became empty for some distance above the pressed part, but filled again immediately the pressure was re- moved ; a circumstance that seemed to show, that the circulation in this arm, notwithstanding the ligature of the arteria innominata, still went on with great ce- lerity, though no pulse could be felt in the brachial and radial arteries. On the contrary, the pulse was very plain in the front branch of the temporal artery, just above the outer angle of the orbit. The left external carotid beat with unusual force. In a few days, how- ever, the pulse became perceptible again at the right wrist. My limits will not allow me to enter into aU the de- tails of this interesting case : suffice it to mention, that the patient suffered considerable febrUe disturbance at some periods after the operation, and it was neces- sary twice to have recourse to venesection. He was also afflicted with a severe cough. The discharge from the wound was copious and fetid. The main liga- ture separated on the fourteenth day. On the twen- tieth day, the patient was sufficiently recovered to walk in the garden. On the twenty-first day, the wound was almost closed ; the patient could move his right arm with the same facility as his left, and he was ginning such strength, that no doubts were enter- tained about the successful result of the operation. On the twenty-third day, hemorrhage came on from the wound: it was stopped by the introduction of lint and the employment of pressure. About twenty-four ounces of blood were lost, whereby the patient was so depressed that the pulse was no longer distinguish- able. On the twenty-fourth day, in the evening, he lost four ounces more blood; on account of his rest- lessness and the painful state of his arm, two grains of opium were administered to him. After one or more returns of bleeding, he died on the twenty-sixth day. When the body was opened, no traces of inflamma- tion or its consequences were found either in the arch of the aorta, the origin of the innominata or the lungs. The aorta was now slit .open longitudinally, and a probe then cautiously passed through it into the inno- minata, when the instrument went through the latter vessel into the cavity of the wound. The inner coat of the innominata was smooth and soft; but about half an inch from the place where the ligature had cut through the vessel, marks of inflammation were no- ticed, and a coagulum adhered to the sides of the ar- tery with considerable firmness, so that nature had probably endeavoured, by means of adhesive inflam- mation, to close the vessel, but had been prevented from completing the salutary process by the destruc- tive ulceration. One portion of the parietes of the innominata was thickened by inflammation, and an anomalous branch, as large as a crow's quill, arose from this artery. The ulcer was twice as extensive inwardly as it was superficially, reaching laterally to the trachea, and un- der the clavicle to the swelling. The tripod of great vessels, viz. the innominata, the subclavian, and the carotid, was destroyed by ulceration to the extent of about an inch, and the ends of both the last vessels opened into the wound. At this place the pleura was considerably thickened by a layer of organized lymph. The inner surface of the carotid was covered with a coagulum, and its coats so much thickened, that a probe could hardly be passed into it. The consolida- tion reached up to the division into the external and in- ternal carotid. The subclavian was pervious as far as the situation of the disease. The diameter of the bra- chial and other arteries of the right arm was natural. The external mammary artery was enlarged, but not the internal. The clavicle was carious, and several lymphatic glands under it in the state of suppuration. Though the result of the operation was unsuccess- ful, it proves, as Dr. Mott correctly remarks, some ui- teresting points; namely, that tying an artery of such magnitude, and so near the heart, may be done with- out occasioning any disturbance either in the functions of the brain, the heart, the lungs, or the right arm. The suppuration, which continually extended itself more and more deeply, is set down by Dr. Mott as the cause of the patient's death; for, as no bleeding took place for several days after the detachment of the prin- cipal ligature, it is plain that this must have fulfilled its duty, and that the artery had been closed.—(See New-York Med. and- Surgical Register, 1818, vol. 1.) [This new and formidable operation, the practicabi- lity of which Dr. Mott has thus demonstrated, and the safety of which is now decided in any future aneu- rism in which it may become necessary, is justly con-i sidered one of the most splendid achievements ever accompUshed, and is destined to give the author's name immortality; and this, with the successful case of liga- ture of the Uiacus communis, confers upon American surgery imperishable laurels. As an evidence of the estimation in which this operation is held in Europe, I feel a national pride in inserting the following extract of a letter from that distinguished surgeon, Professor CoUes, of Dublin, written to Dr. Mott soon after his case of ligature on the innominata had reached him. I think this tribute to the able operator is the more im- portant, since efforts have been made by the envious to detract from the merit of the operation; and it has been publicly stated that the same operation has been performed in Europe, and even by Dr. CoUes himself That this is not the fact wUl be obvious from the ex- tract which follows, and which I introduce without any farther comment. " I shall not attempt to say how much the profession is indebted to you for this bold and splendid ojieration. That it did not succeed I lament on your account; that it wUl hereafter succeed, there cannot be a doubt in 138 ANEURISM. the mind of any reasoning man. Your feelings during the first twenty-two days after the operation are to be envied. The hopes of success continued so strong and so well founded, whUe the slight degree of uncertainty as to the issue must have exalted those feelings to the highest intensity. I have never read the account of an operation in which I would rather have been the ope- rator."—Reese.] The arteria innominata was also tied by Graefe on the 5th of March, 1822, in the Clinical Hospital of the University of Berlin, on account of a subclavian aneu- rism. The carotid was exposed and traced down to the innominata, to which a ligature was applied by means of a blunt tenaculum constructed for the pur- pose, the vessel being tied at most about an inch from the curvature of the aorta, and two inches from the heart. As soon as the ligature was tightened, the pul- sation of the arteries of the right arm, right caro- tid, and right temporal artery ceased; at the same instant the throbbiug of the aneurism stopped, and the tumour became flaccid. The constriction of the cord produced no disturbance of any function. The patient went on so weU for several weeks afterward, that no doubt was entertained of his recovery. How- ever, when the wound was nearly healed, hemor- rhage came on, and though it was suppressed, and hope began to be again indulged, the bleeding recurred, and the patient died on the sixty-seventh day. Below the ligature the innominata was ibund closed with lymph. Graefe has written a distinct essay on the method in which the operation was done; the daily particulars of the case, and preparation from it, are placed in the Royal Anatomical Museum at Berlin.—(See Journ. der Chirurgie von C. F. Graefe, and Ph. v. Walther, b. 3, p. 596, &rc, b. i, p. 587.) Of Mr. Wardrop's prac- tice of tying the subclavian artery in aneurism of the arteria innominata itself, we shaU presently speak. CAROTID ANEURISMS. There is no part of the body where the diagnosis of aneurisms is more liable to mistake than in the neck. Here the disease is particularly apt to be confounded with tumours of another nature. We have already cited in this article examples in which aneurisms of the arch of the aorta so resembled those of the carotid as to have deceived the surgeon who was consulted. The swelling of the lymphatic glands, or of the cellu- lar substance which surrounds the carotid artery, the enlargement of the thyroid gland, and especially ab- scesses, may resemble an aneurism by the pulsations communicated to them by the neighbouring artery. On the other hand, aneurisms of long standing, which no longer throb, and the integuments over which are changed in colour and likely to burst, may the more easUy be mistaken by an inattentive practitioner for chronic abscesses, as the neck is remarkably often the seat of such diseases.—(Boyer, Traite des Maladies Chirurgicales, t. 2, p. 185.) Scarpa mentions one unfortunate patient who was killed by a knife being plunged in a carotid aneurism, on the supposition that the case was an abscess. I need scarcely observe, that by opening a carotid aneurism a surgeon would expose himself to the dis- grace and mortification of seeing the patient die under his hands, as happened in the example cited by Har- derus. — (Apiar. Observationum, Obs. 86.) The possibiUty of tying the carotid artery in cases of wounds and aneurisms, without any injurious ef- fect on the functions of the brain, is now completely proved. Petit mentions that the advocate Vieillard had an aneurism at the bifurcation of the right carotid, for the cure of which he was ordered a very spare diet, and directed to avoid all violent exercise. Three months afterward the tumour had evidently dimi- nished; and at last it was converted into a small, hard, oblong knot, without any pulsation. The patient having died of apoplexy seven years afterward, the right carotid was found closed up and obliterated from its bifurcation, as low down as the right subclavian artery.—(Acad, des Sciences de Paris, an 1765.) Hal- ler dissected a woman whose left carotid was imper- vious.—(Opuscula Pathol Obs. 19, tab. 1.) An ex- ample of the total-closure of both carotids in conse- quence of ossification, is stated by Koberwein to be recorded by Jadelot.—(German transl. of Mr. Hodg- son's work, p. 293.) Hebenstreit, vol. 4, p. 266, ed. 3, of his translation of B. Bell's Surgery, mentions a case in which the carotid artery was wounded in the extir- pation of a scirrhous tumour. The hemorrhage would have been fatal had not the surgeon immediately tied the trunk of the vessel. The patient lived many years afterward This is probably the earliest authentic instance in which a ligature was applied to the carotid artery Mr Abernethy's case is perhaps the second: and that in which Mr. Fleming, a naval surgeon, tied the common carotid in a sailor who attempted suicide, and who was saved by the operation, is stUl later, not having occurred tiU the year 1803—(See Med. Chir. Journ. vol. 3, p. 2.) Dr. BaUlie knew an instance in which one carotid was entirely obstructed, and the diameter of the other considerably lessened, without any apparent Ul effects on the brain.—(See Trans, for the Improvement of Med. and Chir. Knowledge, vol. 1, p. 121.) Sir Astley Cooper has also recorded an example in which the left carotid was obstructed by the pressure of an aneurism of the aorta; and yet during life no paralysis nor im- pairment of the intellects had occurred.—(See Med. Chir. Trans, vol. 1, p. 223.) A simUar case is related by Pelletan.—(Clinique Chir. t. 1, p. 68.) Mr. Abernethy was under the necessity of tying the trunk of the carotid in a case of extensive lacerated wound of the neck, where the internal carotid and the chief branches of the external carotid were wounded. The patient at first went on well: but in the night he became delirious and convulsed, and died about thirty hours after the ligature was applied. This case fell under my own notice, and the inference which I drew was, that the man died more from the great quantity of blood which he lost, and the severe mischief done to the parts in the neck, than from any effect of the ligature of the artery on the brain. In another instance in which the common carotid was tied, on account of a wound of the external caro- tid by a musket-ball, complicated with fracture of the condyle and coracoid process of the lower jaw, every thing went on favourably until the seventh day after the operation. Neither the intellectual faculties nor the functions of the organs of sense had been at all disturbed. But at that period stupor, confusion of ideas, restlessness, a small unsteady pulse, discolor- ation of the face, and loss of strength came on, fol- lowed in the evening by a violent paroxysm of fever. On the eighth day three copious hemorrhages took place from the whole surface of tbe wound, and on the ninth the man died. In this case, however, the affection of the brain, and the other unfavourable symptoms, would be ascribed by nobody to the effects of the ligature on the carotid, but every one would see the cause in the severe and extensive local mischief produced partly by the musket-ball, and partly by the mode in which the operation was performed, the surgeon having extended his incisions from the parotid gland to within an inch of the clavicle!—(See Journ. General de Med. S/-C par Sedillot.) That the carotid may be tied without injuring tbe functions of the brain, and that aneurisms of this ar- tery admit of being cured by the operation, is now fully proved. The following is the second instance in which I have been present at the operation of tying the carotid trunk on account of a wound. A soldier of the 44th regiment was wounded in the neck with a pike at the battle of Waterloo, and was brought to Brussels. After he had been some little time in the hospital, the bleeding, which had stopped, recurred with great violence, both from the mouth and the external wound itself; and it was therefore judged necessary to tie the common carotid, which was done by my friend Mr. Collier. The operation was per- formed by making an incision along the inner edge of the sterno-cleido-mastoideus, raising this muscle from the sheath including the artery, een done; and this extension is in proportion to the greater or less force with which the arterial blood is thrown from the artery into the vein, and the greater or less resistance made by the valves situated in the vein below the puncture, and according to the greater or less number of veins communicating with the aneurismal varix. The seat of the disease is gene- rally the basilic vein, which appears dilated in an un- usual manner, forming an oblong tumour of the size of a walnut, if the disease is recent. In the centre of the swelling is the cicatrix left by the lancet. The rein is less dilated the farther it is from this scar, and in general at the distance of two inches and a half above and below this point the vessel resumes its natu- ral size. The small tumour, as has been explained, pulsates like an artery with a tremulous motion and hissing noise, which is sometimes so great that the patient cannot sleep if he is lying with his head low, and resting on the injured arm. The trunk of the bra- chial artery, from the axilla down to the place where it has been wounded with the lancet, vibrates with extraordinary force. There is no change of colour nor inflammation ofthe skin; and the pain is inconsiderable. The swelling is compressible and yielding; but it re- turns as soon as the pressure is removed from it. When the arm is kept for some time raised up towards the head, the tumour diminishes ; and the same thing happens when pressure is made on the communication between the artery and vein, or when a tight tourni- quet is applied near the axilla. If the disease be com- plicated with aneurism, a second pulsating tumour will be found lying under the aneurismal varix.—(Scarpa, p. 424, ed. 2.) After relating two cases, illustrative of the nature of aneurismal varix, Dr. W. Hunter proceeds to inquire, " Why is the pulse at the wrist so much weaker in the diseased arm than in the other? surely the reason is obvious and clear. If the blood can easily escape from the trunk of the artery directly into the trunk of the vein, it is natural to think that it will be driven along the extreme branches with less force and in less auan- tity. Whence is it that the artery is enlarged all the way down the arm ? I am of opinion, that it is the conse- quence of the blood passing so readily from the artery into the vein, and is such an extension as happens to all arteries in growing bodies, and to the arteries of particular parts when the parts themselves increase in their bulk, and at the same time retain a vascular struc- ture. It is well known that the arteries of the uterus grow much larger in the time of utero-gestation. I once saw a fleshy tumour upon the top of a mans head as large nearly as his head; and his temporal and occipital arteries, which fed the tumour, were en- larged in proportion. I have observed the same change in the arteries of enlarged spleens, testes, &c. so that I should suppose it will be found to be universally true in fact, and the reason of it in theory seems evi- dent."—(.See Med. Obs. and Inq. vol. 2.) In thin subjects the median basilic vein is so close to the brachial artery, the track of which it crosses at a vei y acute angle, that it is almost impossible to open it at this point without risk of wounding the artery at the same time. The bend of the arm indeed is the very situation in which this disease is usually noticed. It is easy to conceive, however, that a venous aneurism may happen wherever an artery of a certain diameter lies immediately under a large vein. Thus, Baron Larrey informs us that his uncle, surgeon to the hospi- tal at Toulouse, saw a case of aneurismal varix, which had been occasioned by a wound of the popliteal vein and artery, and that a history of the disease, accompa- nied with the pathological preparation, was sent to the former Royal Academy of Surgery at Paris. " The varicose swelling, which was as large as two fists, occupied the whole of the ham in a middle-aged man, who some years previously had been wounded with a sword in that part ofthe limb. At a consultation, ampu- tation w as deemed necessary, and was performed with success. At the bottom ofthe varicoseipouch the com- munication between the popliteal vein and artery was observed. The sac itself was evidently composed of the vein, the parts of which, adjacent to* the varicose swelling, were dilated, especially the lower continua- tion of the vessel. The popliteal nerve was rendered Hat, like a piece of tape, and adherent to the outside of the c) st."— I,See Mem. de Chir. Mil. t. 4, p. 340. Boyer, K2 TraiU. des Mai. Chir. be. t. 2, p. 177.) Two cases are likewise recorded by Mr. Hodgson. In one, the dis- ease was caused in the thigh, about four inches below Poupart's ligament, by the point of a heated iron rod, which had passed through the femoral artery and vein. In the other example, the aneurismal varix was situated in the ham, and was the consequence of a wound in that part with a pistol-ball.—(Treatise on the Diseases of Arteries, p. 498.) Larrey records one example of aneurismal varix situated under the clavicle. P. Cadrieux was wounded with a sabre in a duel, on the 20th of November, 1811: part of the attachment of the sterno-mastoid muscle was divided, the anterior scalenus, the subclavian artery and vein at a very deep point, and probably also a portion of the brachial plexus. A most violent hemorrhage took place, foUowed by syncope. Pressure was applied to the wound, and the patient conveyed to the hospital at Gros-Caillou. The external wound, which was small, did not bleed at all the following morning ; but the clavicle was quite con- cealed by a large tumour, which throbbed with the ar- teries, particularly at its lower part. A peculiar noise, like that of the passage of a fluid through tortuous metallic tubes, could also be felt more deeply in the direction of the axillary vein. The arm was quite cold, insensible, motionless, and without any pulse even in the axillary artery itself. On the 22d, the tumour was not larger, but its throbbings were stronger; the jugu- lar vein on the same side was considerably dilated; and the pulsation of the carotid and of the arteries of the opposite arm had augmented. A vein in the right arm was opened, and compresses dipped in campho- rated vinegar, mi.viate of ammonia, and ice applied to the swelling. It would be superfluous here to detaU the diet, bleedings, and other parts of the treatment. On the 8th day, the outer wound was quite healed. On the 10th, the veins of the limb were observed to be swelled, and sensibility and warmth were returning in it; though no pulse could yet be felt. The tumour was much smaller, and restricted to a circumscribed place behind the great pectoral muscle; but the hissing sound was still plainer. By degrees the muscles of the arm and forearm regained their power of motion. The hand, however, continued useless, and affected with pricking pains. On the 20th day, the tumour was quite gone; but the hissing sound was unaltered, and the throbbings were still evident in the veins of the neck and arm. The arm was not at all emaciated. On the 55th day, a pulse at the wrist could be slightly felt; the hissing sound had become less distinct; the veins were less turgid, and their throbbing diminished. A second instance of aneurismal varix, or rather perhaps of a varix of all the veins of the arm, caused by a sword-wound of the axilla, is also recorded by Larrey. He mentions, however, that a pulsation was observable in tbe most prominent of the enlarged ves- sels.—(See Mem. de Chir. Mil. t.i, p. 341, be.) Dr. Dorsey, of Philadelphia, published a case of aneu- rismal varix, which is in several respects interesting. A patient was wounded in the leg with buck-shot; and after the cure of the injury, an aneurismal varix was noticed just below the knee; and in a little time the superficial veins of the limb became dilated, and the hissing noise, characterizing this species of aneu- rism, could be plainly distinguished. The patient was seen by Dr. Dorsey twelve years after the accident; the veins were then considerably distended from the toes up to the groin, all about which latter part pain was constantly experienced, and some ulcers situated on the foot and ankle could not be healed by any of the remedies which were tried. The patient was un- der the care of Drs. Physick and Wistar. The enor- mous distention of the vessels of the leg, and the un- certainty of finding out the communication between the artery and vein, led these gentlemen to tie the first of these vessels in the middle of the thigh. Gangrene soon ensued, and in this state the patient was farther weakened by an unexpected hemorrhage from one of the distended veins; and though the vessel was se- cured with a ligature, the bleeding recurred, the patient became more and more enfeebled, and at length ex- pired. When the limb was examined after death, the whole of the trunk of the femoral artery was found preternaturally dilated ; while all the veins of the limb were considerably distended ; a bougie could readily be passed from the popliteal into the posterior tibial artery, which participated in the dUatation, and from 148 ANEURISM. this last artery the instrument could be passed into the vein, through a cyst situated on the inside of the leg below the knee.—(See Dorsey's Elements of Surgery, vol. 2, p. 210, Philadelphia, 1813.) Professor Scarpa, Dr. Hunter, Mr. B. Bell, Pott, and Garneri mention cases of the aneurismal varix which remained stationary for fourteen, twenty, and thirty- five years. Several cases are related by Brambilla, Guattani, and Monteggia, of a cure having been ob- tained by means of compression. But as this method of cure, if it does not succeed, exposes the patient to the danger of a complication of the disease with an aneurism, it ought not to be employed, except in recent cases where the tumour is small, and in slender pa- tients at an early period of life, and where both of the vessels can be accurately compressed against the bone. Two cases are recorded, in which it was necessary to operate in consequence of the disease being joined with aneurism of the artery, and even bursting. The sacs were opened, and a ligature applied both above and below the aperture in the artery.—(See Park, in Medical Facts and Obs. vol. 4, p. Ill; and Physick,in Medical Museum, vol. 1, p. 65.) The latter form of the disease, which is particularly noticed by Dr. Hun- ter, and also by my friend Mr. Hodgson, is readily understood by recollecting that the artery and vein, when punctured together, do not always unite in such a manner as to let the arterial blood have a direct pas- sage into the vein ; but they may be separated for some distance from each other, so that the blood passes from the artery into the adjacent cellular membrane, where a sac is formed, into which the blood is poured pre- viously to its entrance into the vein.—(See Gibson's Institutes of Surgery, vol.2,p. 158, Philadelphia, 1825.) In the winter of 1819,1 heard a case read to the Me- dical and Chirurgical Society of London, from Mr. At- kinson, of York, who had found it necessary to take up the brachial artery on account of the large and in- creasing size of an aneurismal varix: mortification of the limb ensued. When the aneurism, joined with an aneurismal varix, is circumscribed, but the circum- stances such as to require the brachial artery to be tied, this vessel should be exposed and tied above the swell- ing with a single ligature. It is only when the aneu- rism is diffused that opening the swelling and apply- ing a ligature both above and below the aperture in the artery are thought necessary.—(See Scarpa on ineurism, p. 433, ed. 2; also Guattani, dt Cubiti flex- sura aneurysm atibus, in Lauth's Coll. Scriptorum, i-c.; and P. Adelmann, Tract. Anat. Chir. de Aneu- rismate spurio varicoso. Wirccb. 1824.) ANEURISM BY ANASTOMOSIS. This is the term which the late Mr. John Bell, of Edinburgh, applied to a species of aneurism resem- bling some of the bloody tumours (ncevi materni) which appear in new-born children, grow to a large size, and ultimately bursting emit a considerable quan- tity of blood. Imperfect descriptions of this disease may be traced in writers ; though before the publication of Mr. John Bell's Principles of Surgery it was not classed with aneurisms. Thus Desault has recorded a case of this affection for the express purpose of proving that pul- sation is an uncertain sign of the existence of an aneurism.—(See Parisian Chirurgical Journal, vol. 2, p. 73.) Aneurism by anastomosis often affects adults, in- creasing from an appearance like that of a mere speck or pimple to a formidable disease, and being composed of a mutual enlargement of the smaller arteries and veins. The disease originates from some accidental cause; is marked by a perpetual throbbing; grows slowly but uncontrollably; and is rather irritated than checked by compression. The throbbing is at first in- distinct, but when the tumour is perfectly formed the pulsation is very manifest. Every exertion makes the throbbing more evident. The occasionally turgid states of the tumour produces sacs of blood in the cellular substance, or dilated veins, and these sacs form little tender, livid, very thin points, which burst from time to time, and then, like other aneurisms, this one bleeds so profusely as to induce extreme weakness. The tumour is a congeries of active vessels, and, ac- cording to Mr. John Bell, the cellular substance tlirough which these vessels are expanded, resembles the gills of a turkey-cock or the substance of the pla- centa, spleen, or womb. The irritated and incessant action of the arteries fills the cells with blood, and from these cells it is reabsorbed by the veins. The size of the swelling is increased by exercise, drinking, emo- tions of the mind, and by all causes which accelerate the circulation. In this peculiar disease Dupuytren regards the arte- ries as being in an aneurismal state ; but, besides this circumstance, he says, their extreme ramifications in- termix in a thousand different ways, intercepting spaces, and representing cavities like those which are found in the corpora cavernosa; and he imputes the disease to increased activity of the capillary circulation. —(Fr. transl. of Mr. Hodgson's work, t. 2, p. 300.) It is observed by Mr. Syme, that most surgeons have fol- lowed John Bell in believing this disease to consist of a morbid cellular structure through which the blond passes in its course from the arteries into the veins. However, he has long been one of those who maintain that the apparent cells are really sections of enlarged vessels.—(See Edin. Med. Journ. No. 98, p. 72.) In the dissection of a pulsating tumour of the scalp in a patient who had died after the operation of tying the carotid artery, Dr. Maclachlan found the branches of this vessel on the head " degenerated into dilated tubes of extreme thinness and transparency; which, apparently yielding to the impetus of the blood, had become elongated, contorted, and ultimately convoluted on themselves, so as to form by this species of dou- bling the tumours which constituted this singular dis- ease." They felt like placenta, and the larger portion immediately over the ear looked precisely like a bundle of earthworms coiled together.—(See Glasgow Me- dical Journ. vol. 1, p. 85.) Two cases are given by Pelletan, fully confirming the view taken of the nature ofthe disease by Dr. Maclachlan and Mr. Syme.—(See Clinique Chir. t. 2.) Boyer, who saw one of these cases, describes all the arteries of the swelling as being dilated, tortuous, knotty, and though very large in some places, in others contracted.—(Traite des Mai. Chir. t. 2, p. 295.) In the tumour described by Dr. Maclachlan none of the cells spoken of by Mr. John Bell were found ; no parenchyma as in the spleen; the bulk of the tumour was formed almost entirely by convoluted, dilated arterial trunks, the veins being but little changed from their healthy state. He adds, that these arteries did not appear to communicate more freely than by their ordinary inosculations. Some of these conclusions, as it appears to me, require corroboration by a careful anatomical injection of the vessels. In the female subject the hemorrhage from the aneu- rism by anastomosis is sometimes a substitute for menstruation, as the following example illustrates: Ann Vachot, of St. Maury, in Bresse, was born with a tumour on her chin, of the size and shape of a small strawberry, without pain, heat, or discoloration of the skin. As it produced no uneasiness nor inconvenience whatever, it excited little attention, particularly as it did not seem to increase with the growth of the child. For the first fifteen years there was but little alteration; but about the menstrual period it increased suddenly to double the size, and became more elongated in its form. A quantity of red blood was observed to ooze from its extremity. This flux became, in some measure, periodical, and sometimes was sufficiently abundant to produce an alarming degree of weakness. Each pe- riod of its return was preceded by a violent pain in the head and numbness. Before and after the appearance of these symptoms there was no alteration in the size of the tumour; the only difference was a small enlargement of the cuta- neous veins, with an increase of heat in the part, oc- casioning some degree of tenderness. The menses at length took place, but in small quan- tity and at irregular periods, without influencing the blood discharged from the tumour or the frequency of the evacuation. The breasts were not enlarged till a late period, nor did the approach of puberty seem to have i'ts accus tomed influence on those glands, Sec—(See Parisian Chir. Journ. vol. 2, p. 73, 74.) As far as my observations extend, the true aneurism by anastomosis is a disease with which a surgeon should never tamper; and if it be decided to try any treat nent at all, the only pruden*. plan is either a com- plete removal of the disease witi a knife, or tving the ehiet arteries which supply thf swelling with blood. AXEURISM. 149 The first is the surest mode of relief, and should be preferred, when not forbidden by the magnitude or si- tuation of the tumour. In performing such an operation, as Mr. Wardrop remarks, the surgeon should avoid cutting into the substance or the tumour; for if this be done, the he- morrhage is violent; whereas, by making the incisions beyond the diseased structure, the flow of blood is much more moderate.—(Med. Chir. Trans, vol. 9. p. 212.) In a few naevi pressure may be safely tried; but all attempts to get rid of a true aneurism from anas- tomosis by caustic I should think by no means advi- sable. " This aneurism," Mr. John Bell observes," is a mere congeries of active vessels, which will not be cured by opening it; all attempts to obliterate the disease with caustics, after a simple incision, have proved unsuccess- ful, nor does the interception of particular vessels which lead to it affect the tumour; the whole group of vessels must be extirpated. In varicose veins, or in aneurisms of individual arteries, or in extravasations of blood, such as that produced under the scalp from blows upon the temporal artery, or in those aneurisms produced in schoolboys by pulling the hair, and also in those bloody effusions from blows on the head which have a distinct pulsation, the process of cutting up the varix, aneurism, or extravasation, enables you to obli- terate the vessel and perform an easy cure. But in this enlargement of innumerable small vessels, in this aneurism by anastomosis, the rule is, ' not to cut into, but to cut it out.' These purple and ill-looking tu- mours, because they are large, beating, painful, co- vered with scabs, and bleeding, like a cancer in the last stage of ulceration, have been but too often pro- nounced cancers: incurable bleeding cancers! and the remarks which I have made, while they tend in some measure to explain the nature and consequences of the " disease, will remind you of various unhappy cases, where either partial incisions only have been practised, or the patient left entirely to his fate."—(Principles of Surgery, vol. 1.) That Mr. John Bell has comprised in his account of aneurism by anastomosis certain swellings called na?vi cannot be doubted; nor, indeed, are the differences between this kind of aneurism and some naevi at all defined even by the best writers on surgery. To the consideration of na?vi, however, I have allotted an ar- ticle, in which the method of extirpating particular forms of the disease by means of a ligature will be ex- plained. The following case, recorded by Mr. Wardrop, af- fords a valuable illustration of the nature and struc- ture of one form of this disease. A child was born with a very large subcutaneous nsevus on the back part of the neck. It was of the form and size of half an ordinary orange. The tumour had been daily in- creasing, and when Mr. Wardrop saw it, ten days after birth, the skin had given way, and a profuse hemor- rhage had taken place. The swelling was very soft and compressible"; when squeezed in the hand it yielded like a sponge, and was reducible to one-third of its original size. On removing the pressure, how- ever, the tumour rapidly filled again, and the skin re- sumed its purple colour. " Conceiving the immediate extirpation of the tumour the only chance of saving the infant (says Mr. Wardrop), I removed it as expe- ditiously as possible, and made the incision of the in- teguments beyond the boundary of the tumour; aware of the danger of hemorrhage, where such tumours are cut into. So profuse, however, was the bleeding, that though the whole mass was easily removed by a few in- cisions, the child expired. The tumour having been injected by throwing co- loured size into a few of the larger vessels, its intimate structure could be accurately examined. Several of the vessels, which, from the thinness of their coats ap- peared to be veins, were of a large size, and there was one sufficiently big to admit a full-sized bougie." This vessel was quite as large as the carotid artery of an infant. The boundaries of the tumour appeared distinct, some healthy cellular membrane, traversed by the blood-vessels, surrounding it. On tracing these vessels to the diseased mass, they penetrated into a spongy structure composed of numerous cells and canals, of a variety of forms and sizes, all of which w.re filled with the injeetinn, and communicated di- rectly wiiii the ramifications of the vessels. Thest ceils and canals had a smooth and polished surface, and in some parts resembled very much the cavities of the heart, fibres crossing them in various directions like the columna? tendina?. The opening in the skin, through which the blood had escaped during life, com- municated directly with one of the large cells, into which the largest vessel also passed."—(Wardrop, in Med. Chir. Trans, vol. 9, p. 203.) In the section on Carotid Aneurisms I have mentioned the cases in which Mr. Travers and Mr. Dalrymple cured aneurisms by anastomosis in the orbit by tying the common carotid artery. Professor Pattison also cured an immense anastomosing aneurism of the cheek and side of the face by taking up the carotid artery.— (See Med. anil Phys. Journ. vol. 48, July, 1822.) These facts prove that aneurism by anastomosis, like many other diseases, sometimes admits of being cured on the principle of cutting off or lessening the supply of blood to the part affected. However, surgeons must not be too confident of be- ing always able to cure the disease by tying the main artery from which the swelluig receives its tupply of blood; and the great cause of failure is the impossi- bility of preventing in some situations the transmis- sion of a considerable quantity of blood into the tu- mour, through the anastomosing vessels. A case is recorded by Maunoir, in which he applied a ligature for three days to the carotid artery, and obliterated it; yet the benefit effected seemed to be only temporary, as in a short time the tumour was as large as before. — (See Med. and Phys. Journ. vol. 48.) In fact, every vessel, artery, and vein around the disease seems to be enlarged and turgid; and the inosculations are so in- finite that no point of the circumference of the swell- ing can be imagined which is free from them. Etienne Dumand was born with two small red marks on the antihelix of the right ear. Until the age of twelve years the chief inconveniences were, a sensation of itch- ing about the part, occasional bleeding from it, and the greater size of this than of the other ear. The disease now extended itself over the whole antihelix, and to the helix and concha; and the upper part of the ear became twice as large as natural. Slight alternate dilatations and contractions began to be perceptible in the tumour, which was of a violet colour, and covered by a very thin skin. Soon afterward any accidental motion of the patient's hat was sufficient to excite co- pious hemorrhages, which were difficult to suppress, and at the some time that they produced great weak- ness, caused a temporary diminution of the tumour and its pulsations. At length the disease began to raise up the scalp for the distance of an inch around the me- atus auditorius, and the hemorrhages to be more fre- quent and alarming. Pressure was next applied to the temporal, auricular, and occipital arteries; but as the patient could not endure it, the first two of these ves- sels were tied, the only benefit from which was a slight diminution in the pulsation and bulk of the swell- ing. This treatment did not prevent the return of he- morrhage, and therefore forty-three days after the first operation a ligature was applied to the oecipital artery, which pro eedingwas equally ineffectual. As the dis- ease continued to make progress, the patient entered the Hotel-Dieu, where, on the8th of April, 1818,Dupuy- tren" tried what effect tying the trunk of the carotid ar- tery would produce on the swelling. As soon as the Uga- ture was applied, the throbbing ceased, and the tumour underwent a quick and considerable diminution. On the 17th day, slight expansions and contractions of the diseased part of the ear were again perceptible, though the swelling had diminished one-third. An attempt was now made to compress the tumour by covering it with plaster of Paris; a plan which was somewhat painful, though it lessened the size of the disease. After being sixty-three days in the hospital, the patient was discharged, at which period the tumour was dimi- nished one-third; the throbbings had returned, but no unpleasant noises continued to affect the ear.—(See Breschet's tr. ofM*. Hodgson's work, t. 2, p. 29fi.) An infant, six weeks old, was brought to Mr. Ward- rop, on account of an aneurism by anastomosis (a sub- cutaneous naevus) of a very unusual size, situated on the left cheek. The base of the tumour extended from the temple to beyond the angle of the jaw, completely enveloping the cartilage of the ear. At its upper part there was an ulcer, about three inches in diameter, presenting a sloughing appearance. The tumour was 150 ANEURISM. soft and doughy; its size could be much diminished by pressure; there was a throbbing in it, and a strong pulsation in the adjacent vessels. The disease was daily increasing, and several profuse hemorrhages had taken place from the ulcerated part. Mr. Wardrop, knowing, from the case to which I have already ad- verted, the danger of attempting to extirpate so large a tumour of this nature, was led to try what benefit might be obtained by tying the carotid'artery. A few hours after this operation, the tumour became soft and pliable; its purple colour disappeared, and the tortuous veins collapsed. On the second day, the skin had re- sumed its natural pale colour, and the ulceration con- tinued to extend. On the third, the tumour still dimi- nished. On the fourth, the swelling had considerably increased again; the integuments covering it had be- come livid, and the veins turgid. The inosculating branches of the temporal and occipital arteries had become greatly enlarged. A small quantity of blood had oozed from the ulcer. After remaining without much alteration, the tumour on the seventh day had again evidently diminished. On the ninth, the ulcera- tion was extending itself slowly, and the tumour was lessened fully one-half. On the twelfth, the child's health was materially improving. The auricular por- tion of the swelling had now so much diminished, that the cartilage of the ear had fallen into its natural situ- ation. After a poultice had been applied for two days, the central portion of the swelling, which appeared like a mass of hardened blood, was softened, and Mr. VVardrop removed considerable portions of it. On the thirteenth, the child became very ill, and died the fol- lowing day, exhausted by the irritation of an ulcer, which had involved the whole surface of an enormous tumour. Mr. Wardrop thinks the advantages likely to occur from the plan of tying the main arteries supply- ing tumours of this nature with blood are^ the diminu- tion of the size of the disease; the lessening of the danger of hemorrhage, if the ulcerative process has commenced ; and the rendering it practicable to re- move the swelling with the knife, though the operation may previously have been dangerous or impracticable. —(See Med. Chir. Trans, vol. 9, p. 206—214, &c ) In- stead of endeavouring to promote ulceration in any of these cases, my own sentiments would incline me to leave the business of removing the diseased mass quietly to the absorbents, or at most, I would only assist them with pressure, or by covering the tumour with plaster of Paris. The next case of aneurism by anastomosis, which I shall briefly notice, was one which was under the care of my friend Mr. Lawrence, and situated on the ring finger of the right hand, in a young woman about twenty years of age. The disease was attended with painful sensations extending to various parts of the limb and the breast, and the arm was disqualified for any kind of exertion. In January, 1815, Mr. Hodgson had taken up the radial and ulnai arteries, and the con- sequences of the operation were an entire cessation of of beating, collapse of the swelling, and relief from pain; but these symptoms all recurred in a few days. Finding compression unavailing, and the sufferings of the patient increasing, Mr. Lawrence proposed ampu- tation ofthe finger at the metacarpal joint; but as this suggestion was not approved of, he recommended the patient to try the effects of a division of all the soft parts, by a circular incision close to the palm, so as to cut off the supply of blood. This operation Mr. Law- rence performed in the presence of Mr. George Young and myself, in as complete a manner as can possibly be conceived. All the soft parts, excepting the flexor tendons, with their theca and the extensor tendon, were divided. The digital artery, which had pulsated so evidently in the palm of the hand, was fully equal in size to the radial or ulnar of an adult, and was the principal nutrient vessel of the disease. After tying this and the opposite one, we were surprised at finding so stron" a jet of arterial blood from the other orifices of these°two vessels, as to render ligatures necessary. I can here only add, that the whole finger beyond the cut swelled very considerably ; the incision healed slowly ; the swelling subsided, but did not entirely disappear ; the integuments recovered their natural patient so far recovered the use of her arm, that she could work at her needle for an hour together, and use the arm for most purposes.—(See Wardrop's Obs. on one Species ofNavus, in Med. Chir. Trans, vol. », p. 216.) , „ a j For information on aneurism, consult G. Arnaud on Aneurisms, 8vo. S. C. Lucas, DeOssescentia Artena- rum Senili, ito. Marburgi, 1817. A. F. Walther, Pro- gramma de Aneurysmate, Argent. 1738. (Haller, Disp. Chir. 5,189.) A. de Haller, De Aortai Venmque Cava-, gravioribus quibusdam Morbis Observationes, ito. Gott. 1749. Lauth, Scriptorum Lalivmum de Aneurysmatibus Cullcctio, 4lo. Argent. 1785, which work contains Asman's Diss, de Aneurysmate, 1773 ; Guattani, de Externis Aneurysmatibus, 4to. Roma;, 1772; Laiicisi de Aneurysmatibus, Argent. 1785; Ma- tani de Aneurysmaticis Pracordiorum Morbis Animad- versiones, 1785; Verbrugge, Dissertatio Anatomico- Chirurgica de Aneurysmate, 1773. Penchienali, Re cherches Anat. Pathol, sur les Aneurysmes des Ailires de VEpaule et du Bras ; des Arteres crurales et pnpli- ties ; in Mim. de l'Acad. des Sciences de Turin, 1784. Palletta, Uber die Schlagadergeschwulsl; in Kuhn's and Weigel's Ital. Med. Chir. Bibl. bd. 4. R. Cnillot, Kssais sur VAneurysme, Paris, an 7. Weltinus de Aneurysmate Vera. Pectoris Externo Hemiplegia So- bole, Basil, 1750. Murray, Observationes in Aneu- rysmata Femoris, 1781. Trew, Ancurysmatis Spurii post Vena Basilica Sectionem Orti, Historia et Cu- ratio. See also an account of Mr. Hunter's Method of performing the Operation for the Cure of the Pop- liteal Aneurism, by Sir E. Home, in Trans, of a So- ciety for the Improvement of Med. and Chir. Know- ledge, vol. 1, p. 138, and vol. 2, p. 235. Sabatier, Midecine Opiratoirc, t. 3, vol. 2. The several volumes of the Medico-Chirurgical Transactions. Cases in Surgcryby.I. Warner, p. 141, Src. ed.4. J. B. Heraud, De Aneurysmatibus Externis, Monsp. 1775. J. F. L. Deschamps, Obs. et Reflexions sur la Ligature des principalis Areires blessis, et particuliircment sur VAneurysme de I'Artere poplitee, 8vo. Paris, 1797. Richerand's Nosographie Chirurgicale, t. 4, ed. 4. Pelletan s Clinique Chirurgicale, t. 1 et 2. A. Burns's Surgical Anatomy of the Head and Neck, 8vo. Edin. 1811, and Observations on Diseases of the Heart, ifc. 8vo. Edin. 1809. Ramsden's Practical Ob- servations on the Sclerocele, with four cases of opera- tions for Aneurism, 8vo. Lond. 1811. OZuvres Chir. de Desault, par Bichat, t. 2, p. 553. S. C. Luca qua- darn Obs. Anat. circa Nervos Arteries adeuntes et comitantes, 4to. Francof. 1810. Wells, in Trans, of a Soc. for the Improvement of Med. and Chir. Know- ledge, vol. 3, p. 81—85, Src. G. P. Scheid, Obs. Med. Chir. de Aneurysmate, 8vo. Hardevici, 1792. Corvi- sart, Essai sur les Maladies et les I^esions Organiques du Coeur et des Grose Vaisseaux, edit. 2, or transl. by C. H. Hebb, 8vo. Lond. 1813. C. Bell's Operative Surgery, vol. 1, ed. 2. John Bell's Principles of Sur- gery, vol. 1. Richter's Anfangsgr. der Wundarmey- kunst, b. 1. A. F. Ayrer iiber die Pulsadergeschwiilsle und ihrc Chir. Behandluvg, GStt. 1800. Abernethy's Surgical Works, vol. I. Monro's Observ. in the Edin. Med. Essays. Various productions in the Med. Ob- serv. and Inquiries. The article Aneurism in Rees's Cyclopadia. J. P. Maunoir, Memoires Physiotogiques et Pratiques sur I'Aneurisme et la Ligature, 8vo. Ge- nive, 1802. Freer's Observations on Aneurism, 4to. Lond. 1807; and a Treatise on the Anatomy, Patholo- gy, and Surgical Treatment of Aneurism,by A. Scarpa, translated by J. Wishart, 1808. The original Italian was published 1802. Ant. Scarpa, Memoria sulla le- gatura delta Principali Artcrie delle Arti, con una Jfppendice all' Opera suit' Aneurisma,fol. Pavia, 1817. This tract, and a great deal of valuable additional matter, are contained in the 2d edition of Scarpa's work on Aneurism, by Mr. Wishart, 8vo. Edin. 1819, Callisen's Systema Chirurgia Hodierna, part 2, p. 545! S,c. edit. 1791. Boyer, Traiti des Maladies Chir. t. 2, p. 84, &-c. A. C. Hutchison, Letter on Popliteal Aneu- rism, 8vo. Lond. 1811. J. Hodgson on the Diseases of Arteries and Veins, Lond. 1815, a work of the great- est accuracy and merit. Transl. into German by Dr. Koberwein, with additions by this gentleman, and Dr. Kreyiig, 8vo. Hanov. 1817; and also into French, with valuable annotations by Breschet, 2 t. 8vo. Paris, 1819. G. A Spangenbcrg, F.rfnhrungen iiber die Pulsader- colour; the pulsation and pain were removed, and the jreschwilsti; in Horn's Archiv. 1815. C. H. Ehrmann. la Structure des Arlires, Src. et leurs allirutions ganiqves, Strasb. 1822. Roux, Ni,uvcaux Elhaius de Midecine Operatoire, t. 1. Also, Rouz, Voyage fait ANT A XT 151 d Londres en 1*14, on Parnllilc de la Chirurgie An gtoise anec la Chirurgie Franeoise, p 218, \-c. 18!5. I). Fried. Lud. Kreysig, Die Krankheiten des Hcrzevs, 4 bdnde, 8m. Berlin, 1814—17. C. D. Kiihln, De Aneurysmate Externa, ito. Jena; 1816. A. J. Ristel- hmlier, Mem. sur la Ligature et I'Applatisscni, nt dc I'.li tire, dans I' Opiralion de VAneurisme Paphli, 8oo. A. V. Berlinghieri, Memoria sopra VAllacciatura delV Artent, 8vo. Pisa, 1819. Lassus, Patlmlogie Chir. I. 1, p. 347, &c. T. F. Baltz, De Ophthalmia Catar- rhal! Bellica, Sec. pramittitur F. C. Naegeli Epistola, qud Historia et Descriptio Aneurysmulis, quod in Auila abdominali observavit, ito. Heidelberg, 1816. J. Qile, Exposi du Traitement d'un Ancurisme In- guinale par la Ugature de I'Arlire lliaque Extrrne, Him. Cambrai, 1817, and London Medical Repository fur May, 1820. Hennen's Military Surgery, p. 183— 185, 393, (S-c. ed. 2. F.din. 1820. J. Kir by, Cases, o. Par. 1804; Boyer, Traite des Mai. Chir. t. 6, p. 145, 8vo. Paris, 1818.) Indeed, that Jourdain's proposal was attended with too much difficulty for common prac- tice, was the sentence long ago pronounced upon it by a committee of the Royal Academy of Surgeons in France, nominated for the express purpose of inquir- ing into the merits ofthe suggestion. The method of making an opening into the antrum, will be consi- dered in the sequel of this article. As a general rule, I may here remark, that except when a tumour or fun- gus requires to be extirpated, or a foreign body to be extracted from the antrum, it is quite unnecessary to remove any part of the alveolary process, or cut away any of the bony parietes of the antrum: the drawing of one of the teeth situated below this cavity, and making a perforation in this situation, being the only kind of opening required. This aperture may be preserved as long as necessary, by the introduction of a piece of elastic gum catheter, which is to be fastened to the adjacent teeth, and through which the secretion in the antrum may escape, or lotions be injected.—(See Deschamps, Traite des Mai. des Fosses Nasales^ 4,-c. p. 234.) However, as Hunter remarks, if the forepart of the bone has been destroyed, even though the case be' merely a collection of mucus or pus, an opening may be made on the inside of the lip; but on account of the difficulty of maintaining such an aperture, he still inclines to the practice of drawing one of the teeth— (Natural Hist, of the Teeth, p. 176, ed. 3.) Of all the above cases, abscesses are by far the most common. Violent blows on the cheek, inflammatory affections of the adjacent parts, and especiaUy of the pituitary membrane lining the nostrils, exposure to cold and damp, and, above all things, bad teeth, may bring on inflammation and suppuration within the hollow of the upper jaw-bone. The first symptom is a sensation of pain at first imagined to be a toothache, particularly if there- should be a carious tooth at this part of ike'jaw. Such pain, however, extends more into the nose, than that usually does which arises from a decayed tooth: it also affects, more or less, the eye, the orbit, and the situation of the frontal sinuses.— (See Hunter on the Teeth, p. 175, erf. 3.) But even these symptoms are insufficient to characterize the dis- ease, the nature of which is not unequivocally evinced till a much later period. The complaint is, in general, of much longer duration than one entirely dependent on a caries of a tooth, and its violence increases more and more, until, at last, a hard tumour is perceptible below the cheek-bone. By degrees the swelling ex- tends over the whole cheek; but it afterward rises to a point, and forms a very circumscribed hardness, winch may be felt above the back grinders. This symptom is accompanied with redness, and sometimes with inflammation and suppuration of the external parts. It is not uncommon, also, for the outward ab- scess to communicate with that within the antrum. The circumscribed elevation of the tumour, how- ever, does not occur in all cases. There are instances in which the matter makes its way towards the palate, causing the bones of this part to swell, and at length rendering them carious, unless timely assistance be given. There are other cases in which the matter es- capes between the fangs and sockets of the teeth. Lastly, there are certain examples, in which the matter formed in the antrum makes its exit at the nostril of the same side, when the patient is lying with his head on the opposite one in a low position. If this mode of evacuation should be frequently repeated, it prevents the tumour both from pointing externally and bursting, as it would do if the puruent matter could find no other vent. Cut this evacuation of pus from the nos- tril is not very common ; for, according to Mr. Hunter, the opening between the antrum and cavity of the nose is generally stopped up. He even seems inclined to think, as I have already observed, that the disease may some- times be occasioned by the impervious state of this opening, in consequence of which, the natural mucus of the antrum collects in such quantity, as to irritate and inflame the membrane with which it is in contact, just as an obstruction in the ductus nasalis hinders the passage of the tears into the nose, and causes an ab- scess in the lachrymal sac. This is a point, however, on which even Mr. Hunter would not venture to speak with certainty; for it is by no means impossible, that the impervious state ofthe opening is rather an effect than the cause ofthe disease, since inflammation in the antrum is often manifestly produced by causes of a different kind, and since the opening in question is not invariably closed. Abscesses in the antrum require a free exit for their contents, and if the surgeon neglects to procure such opening, the bones become more and more distended and pushed out, and finally carious. When this hap- pens, the pus makes its appearance, either towards the orbit, the alveoli, the palate, or, as is mostly the case, towards the cheek. The matter having thus made a way for its escape, the disease now becomes fistulous. In all cases, whether the pus be simply confined in the antrum, or whether the case be conjoined with a carious affection of the bones, the principal indication is to discharge the matter. The ancients seem to have known very little about the treatment of diseases of the antrum. Drake, an English anatomist, is reputed to be the first proposer of a plan for curing abscesses of this cavity.—(Anthro- pologiaNova. Londini, 1727.) However, Meibomius was much earlier in proposing, with the same inten- tion, the extraction of one or more ofthe teeth, in order that the matter might have an opening for its escape through the sockets. This plan may be employed with success. The pus frequently has a tendency to make its way outwards towards the teeth; it often affects their fangs; and, after their extraction, the whole of the abscess is seen to escape through the sockets But this very simple plan will not suffice for all cases, as there are numerous instances in which there is no communication between the alveoli and the antrum. Drake, and perhaps before him, Cowper, took no- tice of the insufficiency of Meibomius's method, and hence they proposed making a perforation through the socket into the antrum with an awl, for the purpose of letting out the matter, and injecting into the cavity such fluids as were judged proper. M. Jourdain recommended to the French Academy of Surgery, the injection of detergent lotions into tha ANTRUM. 153 natural opening of the antrum, by means of a curved pipe introduced into the nostril; but, without dwelling upon the difficulty of putting this method in practice, especially where the opening is closed, many assert on the authority of the French surgeons themselves, that the mere employment of injections is not in these cases an effectual mode of treatment.—(See Diet, des rir.ienr.es Med. t. 51, p. 383.) In the treatment of abscesses ofthe antrum, the ex- traction of one or more teeth, and the perforation ofthe alveoli, being generally essential steps, we must con- sider what tooth ought to be taken out in preference to others. A caries, or even a mere continual aching, of any particular tooth, in general, ought to decide the choice. But if all the teeth should be sound, which is not often tho case, writers direct us to tap each of them gently, and to extract that which gives most pain on this being done. When no information can be thus obtained, other circumstances ought to guide us. All the grinding teeth, except the first, correspond with the antrum. They even sometimes extend into this cavity, and the fangs are only covered by the pitu- itary membrane. The bony lamella which separates the antrum from the alveoli, is very thin towards the back part of the upper jaw. Hence, when the choice is in our power, it is best to extract the third or fourth grinder, as in this situation the alveoli can be more easily perforated. Though, in general, the first grinder and canine tooth do not communicate with the antrum, their fangs approach the side of it, and from their socket an opening may readily be.extended into that cavity. When one or more teeth are carious, they should be removed, because they are both useless and hurtful. The matter frequently makes its escape as soon as a tooth is extracted, in consequence of the fang having extended into the antrum, or rather in consequence of its bringing away with it a piece of the thin partition between it and the sinus. Perhaps a discharge may follow from the partition itself being carious. If the opening thus produced be sufficiently large to allow ihe matter to escape, the operation is already completed. But as it can easily be enlarged, it ought always to be so when there is the least suspicion of its being too small. However, when no pus makes its appear- ance after a tooth is extracted, the antrum must be opened by introducing a pointed instrument in the di- rection of the alveoli. Some use a small trocar or awl, others a gimlet for this purpose. The patient should sit on the ground in a strong light, resting his head on the surgeon's knee, who is to sit behind him. Immediately the instrument has reached the cavity, it is to be withdrawn. Its entrance into the antrum is easily known by the cessation of re- sistance. Alter the matter is discharged, surgeons ad- vise the opening to be closed with a wooden stopper, in order to prevent the entrance of extraneous sub- stances. The stopper is to be taken out several times a day, to allow the pus to escape. This plan soon disposes the parts affected to discontinue the suppuration, and resume their natural state. Sometimes, however, the pus continues to be discharged for a long time after the operation, without any change occurring in regard to its quality or quantity. In such instances, the cure may often be accelerated by employing injections of brandy and water, lime-water, or a solution of the sul- phate of zinc. Some surgeons prefer a silver cannula, or a piece of elastic gum catheter, instead of the stopper, as it can always be left pervious except at meals. The exam- ples on record, where the extraction of a tooth and the perforation of the bottom of the antrum were the means of curing abscesses of that cavity, are very nu- merous.— i.See Farmer's Select Cases, No. 9; Gooch's Cases,p. 63, new edition; Palfyn, Anatomie, &rc.) If no opening were made in the antrum, the matter would make its way sometimes towards the front of .this cavity, which is very thin; sometimes towards the mouth; and fistulous openings and caries would in- evitably follow bones free themselves of any dead portions, the dis- charge has less smell and its consistence becomes thicker. When there are loose pieces of dead bone or other foreign bodies to be extracted, it is requisite to make a larger opening in the antrum than can be obtained at its lower part. Instances also occur where patients have lost all the grinding teeth and the sockets are quite obliterated, so that a perforation from below can- not be effected. Some practitioners object to sacri- ficing a sound tooth. In these circumstances, it has been advised to make aperforation in the antrum above the alveolary processes: a method first suggested by Lamorier. It consists in making a transverse incision below the malar process and above the root of the third grinder. Thus the gum and periosteum are di- vided, and the bone exposed. A perforating instru- ment is to be conveyed into the middle of this incision, and the opening in the antrum made as large as requi- site.—(See Mim. de l'Acad. de Chir. t. 4, p. 351 ; Gooch's Obs. append, p. 138.) There are some exten- sive exfoliations of the antrum, where it is absolutely necessary to expose a great part of the surface of the bone, and to cut away the dead pieces which are wedged, as it were, in the livingones. A small trephine may sometimes be advantageously applied to the malar process of the superior maxillary bone. Surgeons formerly treated carious affections of the antrum in the most absurd and unscientific way; in- troducing setons through its cavity, and even having recourse to the actual- cautery. The moderns, how- ever, are not much inclined to adopt this sort of prac- tice. It is now known, that the detachment of a dead portion of bone, in other terms the process of exfoli- ation, is nearly, if not entirely, the work of nature, in which the surgeon can act a very inferior part. In- deed, he should limit his interference to preventing the lodgement of matter, maintaining strict cleanliness, and removing the dead pieces of bone as soqu as they be- come loose. But it is to be understood, that examples occasionally present themselves, in which the dead portions of bone are so tedious of separation, and so wedged in the substance of the surrounding living bone, that an attempt may properly be made to cut them away. TUMOURS OF THK ANTRUM. Ruysch, Bordenave, Desault, Abernethy, Weinhold, and others, have recorded cases of polypous, fungous, and cancerous diseases of the antrum, and examples of this cavity being affected with exostosis. The indolence of any ordinary fleshy tumour in the antrum, while in an incipient state, certainly tends to conceal its existence; but such a disease rarely occurs without being accompanied with some affection of the neighbouring parts; and hence, its presence may ge- nerally be ascertained before it has attained such a size as to have altered, in a serious degree, the natural shape of the antrum. This information may be ac- quired, by examining whether any of the teeth have become loose, or have spontaneously fallen out; whe- ther the alveolary processes are sound, and whether there are any fungous excrescences making their ap- pearance at the sockets; whether there is any habitual bleeding from one side of the nose; any sarcomatous tumour at the side of the nostril, or towards the great angle of the eye. When the swelling, however, has attained a certain size, the bony parietes of tne antrum always protrude, unless the body of the tumour should be situated in the nostril, and only its root in the an- trum. This case, however, is very uncommon. As soon as a tumour is certainly known to exist in the antrum, the front part of this cavity should be open- ed, without waiting till the disease makes farther pro- gress. In a few instances, indeed, we may avail our- selves of the opening which is sometimes found in the alveolary process, and enlarge it sufficiently to allow the tumour to be extirpated. If the front ofthe antrum were freely opened, it would in general be better to cut away the disease in its interior. A swelling of the parietes of the antrum, in conse- Whcn the bones are diseased, the abov plan will u quence of an abscess, or a sarcomatous tumour hi its not accomplish a cure until the affected pieces of bone cavity, may lead us to suppose the case an enlarge- tAibliate. A probe will generally enable us to detect ment of the bones, or an exostosis. The symptoms of caries in the antrum. Ttic fetid smell and ichorous the first two affections have been already detailed. appearance of the disoharer. also, leave little doubt One sign of an exostosis, besides the absence of the thai the bones are diseased; and in proportion as the symptoms characterizing an abscess or a sarcoma, id 154 ANTRUM. the thickened parietes of the antrum forming a solid resistance; whereas, in eases of mere expansion, the dimensions of the surface of the bone being increased, while its substance is rendered proportionally thinner, the resistance is not so considerable. When such an exostosis depends upon a particular constitutional cause, and especially upon one of a vene- real nature, it must be attacked by remedies suited to this affection. But when the disease resists internal remedies, and its magnitude is likely to produce an aggravation of the case, a portion of the bone may be removed with a trephine or a cutting instrument. Such operations, however, require a great deal of delicacy and prudence. Mr. B. BeU, vol. 4, describes a kind of exostosis of the upper jaw, very different from what I have men- tioned, since, instead of its being distinguishable from other diseases of the antrum by the greater firmness of the tumour, the substance of the bone gradually ac- quires such suppleness and elasticity, that it yields to the pressure of the fingers, and immediately resumes its former plumpness when the pressure is discontinued. If the bone be cut, it is found to be as soft as cartilage, and in an advanced stage of the disease, its consistence is almost gelatinous. The swelling increases gradually, and extends equally over the whole cheek, without becoming prominent at any particular point, or only so in the latter periods of the malady, when the soft parts inflame, and become affected. The complaint is de- scribed as totally incurable. Cutting and trephining the tumour, as recommended in other cases of exostosis, only aggravate the patient's unhappy condition. Mr. Abernethy published an account of a very singu- lar disease of the antrum. The patient, who was thirty-four years of age when the account was written, perceived, when about ten years old, a small tumour on his left cheek, which gradually attained the size of a walnut, and then remained for some time stationary. About a year afterward, the tumour having again en- larged, a caustic was applied to the integuments, so as to expose the bone. The actual cautery was next ap- plied, and an opening thus made into the antrum. After the exfoliation, the antrum became filled with a fungus, which rose out upon the cheek, and could not be re- strained by any applications. Part of the fungus also made its way into the mouth, through the socket of the second tricuspid tooth, the other teeth remaining natu- ral. The disease continued in this state nine years, occasionally bleeding in an alarming way. When the patient was in his twentieth year, the whole fungus sloughed away during a fever, and never returned. After this, the sides of the aperture in the bone began to grow outwards, forming an exostosis, which rapidly attained a great magnitude. A small exostosis took place in the mouth, but became no larger than a horse- bean. The exostosis of the maxillary bone was of an irregular figure, and projected from the whole circum- ference of the aperture a great way directly forwards. Mr. Abernethy compared its appearance, when he was writing, with that of a large tea-cup fastened upon the face, the bottom of which may be supposed to commu- nicate with the antrum. The diameter of the cup, formed by the circular edge of the bone, was three inches and a half; the depth two inches and seven- eighths. The general height of the sides of the exos- tosis, from the basis of the face, was two inches; its walls were not thick, and terminated in a thin circular edge. The integuments, as they approached this edge, became thinner, and they extended over it into the ca- vity. The exostosis now reached to the nose in front, and to the masseter muscle behind; above, it included the very ridge of the orbit, and below, it grew from the edge of the alveolary process. A line, that would have separated the diseased from the sound bone, would have included the orbit and nose, and indeed one-half of the face. Mr. Abernethy saw no means of affording the man relief.—(Trans, of a Soc. for the Improvement. of Med. and Chir. Knowledge, vol. 2.) See also a case related by Harrison.—(New-Lond. Med. Journ. vol. 1, p. I.) In a case of fungus, which had distended the antrum, hindered the tears from passing down into the nose, raised the lower part of the orbit, caused a protrusion of the eye, made two of the grinding-teeth fall out, and occasioned a carious opening in the front of the antrum, through which opening a piece ofthe fungus projected, Desault operated as follows: the cheek was first de- tached from the os maxillare, by dividing the internal membrane of the mouth, at the place where it is re- flected over this bone. Thus the outer surface of the bone was denuded of all the soft parts. A sharp per- forating instrument was applied to the middle of this I surface, and an opening made more forwards than the one already existing. The plate of bone situated be- tween the two apertures, was removed with a little falciform knife, which, being directed from behind for- wards, made the division without difficulty. The open- ing thus obtained being insufficient, Desault endea- voured to enlarge it below, by sacrificing the alveolary process. This he endeavoured to accomplish with the same instrument, but finding the resistance too great, he had recourse to a gouge and mallet. A considerable piece of the alveolary arch was thus detached, without any previous extraction of the corresponding teeth, three of which were removed by the same stroke. In this manner an opening was procured in the external and inferior part of the antrum, large enough to admit a walnut. Through this aperture a considerable part of the tumour was cut away with a knife, curved side- ways, and fixed in its handle. A most profuse hemor- rhage took place, but Desault, unalarmed, held a com- press in the antrum for a short time; this being re- moved, the actual cautery was applied repeatedly to the rest of the fungus. The cavity was dressed with lint, dipped in powdered colophony. On the eighteenth day, the swelling was evidently diminished, the eye less prominent, and the epiphora less visible. But, at this period, a portion of fungus made its appearance again. This was almost entirely destroyed by applying the actual cautery twice. It appeared again, however, on the twenty-fifth day, and required a third and last recourse to the cautery. From this time, the progress of the cure went on rapidly. Instead of fungous excrescences, healthy granulations were now formed in the bottom of the sinus. The parietes of the antrum gradually approaching each other, the large opening made in the operation was reduced to a small aperture, hardly capable of admitting a probe. Even this little opening closed in the fourth month, at which time no vestiges of the disease re- mained, except the loss of teeth, and a very obvious depression just where they were situated. In all fungous diseases of the antrum, making a free exposure of them is an essential part of the treatment: if you neglect this method, how can you inform your- self of the size, form, and extent of the tumour? How could you remove the whole of the fungus, through a small opening, which would only allow you to see a very little portion ofthe excrescence? How could you be certain that the disease was extirpated to its very root * Even when the antrum is freely opened, this circumstance can only be learned with difficulty; and how could it be ascertained, when only a point of the cavity is opened? A portion, left behind, very soon gives origin to a fresh fungus, the progress of which is more rapid, and the character more fatal, in conse- quence of being irritated by the surgical measures adopted.—(lEuvres Chir. de Desault, par Bichat, t. 2.) See also other cases, recorded by Canolles (Recueil Pi- riodique de la Soc. de Mid. t. 2, No. 9); Eichorn (Diss. de Polypis in Antro Highmori, Goett. 1814); Sandi- fort (Museum Anat. vol. 2, tab. 30); Leveille (Recueil de la Soc, a c. t. 1, p. 24) ; Weinhold (Von den Krank- heiten der Gesichtsknochen, p. 27, 4to. Halle, 1818). I imagine, that English surgeons, unaccustomed to use the actual cautery, will peruse with a degree of aversion this means, so commonly employed in France. Nor can I expect that they will altogether'approve the use of the mallet and gouge for making a free opening into the antrum. Perhaps it might be better to trephine this cavity with a small instrument for the purpose, and then cut the fungus away. After removing an much of it as possible in tins manner, some instrument of suitable shape might be used to scrape the part where the tumour has its root. However, if there be any case in which potent and violent measures, like those of Desault, are allowable, it is the one of which we "nave just been treating. Inveterate diseases demand powerful means, and tampering with them is geueraUy more hurtful than useful. I have lately been informed of one or two cases, in which the use of the cautery was found necessary in this country, for the stoppage of the bleeding after the removal of fungi from tbe antrum. ANT ANU 155 There is an interesting case of a fungus in the maxil- lary sinus, related in the first vol. ofthe Parisian Chir. Journal. It was at last cured by opening the antrum, applying the cautery, and tying the portion of the tu- mour which had made its way into the nose. In the second volume of the same work is an excellent case, exhibiting tbe dreadful ravages which the disease may produce when left to itself. Professor Pattison, a few years ago, suggested the expedient of t> mg the carotid artery, as likely to bring about the dispersion of fungous diseases ofthe antrum, without the necessity of meddling with the tumour itself. He adverts to three cases, the results of which were, on the whole, favourable to the practice. —(See Burns on Anat. of the Head, S-c. ed. by Pattison.) I consider that this proposal merits farther trials, inas- much as the operation of taking up the carotid artery is an infinitely less severe proceeding than that of ex- tirpating the disease in the cheek, in the manner prac- tised by Desault. INSECTS IN Till ANTRUM. It is said, that insects in this cavity may sometimes make it necessary for the surgeon to open it. This case, however, must be exceedingly rare; and even what we find in authors (Pallas, de insectis Viventibus intra viventia) appears so little authentic, that I should hardly have mentioned the circumstance, if there were not, in a modern work (Med. Comm. vol. 1), a fact which appears entitled to attention. Mr. Heysham, a medical practitioner at Carlisle, relates, that a strong woman, aged sixty, in the habit of taking a great deal of snuff, was subject, for several years, to acute, pains in the antrum, extending over one side of the head. These pains never entirely ceased, but were more severe in winter than summer, and were always sub- ject to frequent periodical exacerbations. The patient had taken several anodyne medicines, and others, with- out benefit, and had twice undergone a course of mer- cury, by which her complaints had been increased. All her teeth on the affected side had been drawn. At length, it was determined to open the antrum with a large trocar, though there were no symptoms of an abscess, nor of any other disease in this cavity. For four (Jays, no benefit resulted from the operation. Bark injections and the elixir of aloes, were introduced into the sinus. On the fifth day, a dead insect was extracted, by means of a pair of forceps, from the mouth of the cavity. . It was more than an inch long, and thicker than a common quill. The patient now experienced relief for several hours; but the pains afterward re- curred with their former severity: oil was next injected into the antrum, and two other insects, similar to the former, were extracted. No others appeared, and the wound closed. The pains were not completely re- moved, but considerably diminished for several months, at the end of which time they became worse than ever, particularly affecting the situation of the frontal sinus. Bordenave has published, in the twelfth and thir- teenth volumes of the M m. de CAcad. de Chir. edit. 12mo. two excellent papers on diseases of the antrum. In the thirteenth volume, he relates the history of a case, in which several small whitish worms, together with a piece of fetid fungus, were discharged from the antrum, after an opening had been made on accomit of an abscess of this cavity, attended with caries.—(P. 3S1.) But, in this instance, the worms had probably been generated after the opening had been made in the cavity; for when they made their appearance, the open- ing had existed nine months. Deschamps refers to another case, in which M. Fortassin, his colleague at La Charite, found in the antrum of a soldier, whom he was dissecting, a worm of the ascaris lumbricus kind, four inches in length.— (Traite des Mai. des Fosses Nasales, Ac. p. 107.) Such an example is also recorded in one of the volumes of the Journ. de Mid. Were a case of this description to present itself in a living sub- ject, it would be advisable to inject oil into the cavity of the antrum, and then endeavour to wash out the extraneous substances, by throwing into the sinus warm water, by means of a syringe.—See Precis d'Observations sur les Maladies du S^nus Maxillaire, par M. Bordenave, in Mem. dc l'Acad. Royale de Chi \urgie, t. 12, edit, in \imo. Also, Suite d'Observations sn the same subject, by M. Bo'drnace, t. 13, of the said work; L. H. RimiS-; Me Morbis Praeipais Sinuum Ossis FroHtiset Maxilla Supcriurts,S. c. Rintelii, 1750; Haller, Disp. Cliir. 1, 205. Jourdain, in Mem. de l'Acad. de Chir. t. 4, p. 357 ; also, his Traite des De p6ts dans le Sinus Maxillaire, <$•£. 12mo. Paris, 1760; his Traite des Mai. de la Buuchc, t. 2; and Journ. de Med. t. 21, p. 57, el t. 27, p. 52—157. This author, who, in 1765, suggested to the Royal Academy of Surgery the method of injecting fluid into the antrum, through the natural opening, is said to have been anticipated in the practice by Alluuel, who first conceived the plan in 1737, and tried it with success in 1739; see Boyer, Traite des Mai. Chir. t. 6, p. 149. Becker, Diss, de Insolito Maxilla Superioris lumore aliisque t-jusdem morbis. Wirceb. 1776. Kemarques et Observations sur les Maladies du Sinus Maxillaire, in (Euvres Chir. de Desault, par Bichat, t. 2, p. 156. Desaull's Parisian Chir. Journal, vols. 1 and 2. Medical Communica- tions, vol. 1. Trans, of a Soc. for the Improvement of Med. and Chir. Knowledge, vol. 2. Natural History of the Human Teeth, by John Hunter, p. 174, 175, edit. 3. Gooch's Chirurgical Works, vol. 2, p. 61, and vol. 3, p. 161, edit. 1792. Callisen's Syslema Chirurgia Hodiema, t. I, p. 346, &c. Dubois, in Bulletin de la Faculte de Midicine, No. 8. J. L. Deschamps, Traite des Maladies des Fosses Nasales, et de leur Sinus, 8vo. Paris, 1804. Eichorn, Diss, de Polypis in antro High- mori, Gott. 1804. liston, Edin. Med. Journ. No. 68. P. V. Leinicker, de Sinu Maxillari, ejusdem Morbis, i$-e. Wurceb. 1809. C. A. Weinhold, Ideen iiber die ab- normen Metamorphosen der Highmoreshble, Leipz. 1810. C. A. Weinhuld, Von den Krankheiten der Gesichtsknochen und Hirer Schleimhaiite, der Ausrot- tung tines grossen Polypen in der linken Oberkiefer- hbhle, dem Verhuten der Einsinkens der Gichtischen und Venerischen Nase, und der Einsetzung Kiinst- licher Choanen, ito. Halle, 1808. Also, an account of a Malignant Tumour removed from the Antrum, by T. Iriiing, in Edin. Med. Journ. Nvs. 83 and 84. [A case of aneurism by anastomosis, situated in the branches of the internal maxillary artery, and cured by tying the carotid, is recorded by Professor Pattison, of the London University. The centre of the tumour occupied the antrum; but the sides of this cavity having been destroyed, the swelling made its way out of it in every direction ; upwards into the orbit, from which it had displaced the eye; laterally into the nos- tril, which it completely filled; and against the septum narium, so as to produce a considerable distortion of the nose. It was as large as a new-born child's head, and attended with profuse and sometimes nearly fatal hemorrhages. Immediately after the performance of the operation, the appearance of the tumour in the nos- tril underwent a remarkable change; just before the ligature was applied, it seemed ready to burst from distention; but as soon as the direct circulation was stopped, its distention ceased, and its surface became shrivelled. The pulsatory movement, previously per- ceptible in it, now could not be detected. A daily im- provement in the expression of the countenance fol- lowed. The swelling entirely disappeared, and the cheek-bone and zygoma, which had been quite con- cealed by it, again became evident. At the end of two years and a half from the operation, there had been no return of the disease, and the disfigurement was so trifling that it was scarcely perceptible.—(See A. Burn's Surgical Anatomy of the Head and Neck, p. 463, ed. 2, with additions by G. S. Pattison, Glasgow, 1824.) In the same edition the efficacy of tying the carotid for the cure of fungous diseases of the antrum is proved by several interesting cases. This is a subject which seems to me to demand the earnest attention of surgi- cal practitioners.—Pref.] ANUS The lower termination of the great intes- tine named the rectum, is so called, and its office is to form an outlet for the feces. The anus is furnished with muscles which are pecu- liar to it. viz. the sphincter, which keeps it habitually closed, and the levatores ani, which serve to draw it up into its natural situation, after the expulsion of the feces. It is also surrounded, as well as the whole of the neighbouring intestine, with muscular fibres, and a very loose sort of cellular substance. It is subject to various diseases, in which the aid of surgery is re- quisite : of these we shall next treat. IMPERFORATE ANUS. As it is of the utmost consequence that this and other malformations should not remain long uuknown [US. 156 AN one of the earliest duties of an accoucheur after deli- very should be an examination of all the natural out- lets of new-born infants. The place in which the extremity of the rectum, or the anus, ought to be, may be entirely or partly shut up by a membrane or fleshy adhesion. In other in- stances, ne vestige ofthe intestine can be found, as the skin retains its natural colour over the Whole space between the parts of generation and the os coccygis, without being more elevated in one place than another. In these cases, the intestine sometimes terminates in one or two culs-de-sac, about an inch upwards from the ordinary situation of the anus.—(See Baillie's En- gravings, fasc. 4, tab. 5.) Sometimes it does not de- scend lower than the upper part of the sacrum; some- times it opens into the bladder or vagina. Dr. Palmer dissected a case where the colon, after reaching the vicinity of the left kidney, began, as it descended, to form a sigmoid flexure; but previously to its arrival at the concavity of the left Ueum, made a sudden turn to the right; and crossing the psoas muscle, reached the projection of the sacrum, where it terminated, without at all entering the pelvis. With this malformation was combined an imperforate meatus urinarius, and other considerable deviations of the genital organs from their natural structure.—(See Medico-Chir. Journ. vol. 1, 8vo. Lond. 1816.) Sometimes the colon terminates in a sac, and the rectum is entirely deficient.—(See Beauregard, in Journ. de M d. 1, 66.) Instances are also upon record where the rectum opened into the urethra.—(Bresl. Samml. 1718, p. 702; Hist, de l'Acad. Roy ale des Sci- ences, 1752, p. 113; Hochstetter, in Med. Wochenblatt, 1780, Aro. 18; 1783, No. 19; Kretschmar, in Horn's Archiv. b. 1, p. 350.) When a surgeon is consulted he must not lose much time in deliberation; for if a speedy opening be not ioade for the feces, the infant will certainly very soon perish, with symptoms similar to those of a strangu- lated hernia. Mr. C. Hutchison thinks it, however, ad- vantageous not to operate till the expiration of from twenty-four to sixty hours after birth, as within tlus period no great inconvenience will arise, and the dis- tention of the rectum with meconium is a guidance to the surgeon in making the incisions.—(See Obs. in Surgery, ed. 2.) After ascertaining the complaint, which is an easy matter, the surgeon should endeavour to learn whether the anus is merely shut by a mem- brane or fleshy adhesion, or whether the anus is alto- gether wanting, in consequence of the lower portion of the cavity of the gut being obliterated or the rectum not extending sufficiently far down. When a membrane or production ofthe skin closes the opening of the rectum, the part producing the obstruction is somewhat different in colour from the neigbouring in- teguments. It is usually of apurpleor livid hue,in con- sequence of the accumulation ofthe meconium on its in- ner surface. The meconium, propelled downwards by the viscera above, forms a small roundish prominence, which yields like dough to the pressure of the fingers; 4?ut immediately projects again when the pressure is removed. When a fleshy adhesion closes the intes- tine, the circumstance is obvious to the eye, if the part- protrude, as is generally the case. The finger feels greater hardness and resistance than when there is a mere membrane, and the livid colour of the meconium rcannot be seen through the obstructing substance. These last signs alone are enough to convince the surgeon of the necessity of the operation ; but they do not clearly show whether the intestine descends as far as it ought in order to form a proper kind of anus. Complete information on this point can only be ac- quired after themembrane or adhesion has been divided; or else after the child's death, when the operation has proved ineffectu»l. Though there be no mark to denote where the anus ought to be situated, and no degree of prominenc-j, yielding like soft dough to the pressure of the fingers, and rising again when such pressure is removed ; yet it may happen, especially on our being consulted immediately after the child is born, that, not- withstanding the absence of such symptoms, denoting the presence of the meconium, and the natural extent of the intestine, as far as where the anus ought to be, the gut may exist and have a cavity as far as the mem- brane or adhesion closing it. When the anus is simply covered with skin, and its place indicated by a prominence arising from the con- tents of the rectum, we have only to make an opening with a knife, sufficient to let out the meconium. Lev- ret recommends a circular incision in the membrane; but a transverse one is sufficient. A small tent of lint is afterward to be introduced, in order to keep the opening from closing. If the anus be only partly closed by a membrane, the opening may be dilated with tents or bougies; but if the aperture be very small, it is preferable to use the bistoury for its enlargement. When no external appearance denotes where the situation of the anus ought to be, the case is much more serious and embarrassing ; and this, whether the intestine be stopped up by a fleshy adhesion or the coalescence of its sides, or whether a part of the gut be wanting. However, it is the surgeon's duty to do every thing in his power to afford relief. For this purpose, an in- cision an inch long or rather more is to be made in the situation where the anus ought to be, and the wound is to be carried more and more deeply in the natural di rection of the rectum. The cuts are not to be made directly upwards, nor in the axis of the pelvis, for the vagina or bladder might thus be wounded. On the contrary, the operator should cut backwards, along the concavity of the os coccygis, where there is no danger of wounding any part of importance. In all cases of this kind the surgeon's finger is the best director. The operator, guided by the index finger of his left hand, introduced within the os coccygis, is to dissect in the direction above recommended, until he reaches the feces, or has cut as far as he can reach with his finger. If he should fail in finding the meconium, as death must unavoidably follow, one more attempt ought to be made by introducing, upon the finger, a middle-sized trocar, in the direction best calculated to reach the rectum without danger to other parts, viz. upwards and backwards. The cannula of the trocar may be left in the puncture, and secured there by tapes, so as to afford an outlet for the feces. In some observations on this subject, addressed to the Medical and Chirurgical Society by Mr. Copland Hutchison, he recommends an elastic gum catheter to be substituted for the cannula after a week, and when the tube can be dispensed with, a sponge tent or piece of bougie to be worn 12 out of the 24 hours.—(See also Obs. in Surgery, ed. 2, 1^6.) In a very interesting case, recorded in Langenfcwk's new Surgical Bibliotheca, the imperforate state of the anus was not discovered till the evening of the 12th day from the child's birth, when hiccough and convul- sions had come on. M. Wolff found the abdomen pro- tuberant, hard, and painful when handled, and nausea, vomiting, and great depression of strength prevailed. Next day, he introduced a large lancet a few lines in front ofthe os coccygis to the depth of an inch without finding the rectum. The puncture was then carried to the depth of two inches, but without effect. With a pharyiigotomus, however, he now succeeded in piercing the rectum; and a glyster was administered, which brought away some meconium. Under the use of glysters and tents the child soon recovered. By such proceedings many infants have been pre- served, which would otherwise have been devoted to certain death. HUdanus, La Motte, Roonhuysen, Mr. Copland Hutchison, and others have successfully adopted the practice. Mr. B. Bell met with two cases, in which the intestine was very distant from the inte- guments, and he was so successful as to form an anus, which fulfilled its office tolerably well for several years; but he found it exceedingly difficult to keep the passage sufficiently pervious. As soon as he removed the dos-, sils of lint, and other kinds of tents, used for maintain- ing the necessary dilatation, such a degree of contrac- tion speedily followed, that the evacuation of the intesti- nal matter became very difficult for a long while after- ward. He employed, at different times, tents made of sponge, gentian root, and other substances, which swell on being moistened. But they always produced so much pain and irritation that it was impossible to persevere in their use. Tents of very soft lint, dipped in oil, or rolls of bougie-plaster, cause less irritation than those com- posed of any other materials. Though keeping the opening dilated may seem sim- ple and easy to such men as have had no opportunities*, of seeing cases of this description, it is far otherwise in practice. Mr. B. Bell assures us, that he never met with any disease thai gave him so much trouble and ANUS. 157 embarrassment as he experienced in the two cases of this sort which occurred in his practice. Although in both instances he made the openings at first sufficiently large, it was only by very assiduous attention for eight or ten months, that the necessity for another operation, and even repeated operations, was prevented. When only the skin has been divided, the rest of the treatment is doubtless more simple ; for then nothing more is requisite than keeping a piece of lint for a few days in the opening made with the knife. But when the ex- tremity of the rectum is at a certain distance, though we may generally hope to effect a cure, after having succeeded in giving vent to the intestinal matter, yet the treatment after the operation will always demand (or a long while a great deal of attention and care on the part of the surgeon. In a highly interesting ex- ample, recorded by Mr. Miller, of Methven, such was the tendency to closure of the new opening, that he was obliged to repeat the operation ten times before the child was eight months old.'—(See Edin. Med. Journ. No. 98, p. 62.) Notwithstanding all these ope- rations, and another one of two hours and three-quar- ters' duration, performed several years afterward for the extraction of an alvine concretion equal in size to a turkey's egg, the power of the sphincter was perfect. The difficulty of success may be considered as in some measure proportioned to the depth of the necessary incision. In a case like that recorded by Dr. Palmer, to which I have above adverted, the inutility of any attempt to discharge the feces by an operation in the usual site of the anus must be sufficiently obvious.— (Medico-Chir. Journ. vol. 1, p. 181.) .sometimes, while the anus appears pervious and well formed, infants suffer the same symptoms as if there were no anus at all. The reason of this depends upon the intestine being occasionally closed by a mem- branous partition situated more or less upwards, above the aperture of the anus (Courtial, Nouvelles Obs. sur les Os, p. 147; John Wayte, in Edin. Med. and Sur- ical Journ. April, 1821; and Cases in Hutchison's Obs. in Surgery, ed. 2), and sometimes the symp- toms are owing to the termination of the gut in a cul- de-sac. This erroneous formation may always be sus- pected when an infant, whose anus is externally open, does not void any excrement for two or three days after its birth, and especially when urgent symptoms arise, such as swelling of the belly, vomiting, 547. Obs. Med. Decad. 2, No. 2.) The first case is tho least dangerous of such malformations. The intestine may also terminate at two places at the same time, viz. at the usual place, so as to form a proper anus more or less perfect; and also in the vagina. If these two openings should be ample enough for the easy evacuation of the excrement,, nothing can be done at so tender an age; for though "voiding the feces through the vagina is a most unpleasant inconvenience, yet there is no effectual means of closing the opening of the intestine in this situation, nor could one be de- vised which would not seriously incommode the infant. But when the two openings are exceedingly small, and the alvine evacuations cannot readily pass out, even with the aid of glysters, the opening of the anus ought to be dilated by cannula? of different sizes. If this method should not avail, the knife must be em- ployed, and the wound dressed as already explained. For the most part the intestine has only one opening in the vagina. In this circumstance, as in the instance in which the feces have no vent at all, we must make an incision in that place which the anus ought to oc- cupy. The natural course of the feces being opened by this operation, which in such a case is not at all pe- rilous, much less excrement will pass out of the vagina, and of course the infirmity will be diminished. By the introduction of a tube into the new anus, the communi- cation between the rectum and vagina might possibly be obliterated, and a perfect cure accomplished. The opening between the intestine and vagina may also be too small for the easy evacuation of the feces, and even expose the infant to the same sort of dangerous symptoms as would occur if the rectum had no open- ing at all. In male infants the rectum sometimes opens into the bladder, and in this circumstance there is generally no anus. The case is easily known by the meconium being blended with the urine, which acquires a thick greenish appearance, and is voided almost continually though in small quantities. Only the most fluid part ofthe meconium is thus discharged. The thicker part not getting from the rectum into the bladder, nor from the bladder into the urethra, greatly distends the intes- tines and bladder, and produces the same symptoms as take place in cases of total imperforation. Hence, without the speedy interference of art to form an anus capable of giving vent to the feces, with which the urinary organs cannot remain obstructed, the infant will inevitably die. This case must, therefore, be treated like the foregoing examples. Though we can hardly hope to prevent altogether the inconveniences resulting from the rectum opening into the bladder, since even a new passage will not completely hinder the feces from following the other course; yet we shall thus afford the child a very good chance of pre- servation, and the only one which its situation wUl allow. In cases in which an outlet, for the feces cannot be procured by any of the methods pointed out above, it has been proposed by Littre to make an opening above one of the groins, find out a portion of intestine, open it, fix it in this situation with a few stitches, and thus form an artificial anus. Sabatier was only ac- quainted with one case in which this proceeding had been actually done, viz. the example where Duret, a French naval surgeon, operated. This gentleman cut into the abdomen at the lower part of the left Uiac re- gion, and having opened the sigmoid flexion of the colon, he fixed it near the wound. The child was saved by the formation of an artificial anus; but at the age of twenty-five months it continued to be troubled with a sort of prolapsus of the lining of the bowel.— (See Recueil Piriodique de la Soc. de Med. t. 4. No. 19; and I Sabatier. Med. Optratoire, t. 3, p. 336, edit. 2.) An instance has been published by Mr. Pring, in which he made an opening in the colon, near its sig- moid flexure, in a lady, who, in consequence of a scir- rhous disease of the rectum, was afflicted with an ob- stinate and perilous obstruction ofthe intestiw.. canal. The patient survived the operation nearly sixteen months, at the end of which time she fell a victim to the disease of the rectum.— (See London Medical and Physical Journal, vols. 45 and 47.) I should be reluc- tant to offer any remarks encouraging the repetition of this practice, aaainst which various considerations pre- sent themselves, particularly in cases where, besides I » mcredifficiUty of emptying the bowels, another dis- 158 ANUS. ease exists, which is itself likely to destroy the patient, and is of a nature not capable of receiving any effect- ual benefit from the bold operation practised ui the ex- ample related by Mr. Pring. Callisen conceives that the descending colon may be most conveniently got at by making an incision in the left lumbar region along the edge of the quadratus lUmborum muscle ; and he prefers this mode of ope- rating to that of making the incision above the groin.— (syst. Chir. Hodierna, t. 2, p. 688, 689, ed. 1800.) Its advantages, however, are not obvious—(See Sabatiir, Medicine Operatoire, t. 3, p. 330. Pappendorf, deAno infantum imperforato, Leipz. 1783. Remarques sur Diffirens Vices de Conformation que les Enfans op- ponent en naissant, par M. Petit, in M'm. de l'Acad. Roy ale de Chir. t. 2, p. 236, edit, in 12mo. H. A. Wrisberg, de praternaturali et raro Intestini Recti cum vesica urinaria coalitu, et independente.Ani de- fectu, ito. Gott. 1779. Ford, in Med. Facts and Obs. vol. 1, No. 10. Chamberlaine, in Memoirs of the Med. Soc. of Lond. vol.5, No. 23. Richerand, Nosographie Chir. t. 3, p. 437, i-c. idit. 4. G. Wayte, in Edin. Med. Journ. vol. 17. Lancet, vol. 1, p. 434. A. C. Hutchi- son, in Pract. Obs. in Surgery, ed. 2, 1826. Miller, in Edin. Med. Journ. No. 98, p. 61. Jolhet, in Journ. de Mid. par Leroux, t. 32, p. 272.) ACSCESSES OF THE ANUS.—FISTULA IN ANO. The custom of giving the appellation of fistula to every collection of matter formed near the anus, has, by conveying a false notion of them, been productive of such methods of treating them, as are diametrically opposite to those which ought to be pursued. A small orifice or outlet from a large or deep cavity, discharging a thin gleet, or sanies, made, as Mr. Pott has explained, a considerable part of the idea which our ancestors had of a fistulous sore, wherever seated. With the term fistulous they always connected a no- tion of callosity; and therefore, whenever they found such a kind of opening yielding such sort of discharge, and attended with any degree of induration, they called the complaint a fistula. Imagining this callosity to be a diseased alteration made in the very structure of the parts, they had no conception that it could be cured by any means but by removal with a cutting instrument, or by destruction with escharotics; and therefore they immediately attacked it with knife or caustic, in order to accomplish one of these ends; and very terrible work they often made. That abscesses formed near the fundament do some- times, from bad habits, from extreme neglect, or from gross mistreatment, become fistulous, is certain; but the majority of them have not at first any one charac- ter or mark of a true fistula; nor can, without the most supine neglect on the side of the patient, or the most ignorant management on the part of the surgeon, de- generate or be converted into one. Collections of matter from inflammation (wherever formed), if they be not opened in time and in a pro- per manner, do often burst. The hole through which the matter finds vent is generally small, and not often situated in the most convenient or most dependent part of the tumour: it therefore is unfit for the discharge of all the contents of the abscess ; and instead of clos- ing contracts itself to a smaller size, and becoming hard at its edges, continues to drain off what is fur- nished by the undigested sides of the cavity. When an abscess near the anus bursts, the small- ness ofthe accidental orifice ; the hardness of its edges; its being found to be the outlet from a deep cavity; the daily discharge of a thin, gleety, discoloured kind of matter; and the induration of the parts round about, have all contributed to raise and confirm the idea of a true fistula. Abscesses about the anus present themselves in dif- ferent forms. Sometimes the attack is made with symptoms of high inflammation; with pain, fever, rigor, Sec, and the fever ends as soon as the abscess is formed. In this case a part of the buttock near the anus is considerably swollen, and has a large, circumscribed hardness. In a short time the middle of this hardness becomes red and inflamed; and in the centre of it mat- ter is formed. This (in the language of our ancestors) is called in general a phlegmon; but when it appears in this parti- cular part, a ph-yma. The pain is sometimes great, the fever high, the »tt- mour large and exquisitely tender; but however dis- agreeable the appearances may have been, or however high the symptoms may have risen before suppuration, yet when that end is fairly and fully accomplished, the patient generally becomes easy and cool; and the mat- ter formed under such circumstances, though it may be plentiful, is good. On the other hand, the external parts, after much pain, attended with fever, sickness, Sec, are sometimes attacked with considerable inflammation, but without any of that circumscribed hardness which character- ized the preceding tumour; instead of which the in- flammation is extended largely, and the skin wears an erysipelatous kind of ajipearance. In this the disease is more superficial; the quantity of matter small, and the cellular membrane sloughy to a considerable extent. Sometimes instead of either of the preceding ap- pearances, there is formed in this part what the French call une suppuration gangreneuse; in which the cel- lular and adipose membrane is affected m the same manner as it is in a carbuncle. In this case, the skin is of a dusky red or purple kind of colour; and although harder than when in a natural state, yet it has, by no means, that degree of tension or resistance, which it has either in phlegmon or in erysipelas. The patient has generally, at first, a hard, full, jar- ring pulse, with great thirst, and very fatiguing rest- lessness. If the progress of the disease be not stopped, or the patient relieved by medicine, the pulse soon changes into an unequal, low, faltering one; and the strength and the spirits sink in such manner, as to imply great and immediately impending mischief. The matter formed under the skin, so altered, is small in quantity, and bad in quality; and the adipose mem- brane is gangrenous and sloughy throughout the ex- tent of the discoloration. This generally happens to persons, whose habit is either naturally bad, or has been rendered so by intemperance. Sometimes the disease makes its first appearance in the induration of the skin, near to the verge of the anus, but without pain or alteration of colour; which hardness gradually softens and suppurates. The mat- ter, when let out, in this case, is small in quantity, good in quality; and the sore is superficial, clean, and well-conditioned. On the contrary, it now and then happens, that although the pain is but little, and the inflammation apparently slight, yet the matter is large in quantity, bad in quality, extremely offensive, and proceeds from a deep crude hollow. The place also where the abscess points, and where the matter, if let alone, would burst its way out, ia various and uncertain. Sometimes it is in the buttock, at a distance from the anus; at other times, near its verge, or in the perina?um; and this discharge is made sometimes from one orifice only, sometimes from seve- ral. In some cases there is not only an opening through the skin externally, but another through the intestines into its cavity: in others, there is only one orifice, and that either external or internal. Sometimes the matter is formed at a considerable distance from the rectum, which is not even laid bare by it; at others, it is laid bare also, and not perforated: it is also sometimes not only denuded, but pierced; and that in more places than one. All consideration of preventing suppuration is ge- nerally out of the question : and our business, if called at the beginning, must be to moderate the symptoms; to forward the suppuration ; when the matter is formed, to let it out; and to treat the sore in such manner as shall be most likely to produce a speedy and lasting cure. When there are no symptoms which require particu- lar attention, and all that we have to do is to assist the maturation of the tumour, a soft poultice is the best application. When the disease is feirly of the phlegmo- noid kind, the thinner the skin is suffered to be- come before the abscess is opened, the better; as the induration of the parts about will thereby be the more dissolved, and, consequently, there will be the less to do after such opening has been made. This kind of tumour is generally found in people of full, sanguine habits; and who, therefore, if the pain be great, and the fever high, will bear evacuation, both by phlebo- tomy and g ntle cathartics: which is not often the case of those, who are said to be of bilious constitu- ANUS. 159 lions; in whom the inflammation is of a larger ex- tent, and in whom the skm wears the yellowish tint of the erysipelas; persons of this kind of habit, and in such circumstances, being in general seldom capa- ble of bearing large evacuation. When the inflammation is erysipelatous, the quan- tity of matter formed is small, compared with the size and extent of the tumour; the disease is rather a sloughy, putrid state of the cellular membraneihan an imposthumation ; and, therefore, the sooner it is opened the, belter: if we wait for the matter to make a point, we shall wait for what will not happen ; at least, not till after a considerable length of time: during which the disease in the membrane will extend itself, and, consequently, the cavity of the sinus or abscess be thereby greatly increased. * When, instead of either of the preceding appearances, the skin wears a dusky purplish-red colour; has a doughy unresisting kind of feel, and very little sensibility; when these circumstances are joined with an unequal, faltering kind of pulse, irregular shiverings, a great failure of strength and spirits, and inclination to doze, the case is formidable, and the event generally fatal. The habit, in these circumstances, is always bad: sometimes from nature, but much more frequently from gluttony and intemperance. What assistance art can lend must be administered speedily; every minute is of consequence; and if the disease be not stopped, the patient will sink. Here (says Pott) is no need for evacuation of any kind: recourse must be immedi- ately had to medical assistance; the part affected should be frequently fomented with hot spirituous fo- mentations; a large and deep incision should be made into the diseased part, and the application made to it should be of the warmest, most antiseptic kind. This also is a general kind of observation, and equally applicable to the same sort jf disease in any part of the body. Our ancestors Iwve thought fit to call it in some a carbuncle, and in others by other names : but it is (wherever seated) really and truly a gangrene of the cellular and adipose membrane: it al- ways implies great degeneracy of habit, and, most commonly, ends ill. Strangury, dysury, and even total retention of the urine are no very uncommon attendants upon ab- scesses in the neighbourhood of the rectum and blad- der: more especially if the seat of them be near the neck of the latter. They sometimes continue from the first attack of the inflammation, until the matter is formed, and has made its way outwards: and sometimes last a few hours only. The two former most commonly are easily relieved by the loss of blood, and the use of gum arabic, with nitre, &c. But in the last (the total retention), they who have not often seen this case, generally have im- mediate recourse to the catheter: but the practice is es- sentially wrong. The neck of the bladder does certainly participate, in some degree, in the .said inflammation. But the principal part of the complaint arises from irrita-on, and the disease is, strictly speaking, spasmodic. The manner in which an attack of this kind is generally made; the very little distention which the bladder of- ten suffers; the small quantity of urine sometimes contained in it, even when the symptoms are most pressing; and the most certain as well as safe me- thod of relieving it; all tend to strengthen such opi- nion. But whether we attribute the evil to inflammation or to spasmodic irritation, whatever can, in any de- gree, contribute to the exasperation of either, must be manifestly wrong. The violent passage of the cathe- ter through the neck of the bladder (for violent in such circumstances it must be) can never be right. If the instrument be successfully introduced, it must either be withdrawn as soon as the bladder is emptied, or it must be left in it: if the former be done, the same cause of retention remaining, the same effect returns; the same pain and violence must again be subnutted to, under (most likely) increased difficulties. On the other hand, if the catheter be left in the bladder, it will often, while its neck is in this state, occasion such disturb- ance that the remedy (as it is called) will prove an exasperation ofthe disease, and add to the evil it is de- signed to nllevii>te. .Nor is this all : for the resistance uiucli the parts while in this stale make, is sometimes so great that if any violence be used, the instrument will make for itself a new route in the neighbouring parts, and lay the foundation of such mischief as fre- quently baffles all our art. The true, safe, and rational method of relieving this complaint (says Pott) is by evacuation and anodyne relaxation : this not only procures immediate ease, but does, at the same time, serve another very material pur- pose ; which is that of maturating the abscess. Loss of blood is necessary; the quantity to be determined by the strength and state of the patient: the intestines should also be emptied, if there be time for so doing, by a gentle cathartic ; but the most effectual relief will be from the warm bath or semicupium, the application of bladders with hot water to the pubes and perina^um, and, above all other remedies, the injection of glysters, consisting of warm water, oil, and opium. There may have been cases which have resisted and baffled this method of treatment; but Pott never met with them. A painful tenesmus is no uncommon attendant upon an inflammation of the parts about the rectum. If a dose of rhubarb, joined with the confect. opii, does not remove it, the injection of thin starch and opium or tinct. thebaic, is almost infallible. The bearing down in femaies, as it proceeds, in this case, from the same kind of cause (viz. irritation), ad- mits of relief from the same means as the tenesmus. In some habits, an obstinate costiveness attends this kind of inflammation, accompanied, not unfrequently, with a painful distention and enlargement of the he- morrhoidal vessels, both internally and externally While a large quantity of hard feces is detained within the large intestines, the whole habit must be disor- dered ; and the symptomatic fever which necessarily accompanies the formation of matter, must be consi- derably heightened. And while the vessels surround- ing the rectum (which are large and numerous) are distended, all the ills proceeding from pressure, in- flammation, and irritation must be increased. Phle- botomy, laxative glysters, and a low, cool regimen must be the remedies : while a soft cataplasm applied externally serves to relax and mollify the swollen, in- durated piles, at the same time that it hastens the sup- puration. When the abscesses have formed, and are fit to be opened, or when they have already burst, they may be reduced to two general heads, viz. 1. Those in which the intestine is not all interested : and, 2. Those in which it is either laid bare or perfo- rated. In making the opening, the knife or lancet should be passed in deep enough to reach the fluid; and when it is in the incision should be continued upwards and downwards in such manner as to divide all the skin co- vering the matter. By these means, the contents of the abscess will be discharged at once; future lodge- ment of matter will be prevented; convenient room will be made for the application of proper dressings; and there will be no necessity for making the incision in different directions, or for removing any part of the skin composing the verge of the anus. Notwithstanding all these collections of matter are generally called fistula, and are all supposed to affect the rectum, the abscess is sometimes really at such a distance from the gut, that it is not at all interested by it; and none of these cases either are or can be originally fistula. In this state of the disease, we have no more neces- sarily to do with the intestine than if it were not there; the case is to be considered merely as an ab- scess in the cellular membrane. A short time ago, some interesting remarks on fis- tula in ano were published in France by Dr. Ribes, whose opinions, however, like those of many other valuable writers, are not invariably free from error; and 1 have no hesitation in extending this observation to one of his statements, though what he has said is alleged to be deduced from the dissection of not less than 75 persons who had died with fistula?. No man who has seen much of this part of surgery, can doubt that the most frequent form of the disease is that in which the abscess has only an external opening, and does not perforate the rectum at all, from which, indeed, the matter is sometimes more or less distant. Nor can any ex|>erienced surgeon question the truth of Mr. Poll's account resuming the diversity of the 1G0 ANUS. nature of the cases of fistula, some being phlegmo- nous, some erysipelatous, and others more like the carbuncle in their origin, progress, and consequences. But besides these circumstances, another one worthy of notice is, that the presence of fistula in ano by no means implies the previous or present existence of piles. However, notwithstanding these considera- tions, the doctrine started by Dr. Ribes is, that a fis- tula is formed by the bursting of an internal pile into the rectum, and the consequent passage of a portion of the contents of the bowel into the orifice. He far- ther asserts that such orifice is always within five or six lines above the junction of th-> internal membrane of the bowel with the external skin, and that it may usually be seen, if the patient forces the gut gently down, as in going to stool. The only correct part or these statements is, I believe, the account ofthe common situation of the internal opening, when the abscess communicates with the bowel, which is not always the case.—(See Recherches sur la Situation de VOri- fice interne de la Fistule de PAnus, i$-e. Quarterly Journ. of Foreign Med. No. 8. Oct. 1820.) This part of the account is confirmed by the observations of Larrey.—(Mem. de Chir. Mil. t. 3, p. 415.) Suppose a large and convenient opening to have been made by a simple incision ; the contents ofthe abscess to have been thereby discharged; and a sore or cavity produced, which is to be filled up. The term filling up. and the former opinion, that the induration of the parts about is a diseased callosity, have been the two principal sources of misconduct in these cases. The old opinion, with regard to hollow and hard- ness, was that the former is caused entirely by loss of substance; and the latter, by diseased alteration in the structure ofthe parts. The consequence of which opinion was, that as soon as the matter was discharged, the cavity was filled and distended, in order to procure a gradual regenera- tion of flesh; and the dressings, with which it was so filled, were most commonly of the escharotie kind, in- tended for the dissolution of hardness. On the other hand, the surgeon who regards the cavity of the abscess as being principally the effect of the gradual separation of its sides, with very little loss of substance, compared with the size of the said cavity; and who looks upon the induration round about, as nothing more than a circumstance which necessarily accompanies every inflammation, will, upon the small- est reflection, perceive that the dressings applied to such cavity ought to be so small in quantity, as to permit nature to bring the sides of the cavity towards each other, and that such small quantity of dressings ought not by their quality either to irritate or de- stroy. If the hollow, immediately it is opened, be filled with dressings (of any kind), the sides of it will be kept from approaching each other, or may even be farther separated. But if this cavity be not filled, or have little or no dressings of any kind introduced into it, the sides immediately collapse, and, coming nearer and nearer, do, in a very short space of time, convert a large hollow into a small sinus. And this is also constantly the case, when the matter, instead of being let out by an artificial opening, escapes through one made by the bursting ofthe containing parts. True, this sinus will not aiways become perfectly closed; but the aim of nature is not therefore the less evident; nor the hint, which art ought to borrow from her, the less palpable. In this, as in most other cases, where there are large sores, or considerable cavities, a great deal will depend on the patient's habit, and the care that is taken of it; if that be good, or if it be properly corrected, the sur- geon will have very little trouble in his choice of dress- ings; only to take care that they do not offend either in quantity or quality: but if the habit be bad, or inju- diciously treated, he may use the whole farrago of ex- ternals, and only waste his own and his patient's time. By light, easy treatment, large abscesses formed in the neighbourhood of the rectum will sometimes be cured, without any necessity for meddling with the said gut. But it much more frequently happens, that the in- testine, although it may not have been pierced or eroded by the matter," has yet been so stripped or denuded, that no consolidation of the sinus can be obtained, but by a division; that is, by laying the two cavities, viz. that of the abscess and that of the intestine, into one. When the intestine is found to be separated from the surrounding parts by the matter, the operation of di- viding it had better (on many accounts^ be performed at the time the abscess is first opened, than be deferred to a future one. For, if it be done properly, it will add so little to the pain, which the patient must feel by opening the abscess, that he will seldom be able to dis- tinguish the one from the other, either with regard to time or sensation ; whereas, if it be deferred, he must either be in continual expectation of a second cutting, or feel one at a time when he does not expect it. Theintention in this operation is to divide the intes. tine reTtum from the verge of the anus up as high as the top of the hollow in which the matter was formed; thereby to lay the two cavities of the gut and abscess into one; and by means of an open, instead of a hol- low or sinuous sore, to obtain a firm and lasting cure. For this purpose, the curved, probe-pointed knife, with a narrow blade, is the most useful and handy in- strument of any. This, introduced into the sinus, while the surgeon's fore-finger is in the intestine, will enable him to divide alt that can ever require division ; and that with less pain to the patient, with more fa- cility to the operator, as well as with more certainty and expedition, than any other instrument whatever. If there be no opening in the intestine, the smallest de- gree of force will thrust the point of the knife through, and thereby make one: if there be one already, the same point will find and pass through it. In either case, it will be received by the finger in ano; will thereby be prevented from deviating; and being brought out by the same finger, must necessarily divide all that is between the edge of the knife and the verge of the anus : that is, must by one simple incision (which is made in the smallest space of time imaginable) lay the two cavities of the sinus and of the intestine into one. Authors make a very formal distinction between those cases in which the intestine is pierced by the matter, and those in which it is not; but although this distinction may be useful when the different states of the disease are to be described, yet in practice, when the operation of dividing the gut becomes necessary, such distinction is of no consequence at all: it makes no alteration in the degree, kind, or quantity of pain which the patient is to feel; the force required to push the knife through the tender gut is next to none, and when its point is in the cavity, the cases are exactly similar. In this statement every man of experience and discernment must agree, notwithstanding the pro- hibition to the operation, delivered by Dr. Ribes, in every case, in which the internal opening cannot be found: a piece of advice (as it seems to me) fully ad- mitting the occurrence of cases which could not be formed in the manner in which he conceives all fistula in ano to bo produced, viz. .by the bursting of a pile, and the entrance of feces into the orifice. Immediately after the operation, a soft dossil of fine lint should be introduced (from the rectum) between the divided lips of the incision ; as well to repress any slight hemorrhage, as to prevent the immediate reunion of the said lips; and the rest of the sore should be lightly dressed with the same. This first dressing should be permitted to continue, until a beginning sup- puration renders it loose enough to come away easily; and all the future ones should be as light, soft, and easy as possible; consisting only of such materials as are likely to promote kindly and gradual suppuration. The sides of the abscess are large; the incision must necessarily, for a few days, be inflamed ; and the dis- charge will, for some time, be discoloured and gleety: this induration, and this sort of discharge, are often mistaken for signs of diseased callosity and undis- covered sinuses; upon which presumptions, escharo- tics are freely applied, and diligent search is made for new hollows: the former of these most commonly in- crease both the hardness and the gleet; and by the latter new sinuses are sometimes really produced. These occasion a repetition of escharotics, and, perhaps, of incisions; by which means, cases which at first, and in their own nature, were simple and easy of cure, are rendered complex and tedious. To quit reasoning, and speak to fact only: In tha ANUS. 16l areat number of the feces were dis- charged involuntarily, and the pulse both immediately and for an hour after the operation was 144. An opiate was given, and the involuntaty passage of feces soon ceased. The sensibility of the right leg was very im- perfect. In tbe night, the patient complained of heat in the abdomen L,buthe felt no pain upon pressure; and the lower extremities, which had been cold a little while after the operation, were regaining their heat, but their sensibility was very indistinct. At six o'clock the fol- lowing morning, the sensibility ofthe limbs was still im- perfect ; but at eight o'clock the right one was warmer than the left, and its sensibility returning. At noon the temperature of the right limb was ninety-four; that of the left or aneurismal one, eighty-seven and a half. At three o'clock, an enema was ordered. The heat of the right leg was now ninety-six; that of the left or diseased limb, eighty-seven and a half. It is un- necessary here to detail all the various circumstances which preceded the patient's death Vomiting, pain in the abdomen and loins, involuntary discharge of urine and feces, a weak pulse, cold sweats, &c. were some of the most remarkable symptoms. At eight o'clock on the second morning after the operation, the aneurismal limb appeared livid and cold, more particu- larly round tbe aneurism; but the right leg was warm; and between one and two o'clock the same day, the patient died. On opening the abdomen, there was not the least appearance of peritoneal inflammation, except at the edges of the wound; and the omentum and in- testines were of their natural colour. The ligature, which included no portion of intestine or omentum, was placed round the aorta about three-quarters of an inch above its bifurcation. When the vessel was opened, a clot of more than an inch in extent filled it above the ligature; and below the bifurcation another clot an inch in extent occupied the right iliac artery, while the left contained a third, which extended as far as the aneurism. The neck of the thigh-bone was also found broken within the capsular ligament, and not united; an accidental complication As there were no appear- ances of inflammation of the viscera, Sir Astley Cooper refers the cause of the man's death to the want of cir- culation in the aneurismal limb, which never recovered its natural heat, nor any degree of sensibility, though the right leg was not prevented from doing so: hence, says this experienced surgeon, "in an aneurism simi- larly situated, tl e ligature must be applied before the swelling has acquired any considerable magnitude.— (Surgical Essays, vol. 1, p. 114, y rub- bing together one drachm of the oxide and twelve drachms of spermaceti ointment.—(See A. T. Thom- son's Dispensatory, p. 51.) Febure's celebrated remedy consisted of ten grains of the white oxide of arsenic dissolved in a pint of dis- tilled water; to which were then added an ounce of the extraetum conii, three ounces ofthe liquor plumbi subacetatis, and a drachm of laudanum. With this fluid the cancer was washed every morning. Febure likewise gave arsenic internally ; and his prescription ■was two grains of the white oxide, a pint of distilled water, syrup of chichory q. s. and half an ounce of rhubarb. Of this mixture a table-spoonftil was given every night and morning with half a drachm of the syrup of poppies. Each dose contained about one- twelfth of a grain of arsenic; but in proportion as the patient was able to bear an increased quantity, the dose was gradually augmented to six table-spoonfuls of the solution. The arseniate or rather superarseniate of potash, is an excellent preparation for internal exhibition. The Dublin Pharmacopoeia directs it to be made as follows: take of white oxide of arsenic, nitrate of potassa, each an ounce. Reduce them separately to powder; then having mixed them, put them into a glass retort and place it in a sand-bath exposed to a gradually raised heat, until the bottom of the retort becomes obscurely red. The vapours arising from the retort should be transmitted through distilled water by means of a pro- per apparatus, in order that the nitrous acid extri- cated by the heat may be disengaged. Dissolve the residue, in four pounds of boiling distilled water, and after due evaporation, set it apart in order that crystals may form. This preparation has long been known under the name of Macquer's arsenical neutral salt. It may be given in the following way: ft. Potassa? superarseniatis gr. ij. Aq. mentha? viridis J iv. Spir. vinosi tenuioris ly M. et cola. Dosis drachma? dua? ter quotidie. The following is Dr. Fowler's method of preparing arsenic for internal use: take of the white oxide of arsenic and pure subcarbonate of potash, each sixty- four grains. Boil them gently in a Florentine flask or other glass vessel, with half a pound of distilled water, until the arsenic is dissolved. To this solution, when cold, add half an ounce of the compound spirit of la- vender, and as much water as will make the whole equal to a pint, or fifteen ounces and a half in weight. The dose of this solution, of which the liquor arseni- calis L. P. is an imitation, is as .follows: from two years old to four, M. ij or iij to v; from five to seven, M. v to vij; from eight to twelve, M. vij to x; from thir- teen to eighteen, M. x to xir; from eighteen upwards, M. xii. These doses may be repeated every eight or twelve hours, the medicine being diluted with thick gruel or barley-water. As the preparation is decom- posed by the infusion and decoction of cinchona, it should never be ordered with either of these medicines. The white oxide of arsenic may be given in the form of pills, made by mixing one grain of it with ten of su- gar, and then beating up the mixture with a sufficient quantity of the crumb of bread to forni ten pills, one of which is a dose. It will only be in my power to spe-. cify here a few of the numerous surgical cases in which the internal employment of arsenic has been proposed. The following are particularly worthy of attention: tetanic affections; cancer; lupus ; elephan- tiasis ; inert cases of lepra (See Bateman's Pract. Sy- nopsis of Cutaneous Diseases, p. 33, ed. 3); various unnamed malignant ulcers ; certain forms or sequela? of the venereal disease, or other unintelligible diseases which cannot be subdued by mercury; different cuta- neous affections, &c. A longer list of diseases for which a trial of arsenic is suggested, may be seen in some papers published by Mr. Hill.—(Edin. Med. and Surg. Journ. vols. 5, 6.) Arsenic has also been recommended by Br. J. Hun- ter for the prevention of hydrophobia.—(See Trans, of a Society for the Improvement of Med. awl Chir. Know- ledge,voL 1.) Latertrials ofthe medicine, however, in this particular case, do not appear to entitle it to any con- fidence. Dr. Marcet found it quite unavailing, though not less than three drops of Fowler's solution were taken every other hour in two drachms of peppermint or sweet- ened water.—(See Med. Chir. Trans, vol. 1, p. 141.156.) After the symptoms or hydrophobia have once began, arsenic is decidedly useless. But although it fails in hydrophobia, some facts pub- lished by Mr. Ireland, and certain observations and ex- periments detailed in Dr. Russel's work on Indian ser- pents, make it appear a truly valuable remedy for the effects of the bites of serpents.—(See Med. Chir. Trans. vol. 2, p. 393.) In cases of poison by arsenic, practitioners univer- sally agree respecting the first indication, which is to empty the stomach as quickly as possible with the stomach pump or an emetic. In this country tbe com- mon practice is to exhibit an emetic of sulphate of zinc or sulphate of copper, which (it is said) ought to be preferred; first, because they do not require much di- lution for their action; a circumstance of no small im- portance where poisons act by being absorbed; and se- condly, because they are extremely expeditious; a dose of fifteen or twenty grains producing almost instanta- neous vomiting, without exciting that previous stage of nausea which so frequently characterizes other eme- tics, and which produces a state of the vascular sys- tem highly favourable to the functions of absorption.— (See Pharmacologia, by Dr. Paris, p. 232, vol. 1, ed. 5.) On the other hand, instead ofthe use of violent eme- tics like antimon. tart, and sulphate of zinc, which Orfila says always increase the irritation created by the poison, he prefers exciting vomiting by making the patient drink large quantities of warm water, milk, water containing sugar or honey, linseed tea, and other mucUaginous fluids, the experiment of tickling the throat with a feather or finger not being omitted. After as much of the poison has been discharged by vomiting as can be thus evacuated, the stomach may be me- chanically washed out with the stomach pump ; a plan first proposed by Boerhaave and afterward improved by MM. Dupuytren and Renault.—(See Orfila, Toxico- logic Generate, t. 1, p. 132. ed. 2, 1818. See also Mr. Jukes's Obs. on this subject in Med. and Phys. Journ. for Nov. 1822, and June, 1823; also Lancet, vol. 1.) By this means, the contents ofthe stomach may either be pumped out at once, or any fluid may be first in- jected and then drawn out again. As arsenic produces its fatal effects chiefly by being absorbed, an important indication, according to this principle, is to administer only such liquids as are least liable to dissolve the ar- senic in the stomach. On this account lime-water has been recommended as proper to be drunk after the sto- mach has been emptied by vomiting. It is remarked by Orfila, that lime-water with milk offers no particular advantage in cases of poison with the solid arsenical acid; but where this acid is fluid, he admits the great utility of lime-water, as in this circumstance, an inso- luble arsenite of lime is formed, the action of which is very weak. This last observation is confirmed by ex- periments on dogs.—(Toxicologic Ginerale,t. 1,/;. 233.) When inflammation of the abdomen and alarming nervous symptoms prevail, the means of relief are, leeches, venesection, the warm bath, fomentations, emollient clysters and antispasmodic narcotic medicines. It should also never be forgotten, that the success ofthe treatment will depend, in a great measure, upon the regimen observed during the patient's convales- cence, which is usually tedious ; and he should be chiefly nourished with milk, gruel, cream, rice, and beverages of a softening mucilaginous nature.—(See Orfila, t. cit. p. 235.) [There can be little doubt that arsenic is the basis of the active ingredients of most of the popular nos- trums of the day which are set forth in our public papers as infallible remediesfor the cure of cancerous affections, as they are termed ; and hence the manifold evils which we often witness from such practice. So long ago as in 1786, Dr. Rush favoured the public with an exposition of the nature of the famous cancerous powder of Dr. Martin; its base was arsenic, though like the specifics of our own time it was alleged to be of a vegetable nature. The consequences arising from applications of this character might be noticed at greatef length than our author has seen fit to do: and the caution to be deduced from facts of this sort might ope- rate more forcibly if they were better understood. The external application of arsenic ought to be had recourse to only after the severest scrutiny into the peculiar character of the case and constitution affected. Even in small quantities it has produced apoplexy, mental , aberration, organic lesion of the stomach, paralysis, ART loss of motion, enlargement of the joints, fatal pete- chia, &c. Arsenic, in fact, may be enumerated among that class of poisons which induces nearly the same ef- fects externally applied as well as when taken inwardly. The experiments of Brodie, as well as those of other philosophers, demonstrate, that its influence on-the system is no less rapid and dangerous when had re- course to as an external application to denuded sur- faces than when applied directly to the stomach. An- other peculiarity of its action deserves also farther to be stated : according to Professor Francis (Lectures on Forensic Medicine), in some cases, even while fa- vourable anticipations from the operation of this power- ful agent locally applied are indulged, of a sudden the general health yields, and death ensues rapidly and unexpectedly; an occurrence of much consideration in the investigations of the juridical physician.—Reese.] ARTERIOTOMY. (From aprvpia, an artery, and rc/ivo), to cut.) The operation of opening an artery, for the purpose of taking away blood for the relief of diseases.—(See Bleeding.) ARTERIES. The process by which a divided or punctured artery is healed is particularly considered under the word Hemorrhage; while the general prin- ciples, which ought to be observed in the application of the means for the stoppage of bleeding, may be col- lected partly from the remarks contained in that part of the work, and partly from what is stated in the arti- cles Amputation, Aneurism, and Ligature. As the condition of a bleeding patient admits of no delay, and the preservation of his life entirely depends upon proper measures being immediately taken, no man ought to be suffered to profess surgery who is not competent to the treatment of wounded arteries, whether injured by accident or in a surgical operation. As Langen- beck observes, an ignorant practitioner, when called to a case of serious hemorrhage, is thrown into such consternation, as actually deprives him of the power of rendering prompt assistance. Pale as a corpse, and trembling, he beholds the jet of blood; and, for the sake of appearing to do something, perhaps he applies spirit of wine, or a very tight bandage, and cries out for farther aid; while simple pressure of the thumb upon a certain point in the vicinity of the injury would prevent all this confusion, and a dangerous loss oft blood. No part of surgery, in fact, is of higher import- ance than the treatment of wounded arteries ; and it deserves, therefore, to be earnestly studied by every practitioner, whether he move in the higher or the lower sphere of the profession. And as a proof of the necessity of country surgeons making themselves ac- quainted with the subject, he recites the case of a turf- cutter, who let the instrument with which he worked fall against the lower part of his leg, whereby the pos- terior tibial artery was wounded. The blood gushed out profusely, and the surgeon who was sent for ap- plied a tourniquet to the popliteal artery, and thus stopped the bleeding for a time; but, unfortunately, the tourniquet was kept so long on the limb, that the foot mortified and sloughed away.—(Bibl. fur die Chir. b. 1, p. 231, 232, Gott. 1806.) From the explanations, delivered in the article Hemorrhage, it will be seen, that in all bleedings from considerable arteries, nothing is equal to the ligature, as a means of preventing the farther loss of blood; and it may be laid down as a standing rule, that each extremity of the wounded ves- sel should be tied as nearly as possible to the wound in its coats. As Mr. Hodgson has remarked, " the ne- cessity of tying both ends of a wounded artery is evi- dent from the feet, that the anastomoses in all parts of the body are so extensive, as to furnish a supply of blood, which may pass through the lower extremity of the wounded vessel in a sufficient stream to produce an alarming, and, in some instances, a fetal hemor- rhage."—(On Diseases of Arteries, o. Lond. 1816.) When leeches are to be kept in any considerable quan- tity, this gentleman recommends them to be placed Ui a large vessel provided with a false bottom, so perforated as to allow them a ready passage. " This false bottom should be raised from three to six inches above the real bottom, or to such an extent as wUl admit of a turf of nearly equal dimensions being placed between them It should fit closely to the sides, that the earth may not be disturbed by the frequent introduction of fresh wa- ter. It is necessary that the vessel be also furnished with a stop-cock, in order that the water may be drawn off as often as may be considered expedient. But pre- viously to onr placing the leeches in this vessel, they should be singly examined. If, on being handled, they contract, and feel hard and firm, it affords the best in- dication of their being healthy; but should they feel flabby, or exhibit protuberances, or white ulcerous specks on the surface, they should be kept in jars by themselves, the water and the turf of which should be frequently renewed."—(Op. cit. p. 138.) Sometimes leeches cannot be easily made to fix on the part to which they ought to be applied; but they will do so if the place be first cooled with a cloth dipped in cold water, or if it be moistened with cream or milk, and they be confined in the situation with a small glass. According to Dr. Johnson, the part on which they are intended to fix should be as clean as possible; it should, therefore, be first washed with soap and water, and afterward with water alone, which will be more ne- cessary should any liniment or embrocation have been used. Leeches are often found to bite better when re- moved from the water at least an hour previously to their application. In the common practice of putting as many of them as may be required into a wine-glass, and inverting it upon the part affected, there is the dis- advantage that they frequently retire to the upper part of the glass, and cannot be got down again with- out some risk of displacing those which have already fastened. To remedy this inconvenience, Dr. Johnson recommends glass vessels of various sizes and figures, but none of them more than an inch deep. But in his own practice he prefers applying leeches with his hand. " Bring a leech towards the part whereon you intend to fix it, and as soon as it begins to extend the head to seek an attachment, endeavour that it may affix itself to the place required." When it evinces no disposition to bite, a little puncture may be made with a lancet, when the animal will fix itself. " When the patient is fearful of the lancet, and one leech only shall have bit- ten where several are required, it may be of use to re- move it, which is readily done by inserting the nail of She finger between its mouth and the skin. The blood •then flowing from the orifice will induce the remainder ■to bite with the greatest avidity. As soon as the leeches are gorged they drop off; this usually happens within ten or fifteen minutes. Sometimes they remain affixed a considerable time, and become indolent; but they are quickly aroused from this state by sprinkling them with a few drops of cold water."—(Johnson, op. cit. p. 141.) When they fall off, the bleeding may be promoted, if necessary, by fomenting the part. When the bleeding continues longer than is desirable, a slight compress will usually stop it; but in more troublesome cases the compress must be dipped in brandy or spirits of wine. In young infants the hemorrhage from the bites of leeches has sometimes proved fatal, and the same thing may happen in adults. An example of each fact is related by Beauchene (Gazette de Santc, Sept. 1815). When the bleeding is very troublesome, Autenrieth advises pieces of charpie to be pushed into the orifices of the bites ; a method which he assures us is perfectly effectual.—(Tubingen Blatter, b. 2, st. 1, p. 57.) In order to make a leech disgorge, it is usual to throw a little salt upon it: in a few seconds the blood is ejected, the leech assumes a coiled form, and is seldom found fit for use again before the end of four or five days. As salt, however, frequently blisters the leech, it has been proposed to empty the animal by regular and uniform pressure; but though Dr. Johnson consi- ders this plan better than the other, he admits that it ia scarcely practicable without injuring the internal struc- ture of the leech. He says, the best method, and that from which the animal suffers the least inconvenience, is pouring a small quantity of vinegar upon its head. Leeches which have been recently applied should al- ways be kept by themselves, and allowed to retain for their nourishment about one-third of the blood which they extract. For a great deal of valuable information respecting leeches, see Dr. Johnson's work, the title of which is above specified. When leeches are very scarce, their tails may be snipped off while they are sucking, and the blood will then flow, drop by drop, from the artificial opening, as fast as the animals suck it; or, with the same view, an incision may be made with a lancet close to the tail. —(Johnson, op. cit. p. 144.) SCARIFICATION WITH A LANCET is mostly done in cases of inflamed eyes. An assistant is to raise the upper eyelid, while the surgeon himself depresses the lower one, and makes a number of slight scarifications where the vessels seem most turgid, try- ing particularly to cut the largest completely across. ILL CONSEQUENCES SOMETIMES FOLLOWING BLEEDING IN THE ARM. 1. Ecchymosis. The most common is the thrombus, or ecchymosis, a small tumour around the orifice, and occasioned by the blood insinuating itself into the adjoining cellular sub- stance at the time when it is flowing out of the vessel. Changing the posture of the arm will frequently hinder the thrombus from increasing in size, so as to obstruct the evacuation of the blood. But, in some instances, the tumour suddenly becomes so large that it entirely interrupts the operation, and prevents it from being finished. In these cases, however, the most effectual method of preventing the tumour from becoming still larger is to remove the bandage. By allowing the bandage to remain, a very considerable swelling may be induced, and such as might be attended with great trouble. If more blood be required to be taken away, it ought to be drawn from another vein, and, what is still better, from a vein in the other arm. The best applications for promoting the absorption of these tumours, are those containing spirit, vinegar, or the muriate of ammonia; Compresses wetted with any lotion of this sort may be advantageously put on the swelling and confined there writh a slack bandage. 2. Inflammation of the integuments and subjacent cellular substance. According to Mr. Abernethy, the inflammation and suppuration of the cellular substance in which the vein lies, are the most frequent occurrences. On the subsi- dence of this inflammation, the tube of the vein is free from induration. Sometimes the inflammation is ra- ther indolent, producing a circumscribed and slowly suppurating tumour. Sometimes it is more diffused, and partakes of the erysipelatous nature. On other occasions it is phlegmonous. When the lancet has been bad, so as rather to have lacerated than cut the parts; when the constitution is irritable, and especially when care is not taken to unite the edges of the puncture, and the arm is allowed to »move about, so as to make the two sides of the wound rub against each other, inflammation will most probably ensue. The treatment of this case consists in keeping the arm perfectly at rest in a sling, applying the satur- nine lotion, and giving one or two mild saline purges. When suppuration takes place, a small poultice is the best application. 3. Absorbents inflamed. Sometimes, particularly when the arm is not kept properly quiet after bleeding, swellings make their ap- pearance about the middle of the arm, over the large vessels, and on the forearm, about the mid-space be- tween the elbow and wrist, in the integuments covering the flexor muscles. The swelling at the inner edge of the biceps is sometimes as large as an egg. Before such swellings take place, the wound in the vein often inflames, becomes painful, and suppurates, but without any perceptible induration of the venal tube, either at this time, or after the subsidence of the inflammation Pain is felt shooting from the orifice in the vein, in ** BLEEDING. 189 lines up and down the arm, and upon pressing in the course of this pain, its degree is increased On ex- amining the arm attentively, indurated absorbents may be plainly felt, leading to the tumour at the side of the biceps muscle. The pain and swelling often extend to the axilla, where the glands also sometimes enlarge. Cord-like^ substances, evidently absorbents, may sometimes be felt, not only leading from the puncture to the swelling in the middle ofthe arm, but also from this latter situa- tion up to the axillary glands, and from the wound in the vein down to the enlarged glands at the mid-space between the elbow and wrist, over the flexor muscles of the hand. The enlarged glands often proceed to suppuration, and the patient suffers febrile symptoms. It may be suspected that the foregoing consequences arise from the lancet being envenomed, and from the absorption of the virulent matter; but the frequent descent of the disease tagf^inferior absorbents militates against this BuppositrM(P When the absorbents become inflamed, they quickly communicate the affection to the surrounding cellular substance. These vessels, when indurated, appear like small cords, perhaps of one-eighth of an inch in diameterga this substance cannot be tbe slender sides of the vessels, suddenly increased in bulk, but an in- duration of the surrounding cellular substance. The inflammation of the absorbents, in consequence of local injury, is deducible from two causes : one, the absorption of irritating matter; and the other, the effect of the mere irritation of the divided tube. When viru- lent matter is taken up by the absorbents, it is generally conveyed to the next absorbent gland, where its pro- gress being retarded, its stimulating qualities give rise to inflammation, and, frequently, no evident disease of the vessel through which it has passed can be dis- tinguished. When inflammation of the absorbents happens, in consequence of irritation, the part of the vessel nearest the irritating cause generally suffers most, while the glands, being remotely situated, are not so much in- flamed. The treatment of the preceding case consists in keeping the arm perfectly quiet in a sling, dressing the puncture of the vein with any mild simple salve, cover- ing the situation of the inflamed lymphatics with linen wet with the saturnine lotion, and giving some gently purging medicine. When the glandular swellings suppurate, poultices should be applied, and if the matter does not soon spon- taneously make its way outwards, the surgeon may open the abscess.—(See Abernethy's Essays on this subject.) 4. Inflammation of the Vein. When the wound does not unite, the vein itself is very likely to inflame. This affection will vary in its degree, extent, and progress. One degree of inflam- mation may only cause a slight thickening of the venal tube, and an adhesion of its sides. Abscesses, more or less extensive, may result from an inflammation of greater violence, and the matter may sometimes be- come blended with the circulating fluids, and produce dangerous consequences, or the matter may be quite circumscribed, and make its way to the surface. When the vein is extensively inflamed, a good deal of sympa- thetic fever is likely to ensue, not merely from the ex- citement which inflammation usuaUy produces, but also from the irritation continued along the membra- nous lining of the vein towards the heart. If, how- ever, the excited inflammation should fortunately pro- duce an adhesion of the sides of the vein to each other at some little distance from the wounded part, this ad- hesion will form a boundary to the inflammation, and prevent its spreading farther. The effect of the adhe- sive inflammation in preventing the extension of in- flammation along membranous surfaces, was origin- ally explained by Mr. Hunter. In one case Mr. Hunter applied a compress to the inflamed vein above the wounded part, and he thought that he had thus suc- ceeded in producing an adhesion, as the inflammation was prevented from spreading farther. When the in- flammation does not continue equally in both directions, but descends along the course of the vein, its extension in the other direction is probably prevented by the ad- hesion of the sides of the vein to each other.—(See Obs. on the Inflammation of the internal coats of Veins, in Trans, of a Soc. for the Improvement of Med. and Chir. Knowledge, vol. 1, p. 18, i-c.) More information on this subject will be found under the head of Veins. Mr. Abernethy mentions his having seen only three cases in which an inflammation of the vein succeeded ►venesection. In neither of these did the vein suppu- rate. In one about three inches of the venal tube in- flamed, both above and below the puncture The in- teguments over the vessel were veiy much swollen, red, and painful, and there was a good deal of fever, with a rapid pulse and furred tongue. The vein did not swell when compressed above the diseased part. In another instance, the inflammation of the vein did not extend towards the heart, but only downwards, in which direction it extended as far as the wrist. The treatment is to lessen the inflammation of the vein by the same means which other inflammations re- quire, and to keep the affection from spreading along the membranous lining of the vessel towards the heart, by placing a compress over the vein a little way above the puncture, so as to make the opposite sides of the vessel adhere together. Mr. Abernethy conceives a case possible in which the vein may even suppurate, and a total division of the vessel be proper, not merely to obviate the exten- sion of the local disease, but to prevent the pus from becoming mixed with the circulation. Were such a proceeding deemed right, I think Mr. Brodie's method of cutting the vessel would be best. However, I have never heard of any ease in which the practice has been adopted. As for the scheme of tying the vein above the diseased part of it, the severe effects fre- quently following this method must, as Mr. Dunn has reminded me, render it less eligible than an incision. In the case of an inflamed vein, Dr. Chapman states that nothing is so efficacious as blisters; a practice said to have been first suggested by Dr. Physick.—(See afatal case of Inflammation of the vessel from Vene- section, in Philadelphia Journ. Feb. 1824.) I was lately favoured by Mr. Howship with a view of the state of the parts in a case where a lady had died after an inflammation of the veins of the arm, brought on by venesection: they were considerably thickened, and in some cases quite solid and impervious.—(See Veins.) 5. Inflammation of the Fascia of the Forearm, or dif- fuse inflammation of the cellular membrane. Sometimes, in consequence of the inflammation arising from the wound of the lancet in bleeding, the arm becomes very painful, and can hardly be moved. The puncture often remains unhealed, but without much inflammation of the surrounding integuments. The forearm and fingers cannot be extended without great pain. The integuments are sometimes affected with a kind of erysipelas; being not very painful when slightly touched, but when forcibly compressed, so as to affect the inferior parts, the patient suffers a good deal. The pain frequently extends towards the axilla and acromion; no swelling, however, being percepti- ble in either direction. These symptoms are attended with considerable fever. After about a week, a small superficial collection of matter sometimes takes place a little below the internal condyle: this being opened, a very little pus is discharged, and there is scarcely any diminution of the swelling or pain. Perhaps, after a few days more, a fluctuation of matter is distinguished below the external condyle; and this abscess being opened, a great deal of matter gushes from the wound, the swelling greatly subsides, and the patient's future sufferings are comparatively trivial. The last opening, however, is often inadequate to the complete discharge of the matter, which is sometimes originally formed beneath the fascia, in the course of the ulna, and its pointing at the upper part ofthe arm depends on the thinness of the fascia in this situation. The collection of pus descends under the lower part of the detached fascia, and a depending opening for its discharge becomes necessary. This being made, the patient soon gets well. In these cases the vein is not inflamed; but some- times the glands of the armpit and just above the elbow sweU. The integuments are not much affected, and the patient complains of a tightness of the forearm. Matter does not always form, and the pliabUity of the arm after a good whUe gradually returns again. Mr. Watson relates a case which was foUowed by « *s 190 BLE permanent contract ion of the forearm. Mr. Abernethy is of opinion that a similar contraction of the forearm, from a tense state of the fascia, may be relieved by detaching the fascia from the tendon of the biceps, to which it is naturally connected. Mr. Watson seems to have obtained success in his first case by having cut this connexion. In the treatment of an inflammation of the fascia, or of an extensive quantity of the cellular membrane, in consequence of venesection, general means for the cure of inflammation shoifldbe employed, especially nume- rous leeches, cupping, purgatives, Sec. The limb should be kept quiet, and the inflamed part relaxed. As soon as the inflammation abates, the extension of the forearm and fingers ought to be attempted and daily performed, to obviate the contraction which might otherwise ensue. Mr. C. Bell objects to calling the affection an inflam- mation of the fascia, because he sees no proof of this part being inflamed; and he conceives that the symp- toms proceed from the inflammation spreading in the cellular membrane and passing down among the mus- cles and under the fascia. On this point I believe him to be quite correct, and that the disorder partakes of the character of diffuse inflammation of the cel- lular membrane so well described by Dr. Duncan.— (See Edin. Med. Chir. Trans: vol. 1.) To this subject, however, I shall return in the article Erysipelas. The fascia acts as a bandage, and from the swelling of the parts beneath it binds the arm, but is not itself in- flamed and contracted. When necessary to divide the fascia, Mr. Charles Bell thinks it would be better to begin an incision near the inner condyle of the hume- rus, and to continue it some inches down the arm, rather than perform the nice if not dangerous opera- tion of cutting the fascia at the point where the expan- sion goes off from the round tendon of the biceps. When tbe elbow-joint and forearm continue stiff after all inflammation is over, Mr. C. Bell recommends fric- tions with camphorated mercurial ointment, &c, and the arm to be gradually brought into an extended state by placing a splint on the forepart of the limb.—(Ope- rative Surgery, vol. 1, p. 65.) 6. Ill Consequences of a Wounded Nerve. Mr. Pott used to mention two cases in which the patients suffered distracting pains, followed by con- vulsions and other symptoms, which could only be as- cribed to nervous irritation, arising frdm a partial divi- sion of the nerve, and he recommended its total divi- sion, as a probable remedy. Dr. Monro related simi- lar cases in which such treatment proved successful. Hence, it is highly necessary to know the charac- teristic symptoms of the case, particularly, as all the foregoing cases would be exasperated by the treat- ment just now alluded to. It is to Mr. Abernethy that we are indebted for several valuable remarks elucidat- ing this subject. He informs us, that the two cutane- ous nerves are those which are exposed to injury. Most frequently all their branches pass beneath the veins at the bend of the arm; but sometimes, although the chief rami go beneath these vessels, many small filaments are detached over them, which it is impossi- ble to avoid wounding in phlebotomy. Mr. Abernethy thinks the situation of the median nerve renders any injury of it very unlikely. If, how- ever, a doubt should be entertained on this subject, an attention to symptoms will soon dispel it. When a nerve is irritated at any part between its origin and termination, a sensation is felt as if some injury were done to the parts which it supplies. If, therefore, the cutaneous nerves were injured, the integuments of the forearm would seem to suffer pain; if the median nerve, the thumb and next two fingers would be pain- fully affected. What are the ills likely to arise from a wounded nerve" If it were partially cut, would it not, like a tendon or any other substance, unite 1 It seems pro- bable that it would do so, as nerves as large as the cu- taneous ones of the arm are very numerous in various situations of the body, and are partially wounded in operations, without any peculiar consequences usually ensuing The extraordinary pain sometimes experi- enced in bleeding, may denote that a cutaneous nerve is injured. The situation of the nervous branches is such, that they must often be partially wounded in the operation, though they probably unite again, in almost all cases, without any ill consequences. Yet, says BLE Mr. Abernethy, it is possible that an inflammalion'of the nerve may accidentally ensue, which would be aggravated if the nerve were kept tense, in conse- quence of its partial division. The disorder, he thinks, arises from inflammation of the nerve in common with the other wounded parts. This gentleman supposes, i that an inflamed nejve would be very likely to commu- nicate dreadful irritation to the sensorium, and that a cure would be likely to arise from intercepting its communication with that organ. The general opinion is, that the nerve is only par- tially divided, and that a complete division would bring relief. Mr. Pott proposed enlarging the original orifice. It is possible, however, that the injured nerve may be under the vein, and if the nerve be inflamed, even a total division of it at the affected part would perhaps fail in relieving the general nervous irritation, which the disease has occasioned. To intercept the communication of the inflamed nerve with the senso- rium, however, promises perfect relief, £Utt object can only be accomplished by making a tran^Tse inci- sion above the orifice of the vein. The incision need not be large, for the injured nerve must lie within the limits of the original orifice, and it need only descend as low as the fascia of the forearm, above which all the filaments of the cutaneous nerves are situated. As the extent of the inflammation of the nerve is un- certain, Mr. Abernethy suggests even making a divi- sion of the cutaneous nerve still farther from the wound made in bleeding. Examples are recorded, in which not only extraor- dinary pain was occasioned by the prick of the lancet, but erysipelas of the skin, ending in gangrene of the whole limb, and the death ofthe patient.—(Richerand, Nosogr. Chir. t. 2, p. 390, ed. 2.) A case in which the greater part of the integuments of the arm had been destroyed by erysipelas thus produced, I once saw un- der the care of Mr. Vincent, in St. Bartholomew's Hos- pital. In former times, it was customary to refer many of the bad symptoms occasionally following venesection to a puncture of the tendon of the biceps; but this doctrine is now in a great measure renounced, the ex- periments of Haller having completely proved that tendons and aponeuroses are, comparatively speaking, parts endued with little or no sensibility. In the foregoing account, the various ill conse- quences occasionally arising from venesection are re- presented separately: no doubt, in some cases, they may occur together. See R. Butler's Essay concerning Blood-letting, ire. 8»». Land- 1734. M. Martin, Traite de la Phliboto- mie et de VArteriotomie, 8oo. Paris, 1741. Quesnay, Traite des Effets et de i Usage de la Saignee, \2mo. Paris. G. Vieusseux, Dela Saignee, etde son Usage dans la plupart des Maladies, 8vo. Paris, 1815. J. J. Walbaum, De Venasectione, Gott. 1749. (Haller, Disp. Chir. 5, 477.) B. Bell's System of Surgery. Essay on the ill Consequences sometimes following Venesection, by J. Abernethy. R. Carmichael on Va- rix and Venous Inflammation, in Trans, of Assoc. Physicians, vol. 2. Duncan on Diffuse Inflammation of the Cellular Membrane, in Edin. Med. Chir. Trans. mil. 1. Medical Communications, vol. 2. Ruber and, Nusogr. Chir. t. 2, p. 416, edit. 4. J. Hodgson en the Diseases of Arteries and Veins, 8vo. Jjond. 1815. B. Travers, in Surgical Essays, part 1, 8vo. Lond. 1818. Chapman, in Philadelphia Juurn. Feb. 1824. Freteau, sur VEmploi des Emissions Sanguinis, ire. 8vo. Pa- ris, 1816. Mapleson on the Art of Cupping, lUmo. Lond. 1813; and Dr. J. R. Johnson's valuable Trea- tise on the Medicinal Leech, including its Medical and Natural History, with a description of its Anatomi- cal Structure, and Remarks upon the JJiseases, Preser- vation, and Management of Leeches. 8vo. Lond. 181G. BLEEDING. See Hemorrhage and Arteries. BLENORRHAGIA, or Blenorrhvea. (From fiXtwa, mucus, and pio>, to flow.) A discharge of mucus. Swediaur. who maintains that gonorrhoea is attended with a mucous, and not a purulent discharge prefers the name of blenorrhagia for the disease. However, in treating of gonorrhu?a, we shall find, that this last appellation is itself not altogether free from objec- tions. BLEPHAROPTOSIS. (From fftiibapov, the eyelid, and irruois, a falling down.) Called also ptosis. An inability to raise the upper eyelid.—(See Ptosis.) BLI BOU 191 BLEPHAROTIS. An inflammation of the eyelids. BLINDNESS. This is an effect of many diseases of the eye. See particularly, Amaurosis; Cataract; Cornea, opacities of; Glaucoma; Gutta Serena, Hydrophthalmia; Leucoma; Ophthalmy; Pterygium; Pupil, closure of; Staphyloma, ^ c. BLISTERS. Applications which, when put on the skin, raise the cuticle in the form of a vesicle, filled with a serous fluid. Various substances produce this effect; but the powder of cantharides is what ope- rates with most certainty and expedition, and is now invariably made use of for the purpose. The blister plaster is thus composed : ft. Cantharidis in pulv. sub- tillissimum trita tbj. Emplastri cera tbiss. Adipis prap. Ibss. The wax plaster and lard being melted, and allowed to. become nearly cold, the powdered can- tharides are afterward to be added. When it is not wished to maintain a discharge from the blistered part, it is sufficient to make a puncture in the cuticle to let out the fluid; but when the case requires a secretion of pus to be kept up, the surgeon must remove the whole of the detached cuticle with a pair of scissors, and dress the excori- ated surface in a particular manner. Practitioners used formerly to mix powder of cantharides with an ointment, and dress the part with this composition. But such a dressing not unfrequently occasioned very painful affections of the bladder, a scalding sensation in making water, and most afflicting stranguries. An inflammation of the bladder, ending fatally, has been thus excited. The treatment of such complaints con- sists in removing every particle of cantharides from the blistered part, which is to be well fomented, and administering freely mucilaginous drinks. Camphor is now suspected to prove more hurtful than useful. These objections to the employment of salves, con- taining cantharides, for dressing blistered surfaces, led to the use of mezereon, euphorbium, and other irritat- ing substances, which, when iacorporated with oint- ment, form very proper compositions for keeping blisters open, without the inconvenience of irritating the bladder. The favourite application, however, for keeping open blisters is the powder of savine, which was brought into notice by Mr. Crowther, in the first edition of his book on the White Swelling. He was led to the trial of different escharotic applications in the form of ointment, in consequence of the minute attention which caustic issues demand; and, among other things, he was induced to try powdered savine, from observ- ing its effects in the removal of warts. Some of the powder was first mixed with white cerate, and applied as a dressing to the part that had been blistered ; but the ointment ran off, leaving the powder dry upon the sore, and no effect was produced. Mr. Crowther next inspissated a decoction of savine, and mixed the ex- tract with the ointment, which succeeded better, for it produced a great and permanent discharge. At last, after various trials, he was led to prefer a preparation analogous to the unguentuin sambuci P. L. The fol- lowing formula answers every desirable purpose : R. Sabinas recentis contusa Ibij. Ceraftavas Ibj. Adi- pis suilla Ibiv. Adipe et cera liquefacta, incoque sabinam et cola. The difference of this formula from that which Mr. Crowther published in 1797, only consists in using a double proportion of the savine leaves. The ceratum sabina? of Apothecaries' Hall, he says, is admirably made: the fresh savine is bruised with half the quan- tity of lard, which is submitted to the force of an iron press, and the whole is added to the remainder of the lard, which is boiled until the herb begins to crisp; the ointment is then strained off, and the proportion of wax ordered, being previously melted, is added. On the use of the savine cerate, immediately after the cuticle raised by the blister, is removed, it should be observed, says Mr. Crowther, that experience has proved the advantage of using the application lowered by a half or two-thirds of the unguentum cerse. An attention to this direction will produce less irritation and more discharge, than if the savine cerate were used in its full strength. He found fomenting the part with flannel wrung out of warm water, a more easy and preferable way of keeping the blistered sur- face clean, and fit for the impression of the ointment, than scraping the part, as has been directed by others. An occasional dressing of the unguentum resina? flava?, he found very useful in rendering the sore free from an appearance of slough, or rather dense lymph, which is sometimes so firm in its texture, as to be separated by the probe with as much readiness as ihe cuticle is detached after blistering. As the discharge diminishes, the strength of the savine dressing should be propor- tionally increased. The ceratum sabina? must be used in a stronger or weaker degree, in proportion to the excitement produced on the patient's skin. Some re- quire a greater stimulus than others for the promotion of the discharge, and this can only be managed by the sensations which the irritation of the cerate occasions. Mr. Crowther tried ointments containing the flowers of the clematis recta, the capsicum, and the leaves of the digitalis purpurea. The first two produced no ef- fect; the last was very stimulating. He also tried caustic potassa mixed with spermaceti cerate, in the proportion of one drachm to an ounce: it proved very stimulating, but produced no discbarge. One grain of the oxymuriate of mercury, blended with two ounces of the above cerate, proved so intolerably painful, that at the end of two hours it became necessary to remove the dressing; and the patient was attacked with a se- vere ptyalism.—(Practical Obs. on the White Swelling, &c.2d ed. 1808.) Instead of keeping a blister open, it is frequently a judicious plan to renew the application of the emplas- trum cantharidis, after healing up the vesication first produced, and to continue in this manner a succession of blisters, at short intervals, as long as the circum- stance of the case may demand. Where the skin is peculiarly irritable, and particularly in young chil- dren, where the emplastrum cantharidis sometimes acts so violently as to produce sloughing, or, in any cases, where the plaster produces strangury and irri- tation of the urinary organs, I aim informed, that the inconvenience may be avoided, and the cuticle raised very well, if a piece of silk paper be interposed be- tween the plaster and the integuments. Dr. A. T. Thomson recommends for the same purpose a piece of thin gauze wet with vinegar, and applied smoothly and closely over the plaster.—(Dispensatory, p. 717, ed. 2.) For infants, a proportion of opium has sometimes been added to the plaster, in order to render its action less violent; a proposal made, I believe, by the late Mr. Chevalier. Others recommend the plan of not letting the blister continue so long applied to children as to other patients.—(See Paris's Pharmacologia, vol. 2, p 186, ed. 5.) BOIL. See Furunculus BONES, Diseases of. See Antrum, Caries, Exos- tosis, ./units, Mallities, Necrosis, Osteosarcoma, Rick- ets, and Venereal Disease. The following works re lative to the pathology of the bones, deserve notice :— F. C. Spoendlt,De Sensibililate Ossium Morbosa,4to. Gott. 1814. A. Murray, De Sensibilitate Ossium Mor- bosa (Ludw. Script. Neur. 4). O. Murray, Diss. Acad, de Sensibilitate Ossium Morbosa. Frank. Del Op. 12. J. G. Sturmius, De Vulncribns Ossium Helmsl. 1743. A. Bonn, Tab. Ossium Morbosorum pracipue Thesauri Hoviani, fol. Amst. 1785—1788. C. F. Clossius, neber die Krankheiten der Knochen, 12/no. Tubing. 1799 A. G. Naumann, de Ostitide, 4to. Lips. 1818. R. Nesbitt, Human Osteogeny; two Lec- tures on the Nature of Ossification, 8vo. Lond. 1736. Sandifort, Museum Anatomicum Lugduno Batava De.scriptum, 2 vol. fol. Lugd. 1793. Weidmann, De Necrosi Ossium, fol. Francof. 1793. Brodie on Dis- eases of Joints, 8vo. Lond. 1818. Howship, in Med. Chir. Trans. Dr. Cumin, in Edin. Med. and Surgical Journ. No. 82; and various other publications speci- fied at the end of the article Necrosis. BOUGIE is a smooth flexible instrument which is introduced into the urethra for the cure of diseases of that passage (see Urethra); and is so named from its generally containing wax in its composition, and bear- ing some resemblance to a wax taper, in French, bou- gie. However, the kinds of bougies are various, and some of them employed in modern surgery', so far from having any simUitude to a wax taper, are formed altogether of metal. They admit of being divided into those which are solid, and others which are hollow, and are more commonly named catheters.—(See Ca- theter.) The exact period when bougies were first used, is a doubtful point in the history of surgery. By Andrew Lacuna, a Spanish physician, the invention is ascribed to a Portuguese empiric; and in 1551, the same author 192 BOtJGIE. published what had been communicated to him upon this subject In the year 1554, Amalus Lusrtanus pub- lished a work, hi which he refers to several witnesses to prove, that the empirical practitioner above alluded to, had learned from him the use of bougies, while on the other hand, he candidly owns, that he himself was indebted to Aldereto, of Salamanca, for a knowledge of these instruments. In 1553, however, Alph. Ferri, of Naples, endeavoured to show, that his acquaintance with the utility of bougies reached as.far back as 1548, and, of course, that he had anticipated Lacuna, and per- haps even Aldereto. But, instead of representing him- self as the original inventor of bougies, he mentions that they were known to Alexander of Tralles, which, if true, carries back the invention to the sixth century. A. Ferri, also before describing bougies and escharotic ointments, mentions various means of examining the state of the urethra, and, among other things, cylin- ders made of flexible lead and of different sizes. Es- charotic ointments for what were termed carnosities of the urethra, and bougies, were also described by Petro- nius in 1565, and afterward by A. Pare. The oldest bougies, which were wicks of cotton or thread, covered with wax and escharotic plasters, were in time suc- ceeded by those composed of linen smeared with wax. This change was made with the view of letting them have a hollow construction; an improvement which was first noticed by Fabricius ab Aquapendente.—(Op. Chir. 1617.) In the middle of the 17th century, the manner of making and using bougies was well known to Scul- tetus, as appears from his Armamentarium Chirurg. tab. 13,fig. 9, 10. The making of bougies has now become so distinct a trade, that it may besconsidered superfluous to treat of the subject in this Dictionary. However, though a surgeon may not actually choose to take the trouble of making bougies himself, he should understand how they ought to be made. Swediaur recommends the foUowing composition : ft. Cera? flava? Ibj. Spermatis ceti 3 iij. Cerussa? acetata? 3 v. These articles are to be slowly boiled together, till the mass is of proper consistence. Mr. B. Bell's bougie plaster is thus made: ft. Emplastri lythargyri \ iv, Cera? flava? 5 iss. Olei oliva? 3 iij. The last two ingredients are to be melted in one vessel and the litharge plaster in another, be- fore they are mixed. In Wilson's Pharmacopoeia Chi- rurgica, I observe this formula: ft. Olei oliva? ibiss. Cera? flava? Ibj. Minn Ibiss. Boil the ingredients to- gether over a slow fire till the minium is dissolved, which will be in about four or six hours. The compo- sition for bougies is now very simple, as modern sur- geons place no confidence in the medicated substances formerly extolled by Daran. The linen, which may be considered as the basis of the bougie, is to be im- pregnated with the composition, which is generally wax and oil, rendered somewhat firmer by a proportion of resin. Some saturnine preparation is commonly added, as the urethra is in an irritable state, and the mechanical irritation might otherwise increase it. Of whatever composition bougies are made, they must be of different sizes, from (hat of a knitting-kneedle to that of a large quill, and even larger. Having spread the composition chosen for the purpose on linen rag, cut this into slips from six to ten inches long, and from half an inch to an inch or more in breadth. Then dex- terously roll them on a glazed tile into the proper cylin- drical form. As the end of the bougie, which is first introduced into the urethra, should be somewhat smaller than the rest, the slips must be rather nar- rower in this situation, and when the bougies are rolled up, that side must be outwards on which the plaster is spread. Daran and some of the older writers, attributed the efficacy of their bougies to the composition used in forming them. On the contrary, Mr. Sharp appre- hended that it was chiefly owing to the pressure which was made on the affected part; and Mr. Aikin adds, that as bougies of very different compositions succeed equally well in curing the same diseases in the ure- thra, it is plain that they do not act from any peculiar qualities in their composition, but by means of some common property, probably their mechanical form. As the healthy as well as the diseased parts are ex- posed to the effects of bougies made of very active ma- terials, modern surgeons always prefer such as are made of a simple unirritating composition. Plenck recommended bougies of catgut, which may be easily introduced into the urethra, even when it is greatly contracted, their size being small, their sub- stance firm, and dilatable by moisture. Il is objected to catgut, however, that it sometimes expands beyond the stricture, and gives great pain on being withdrawn. Formerly, catgut bougies were sometimes coated with elastic gum, a valuable material, of which I shall next The invention of elastic bougies and catheterrorigin- ated with Bernard, a silversmith at Paris, who in the year 1779 presented some instruments of this kind to the Academy of Surgery, which period was prior to the claim made by Professor Pickel of Wurzburg to the discovery.—(See Journ. de Med. an 1785.) For the composition of bougies, elastic resin or gum is thought to be very desirable, as it unites firmness and flexibility. Mr. Wilson, in his Pharmacopoeia Chi- rurgica, is inclined to think that the art of making these instruments consists in finding a suitable solvent for the Indian gum. As this substance, if dissolved in ether, completely recovers its former elasticity upon the evaporation of this fluid, it is supposed that ether, though rather too expensive, would answer. I find it positively asserted, however, in a modem work of great repute, that the idea of elastic gum being the substance really employed is a mistake, as the material used is nothing more than linseed oil boiled for a considerable time, and used as a varnish for the silk, linen, or cotton tube.—(See Diet, des Sciences Med. art. Bougie.) Very cheap and good elastic gum bougies are made by Feburier, No. 51 Rue du Bac, at Paris, who has twelve different sizes. His elastic gum catheters are also well made, though for smoothness and regularity I think they are not equal to some which are now con- structed in London : but I believe Feburier's smallest size is rather less than any which are made in this city; an advantage which no doubt our artists will soon be able to give their productions. This ingeni- ous mechanic does not employ catgut in the composition of the elastic gum bougies, for which he is so cele- brated. These bougies are most excellent when you can get them to pass; for they dilate the stricture with the least possible irritation. But sometimes they can- not be introduced when a wax bougie can ; and from the trials which I have made of them, I conceive this arises from their elasticity and continual ten- dency to become straight when they reach the pe- rineum, so that the point presses on the lower surface of the urethra. Hence, when the obstruction is on that side, it must be very difficult to get the end of the bougie over it. A few years ago, Mr. Smyth discovered a metallic composition of which he formed bougies, to which some practitioners impute very superior qualities. These bougies are flexible, have a highly polished sur- face of a silver hue. and possess a sufficient degree of firmness for any force necessary in introducing them for the cure of strictures ofthe urethra. The advocates for the metallic bougies assert, that such instrument! exceed any other bougies which have yet been invented, and are capable of succeeding in all cases in which the use of a bougie is proper. They are either solid or hollow, and are said to answer extremely well as ca- theters ; for they not only pass into the bladder with ease, but may also be continued there for any conve- vient space of time, and thus produce essential benefit. —(W. Smyth, Brief Essay on the Advantages of Flex- ible Metallic Bougies, 8vo. Lond. 1804.) The greatest objection which has been urged against them is that they are attended with a risk of breaking, i' have heard of an eminent surgeon being called upon to cut into the bladder, in consequence of a metallic bougie having broken, and a piece of it passing into that or- gan, where it became a cause of the severe symptoms which are commonly the effect of a stone in the blad- der. For the particulars of an interesting case, in which a metallic bougie broke in the urethra, the read- er may consult London Med. Repository, vol 9, No. 51. The manufacture of metallic bougies, however, is now brought to such perfection, that though they are used to a great extent in modern practice, we rarely hear of their breaking; but it is most prudent not to be too bold with those of small diameter The bougie, with its application, says Mr. Hunter, ia perhaps one of the greatest improvements in surgery BRO Which these last thirty or forty years have produced. " When I compare the practice of the present day with what it was in the year 1750, I can scarcely be persuaded that I am treating the same disease. I re- member, when about that time I was attending the first hospitals in the city, the common bougies were either a piece of lead or a small wax candle; and although the present bougie was known then, the due preference was not given to it nor its particular merit understood, us we may see from the publications of that time." Daran was the first who improved the bougie and brought it i n to general use. He wrote professedly on the diseases for which it is a cure, and also of the manner of preparing it; but he has introduced much absurdity into his descriptions of the diseases, the modes of treat- ment, and the powers and composition of his bougies. When Daran published his observations on the bou- gie, every surgeon tried to discover the composition, and each conceived that he had found it out, from the bougies which he composed producing the effects de- scribed by Daran. It was never suspected, that any extraneous body of the same shape and consistence would do the same thing.—(See A Treatise on the Ve- nereal Disease, p. 116. Sharp's Critical Inquiry, rji. 4. Aikin on the External Use of Lead. Daran, Obs. Chir. sur les Maladies del'Uritre, 12mo. Paris, 1748 and 1768. Olivier, Leltre dans laquelle on dimontre les avantages que Von pent retirer de Vusage des bou- gies creuses,ic. 8oo. Paris, 1750. Desault, Jouin. de Chir. t. 2, p. 375, and t. 3, p. 123, 1792. Smyth's Brief Essay on Flexible Metallic Bougies, 8vo. Lond. 1804. Diet, des Sciences Midicales, t. 3,p. 265, i-c. 8vo. Pa- ris, 1812.) Of armed bougies, as well as of some other kinds, and of the manner of using bougies in general, I shall speak in the article Urethra, Strictures of. BRAIN. For concussion, compression of, Sec, see Head, Injuries of. For the hernia of, see Hernia Ce- rebri. BREAST. See Mammary Abscess; Mamma, Re- moval if; Cancer, i-c. BRONCHOCELE. (From (Spdyxos, the windpipe, and KrfXrt, a tumour.) The Swiss call the disease gotre or goitre. Heister thought it should be named tra- cheocele. Prosser, from its frequency in the hilly parts of Derbyshire, called it the Derbyshire neck; and not satisfied respecting the similitude of this tumour to that observed on the necks of women on the Alps, the Eng- lish Bronchocele. By Alibert the disease is called Thy- rophraxia. 1. The simple bronchocele or thyrophraxia is the most common form of the disease, and is a mere en- largement of the thyroid gland. The integuments covering the part are quite unchanged. Women are observed to be more subject to it than men. It is also well known to be in general free from danger, the office of the thyroid gland not being of such import- ance in the animal economy as to be essential to the continuance of life. Alibert has seen one example in which the tumour became cancerous, and destroyed the mother of a family. 2. The compound bronchocele is that which presents the greatest variety, and astonishes every beholder. Sometimes a more or less voluminous cyst is formed BRO 193 According to Prosser, the tumour generally begins between the eighth and twelfth years. It enlarges slowly during a few years; but at last it augments rather rapidly, and forms a bulky pendulous tumour. Women are far more subject to the disease than men. and the tumour is observed to be particularly apt to in- crease rapidly during their confinement in childbed. Sometimes bronchocele affects the whole of the thyroid gland, that is to say, the two lateral lobes and the in- tervening portion; and it is in this kind of case, that it is not unusual to remark three distinct swellings, for the most part of unequal size. Frequently only one lobe is affected ; while in many other cases the three portions ofthe thyroid gland are all enlarged and so con- founded together, that they make, as it were, only one connected globular mass. Finally, in some dissections the thyroid gland has been found quite unchanged, the whole of the tumour having consisted of a sarcomatous disease of the adjacent lymphatic glands and cellular membrane.—(Postiglione, p. 21.) When only one lobe of tbe thyroid gland is affected, it may extend in front of the carotid artery, and be lifted up by each diastole of this vessel, so as to have the pulsatory motion of an aneurism.—(A. Burns's Surgical Anatomy of the Head and Neck, p. 195, and Parisian Chirurgical Journ. vol. 2, p, 292,293.) Alibert believes that he first made the remark that the right lobe was more fre- quently enlarged than the left.—(Nosol. Nat. t. 1, p. 465.) The same thing was invariably noticed in every case seen by Mr. Rickwood in the neighbourhood of Horsham in Sussex.—(See Med. and Phys. Journ.for Aug. 1823.) The ordinary seat of bronchocele, as Flajani remarks, is the thyroid gland; but sometimes cysts are formed in the cellular membrane.—(Collez. d'Oss. t. 3, p. 277.) And Postiglione also observes, that the swelling is sometimes encysted, and filled with matter of various degrees of consistence, resembling honey, &c.; in some cases it is emphysematous, or filled with air; and in otherinstances it is sarcomatous, having the consistence of a gland, which is enlarged, but not scirrhous. These different characters prove, says he, that the treatment ought not to be the same in all cases.—(Mcmoria sulla Natura del Gozzo, p. 20.) Bronchocele is common in some of the valleys of the Alps, Apennines, and Pyrenees. Indeed, there are certain places where the disease is so frequent, that hardly an individual is totally exempt from it. Larrey, in travelling through the valley of Maurienne, noticed that almost all the inhabitants were affected with goitres of different sizes, whereby the countenance was deformed, and the features rendered hideous.—(Mem. de Chir, Mil. t. 1, p. 123.) And Postiglione remarks that in Savoy, Switzerland, the Tyrol, and Carintbia there are villages in which all the inhabitants without excep- tion have these swellings, the position and regularity of which are there considered as indications of beauty. — (Memoria sulla Natura del Gozzo, p. 22.) In many the swelling is so enormous, that it is impossible to conceal it by any sort of clothing. A state of idiotism is another affliction which is sometimes combined with goitre, in countries where the latter affection ib en- demic. However, all who have the disease are not idiots, or cretins, as they have been called; and in Switzerland and elsewhere it is met with in persons round it, filled with a pultaceous or purulent matter, who possess the most perfect intellectual faculties. Sometimes in compound bronchoceles, calcareous and When bronchocele and cretinism exist together, Fodert other heterogenous substances are found. In two cases Alibert found on the outside ofthe enlarged gland a yellow fatty mass; and in a third instance the gland itself formed a true sarcoma.—(Nosologic Naturelle. t. 1, p. 464, 465,/oZio, Paris, 1817.) The term bronchocele always signifies in this country an enlargement of the thyroid gland, which, with the disease of the surrounding parts, sometimes not only occupies all the space from one angle of the jaw to the other, but forms a considerable projection on each side of the neck, advancing forwards a good way beyond the chin, and forming an enormous mass, which hangs down over the chest. The swelling, which is more or less unequal, in general has a soft, spongy, elastic feel, es;>ecially when the disease is not in a very advanced state; but no fluctuation is usually perceptible and the part is exceedingly indolent. The skin retains nearlv its ordinary colour; but when the tumour is of very long standing and great siie, tbe veins of the neck be- come mure or less varicose. Vol. I.-N and several other writers ascribe the affection of the mind to the state ofthe thyroid gland.—(See Traiti sta- le Goitre et le Cretinisme, 8vo. Paris, an «.) However, this opinion appears to want foundation, since the men- tal faculties are from birth weak, and in many the idiotism is complete where there is no enlargement of the thyroid gland, or where the tumour is not bigger than a walnut, so that no impediment can exist to the circulation to or from the brain.—(Burns on the Sur- gical Anatomy of the Head and Neck, p. 192.) The direct testimony of Dr. Reeves also proves that in coun- tries where cretins are numerous many people of sound and vigorous minds have bronchocele.—(See Dr. Reeve's Paper on Cretinism, Edin. Med. and Surgical Journal, vol. 5, p. 31.) Hence, as Mr. A. Burns remarked, the combination of bronchocele and cretinism must be con- sidered as accidental; a truth that seems to derive con- firmation from the fact that in some parts of this country bronchocele is frequent, where cretinism is seldom or never seen. lUCLLK 194 BRONCU Bronchocele is not confined to Europe; it is met with in almost every country on the g obe. Professor Bar- ton, in his travels among the. Indians settled at Oneida in the state of New-York, saw the complaint in an old woman, the wife of the chief of that tribe. From this woman Barton learned that bronchoceles were by no means uncommon among the Oneida Indians, the com- plaint existing in several of their villages. He found also that the disease resembled that seen in Europe, in respect to its varieties. He did not indeed himself see the pendulous bronchocele which descends over the breast; but he understood that it was not uncommon among the women on the banks of the Mohawk river, who wore a particular dress for its concealment. In North America bronchoqele attacks persons of every age ; but it is most frequently seen in adults; a dif- ference from what is noticed in Europe. Bronchocele is said to be frequent in Lower Canada. Bonpland, the companion of Humboldt, informed Alibert that the disease was endemic in New Grenada, and that it.pre- vailed in such a degree in the little towns of Honda and Monpa, on the banks of the Magdalen river, that scarcely any of the inhabitants were free from it. The blacks and those who led an active, laborious life, how- ever, are reported to escape the complaint. Some of the natives of the isthmus of Darien are said to be ter- ribly disfigured by it.—(Alibert, Nosol.Nat. t. 1, p. 469. Also, Observations sur quelques phinomines peu con- nus qu'nffre le goitre sous les tropiques, dans les plaines et sur les plateaux des Andes, par A. de Hum- boldt, in Journ. de Physiologie par F. Magendie, t. 4, p. 109, Paris, 1821.) In European women bronchocele usually makes its appearance at an early age, generally between the eighth and twelfth year, and it continues to increase gradually for three, four, or five years, and is said sometimes to enlarge more during the last half year than for a year or two previously. It does not gene- rally rise so high as the ears, as in the cases mentioned by Wiseman. Sometimes, however, this happens, as we see in the case of Clement Desenne, of whom Ali- bert has given an engraving. In this patient, a part of the tumour, as large as a hen's egg, projected into the mouth.—(Nosol. Nat. t. 1, p. 466.) The swelling extended from the ears to the middle of the breast. A seton produced a partial subsidence of it; but when it was withdrawn the orifices closed. After two years more, the swelling became painful, suppuration look place, and fifteen pints of matter were discharged; and six ounces every day after the swelling had burst, came away with the dressings for three months; but, notwithstanding all this suppuration, and more after- ward, the tumour was only partially lessened. The disease, mostly has a pendulous form, not unlike, as Albucasis says, the flap or dewlap of a turkey-cock, the bottom being the largest part of the tumour. Ali- bert mentions a case in which the swelling hung down to the middle of the sternum, and the large mass, which was quite a burden to the patient, used to become hard and, as it were, frozen in very cold weather. This author, however, cannot be right, when he adds, that it was an inert body, destitute of vitality '.—(Nosol. Nat. t. 1, p. 466.) In another curious instance, the tumour formed a long cylinder which reached down to the mid- dle of the thigh, the diameter becoming gradually smaller downwards.—(P. 468.) The common seat of bronchocele is the thyroid gland; but frequently the surrounding cellular membrane is more or less thick- ened, and contributes to the swelling. Sometimes also the neighbouring lymphatic glands are affected, when its base is widened and extends from one side of the neck to the other. In this circumstance, the swelling gradually loses itself in the surrounding parts, and is not circumscribed as in ordinary instances.—(Postig- lione, Mem. sulla Natura del Gozzo, p. 20.) It is soft, or rather flabby to the touch, and somewhat moveable; but after afew years, when it has ceased enlarging, it becomes firmer and more fixed. .When the disease is very large, it generally occasions a difficulty of breathing, which is increased by the patient's catching cold or attempting to run. In some subjects the tu- mour is so large, and affects the breathing so much, that aloud whizzing is occasioned; but there are many- exceptions to this remark. Sometimes when the swell- ing is of great size, patients suffer very little inconve- nience ; while others are greatly incommoded, though the tumour is small. In general tha inconvenience is trivial The voice is sometimes rendered hoarse, and in particular cases the difficulty of speech is ver> con- siderable.—(See Flajani, Collez. d'Oss. t. 3,p. 271.) The difficulty of respiration, produced by the pressure of the tumour and the enlargement of other glands, as this author remarks, is the most dangerous effect of the disease, since by disordering the pulmonary circu- lation, it renders the pulse irregular and intermittent, and a strong throbbing is excited in the region of the heart, followed by fatal disease ofthe lungs themselves; consequences often not suspected to have any connexion with the bronchocele, though it is in reality the imme- diate cause of them.—(Vol. cit. p. 278.) The causes of bronchocele are little known. To the doctrine that bronchocele is caused by the earthy im- pregnation of wjiter used for drink, the following ob- jections offer themselves: 1. The water of Derbyshire, in districts where this disease is considered endemic, contains much supercarbonate of lime; but that in common use about Nottingham, where the disease is also prevalent, is impregnated with sulphate of lime. However, that the disease is not produced by water impregnated by sulphate of lime is evident; for, as Ali- bert observes, the waters of saint Jean, Saint s'nlpice, and Saint Pierre, where bronchocele is frequent, contain much less of this earth than the waters of Upper Mau- rienne, where the disease is hardly ever noticed, though the houses are built upon a vast quarry of gypsum. Tne same fact was observed by Bonpland in New Grenada. —(Nosol. Nat. t. 1, p. 471.) Nor, as Fodere explained, can the cause ofthe disease be correctly referred to the use of any particular kind of food. Certain localities, however, seem to contribute to its frequency ; for this author observes, that the disease is not prevalent in very high places nor in open plains; but that it be- comes more and more common as we descend into deep valleys made by torrents, where there is a good deal of marsh, and abundance of fruit-trees. The air is here constantly humid. 2. Abstinence from un- boiled water does not diminish or interrupt the gradual progress of the disease. 3. Patients are cured of the disease, who still continue to drink water from the same source as before, without taking any precaution, as boiling, &c. 4. The disease in this country is less frequently found among men. 5. Many instances may be related of a swelling in the neck, sometimes very painful, and generally termed bronchocele, being pro- duced very suddenly, by difficult parturition, violent coughing, or any other unusually powerful effort.— (See Edin. Med. and Surgical Journ. vol. 4, p. 279.) When the gland is suddenly enlarged during a violent exertion, the distention is said to be produced by the passage of air from the trachea into the substance of the thyroid gland and surrounding cellular membrane. But whether this statement be a fact or not, it is un- questionably true, that in many patients the tumour always increases when they speak loud, sing, or make any effort.—(Flajani, Collez. d'Oss. Sc. t. 3, p. 276; and Postiglione, p. 24.) The disease is sometimes seen in scrofulous subjects ; but there is every reason to believe that it is quite independent of the other dis- order, as Prosser, Wilmer, and Kortum have particu- larly explained. The following are some points of difference between bronchocele and scrofula, as indi- cated by Dr. Postiglione. 1. The true bronchocele is simply a local disease of the neck, the constitution being unaffected. On the contrary, scrofula extends its effects to the whole system, attacking not only the lymphatic glands, but also the muscles, cellular mem- brane, ligaments, cartilages, and hones. 2. Both dis- eases chiefly occur in young subjects; but bronchocele often begins at a later age than scrofula, and does not, like the latter, spontaneously disappear as the patient approaches puberty and gains strength. 3. Scrofulous glands often suppurate and ulcerate; bronchocele rarely undergoes these changes. 4. The thickening of the upper lips of scrofulous subjects is not an attendant on bronchocele; and while the former patients generally enjoy their mental faculties in perfection as long as they live, the latter disease in certain countries is often joined with cretinism. Scrofula is likewise always hereditary, while bronchocele is not so; no healthy persons become scrofulous by living a long while among scrofulous patients, but many individuals con- tract bronchocele by going from a country where this disease is unknown, and taking up their residence in places where it abounds. 5. Nature alone often curea BRONCHOCELE. 195 scrorula, while art is rarely successful; on the con • trary, bronchocele is seldom cured by nature, but very frequently by art. 6. The muriate of lime, recommended by Fourcroy for the cure of scrofula, is always useless; but in bronchocele it proves a valuable remedy.— (Postiglione, Memoria sulla Natura del Gozzo, i-c. p. 25.) The error of confounding bronchocele with scrofula is now generally acknowledged. At the Hos- pital St. Louis, says Alibert, scrofulous patients are numerous, while those with bronchocele are very rare. (Nosol. Nat. t. 1, p. 465.) In Derbyshire, Genoa, and Piedmont, bronchocele has been attributed to drinking water cooled with ice. To this theory many of the objections concerning the earthy impregnation of water stand in full force ; with this additional reflection, that "in Greenland, where snow-water is commonly used, these unsightly protuberances are never met with, nor (says Watson) did I ever see one of them in Westmore- land, where we have higher mountains and more snow than in Derbyshire, in which country they are very common. But what puts the matter beyond a doubt is, that these wens are common in Sumatra, where there is no snow during any part of the year."—(Wat- son's Chemical Essays, vol. 2, p. 157.) The above opinion was also refuted by Fodere, who remarks, that the Swiss who reside at, the bottom of the glaciers are the least subject to the disease. Bronchoceles are also said to be unknown in Lapland. Respecting the influence of particular water in bringing on the disease, Dr. Odier gives credit to the opinion, because it has appeared to him that distilled water prevented the increase of the tumour, and even tended to lessen its bulk.—(See Manuel de Midecine Pratique, 8vo. Genev. 1811.) However, that every ex- planation hitherto devised of the causes of broncho- cele is quite unsatisfactory, is fully proved by the ob- servations of the celebrated Humboldt. Persons af- flicted with bronchocele (he remarks) are met with in the lower course of the Magdalen river (from Honda to the conflux of the Cauca); in the upper part of its course (between Neiva ana Honda); and on the flat high country of Bogota, six thousand feet above the bed of the river. The first of these three regions is a thick forest, while the second and third present a soU destitute of vegetation; the first and third are exceed- ingly damp, the second is peculiarly dry; in the second and third regions, the winds are impetuous; in the first the air is stagnant. To these striking differences, we will add those relative to temperature. In the first and second regions, the thermometer keeps up all the year between 22 and 33 centigrade degrees; in the third, between 4 and 17 degrees. The waters drunk by the it.habitants of Mariquita, Honda, and Santa Fe de Bo- gota, where bronchoceles occur, are not those of snow, and issue from rocks of granite, freestone and lime The temperature of the waters of Santa Fe and Mom- pox, drunk by those who have this disease, varies from nine to ten degrees. Bronchoceles are the most hideous at .Mariquita, where the springs which flow over gra- nite are, according to my experiments, chemically more pure than those of Honda and Bogota, and where the climate is much less sultry, than upon the banks ofthe Magdalen river. Perhaps it may be thought that the atony of the glandular system (?) depends less upon the absolute temperature than upon the sudden refri- geration of the atmosphere, the difference of tempera- ture in the night and day; but in the Magdalen valley, where the constancy of low tropical regions prevaUs, the extent of the scale that the thermometer pervades in the course of the whole year, is only a small num- ber of degrees. Sec.—(Humboldt, in Journ. de Physi- ologic par F. Magendie, t. 4, p. 116.) The same distinguished observer confirms previous accounts of the variety of bronchoceles among the original copper-coloured natives of America and ne- groes. It appears, also, that in South America bron- chocele is progressively extending itself from the lower provinces to tha flat elevated regions of the Cordilleras; and this in so serious a degree that in 1823 the subject was adverted to in a report made to Congress by M. Restn-ppo. one of the Colombian ministers. An observation lately made by an intelligent writer would lead one to conclude, that cretinism depends upon malformation of the head. Speaking of goitre, as it appears among the inhabitants of the valley of Maurieiine, Baron Larrey informs us, that in many of these people, with this fr ghtful deformity is joined that V A of the cranium, of which the smallness and excessive thickness are especially remarkable.—(Mem de Chir. Milit. 1.1, p. 123.) Dr. Leake thinks that tumours of this sort may be owing to the severity of the cold damp air, as they generally appear in winter, and hardly ever in the warm dry climates of Italy and Portugal. The latter part of the observation, however, is not cor- rect, for Doct. Postiglione, and other Italian writers, assure us that the disease is extremely common in some of the warmest parts of Italy. " Qui in Napoli, e per tutto it regno, si veggono molt gozzuti, mat non in numero tale, come in Casoria, ed in pochi altri villaggi." —(P. 21.) Prosser is inclined to consider the broncho- cele as a kind of dropsy of the thyroid gland, similar to the dropsy of the ovary; and he mentions that Dr. Hunter dissected one thyroid gland which had been considerably enlarged, and contained many cysts filled with water. These, he erroneously concludes, must have been hydatids. Dr. Baillie remarks, that when a section is made ofthe thyroid gland affected with this disease, the part is found to consist of a number of cells containing a transparent viscid fluid. In all probability the ordinary bronchocele is entirely a local disease, patients usually finding themselves in other respects perfectly well. The tumour itself fre- quently occasions no particular inconvenience, and is only a deformity. There is no malignancy in the dis- ease, and the swelling is not prone to inflame or sup- purate, though, as Dr. Hunter remarks, abscesses do occasionally form in it. Alibert's case of bronchocele becoming cancerous is singular. Mr. Gooch never knew life to be endangered by this sort of tumour, however large ; a remark very much at variance with the observations of some other practitioners ; but he had seen great inconvenience arise from it when com- bined with quinsy. In fact, the pressure of a large bronchocele may not only greatly afflict the patient, by rendering respiration difficult, but actually cause death by suffocation.—(See Obs. sur un Goitre volumineux, comprimant la Trachee-artire; par L. Winslow, in Bulletin de I'Athinie de Med. ic.) " Some persons, as Alibert remarks, have the disease all their lives without suffering any inconvenience from it; some ex- perience a suffocating oppression of the breathing; and in others there is an impediment in the circulation, and a tendency to apoplexy, arising from the strangu- lation which afflicts them."—(Nosol. Nat. t. 1, p. 466.) Dr. Hunter says, that the bronchocele frequently ap- pears two or three years before or after the commence- ment of menstruation, and that it sometimes sponta- neously disappears, when this evacuation goes on in a regular manner. Mr. A. Burns affirms the same thing. On the contrary, according to Prosser, this change in the constitution hardly ever affects the tumour. TREATMENT OF BU0NCH0CKLE. That certain localities, perhaps not yet correctly un- derstood, contribute to the origin of this disease, is well proved by a fact stated by Alibert, viz. that change of air has more effect on the complaint than medicines, as he has known many Swiss ladies who came to Paris with bronchoceles, in whom the tumour subsided after they had resided some time in that city.—(Nosol. Nat. t. 1, p. 473.) A blister, kept open, has put a stop to the growth of the tumour; but this method is not much fol- lowed at present, as better plans of treatment have been discovered. A few years ago the favourite mode of curing bronchocele consisted in giving internally burnt sponge, and occasionally a calomel purge, at the same lime that frictions were made upon the tumour itself. The utility of burnt sponge in the treatment of bronchocele, as Dr. Coindct and* others have now fully proved, depends upon the iodine in its composition. The efficacy of burnt sponge was thought to be great- est, when exhibited in the form of a lozenge composed of ten grains of this substance, ten of burnt cork, and the same quantity of pumice-stone. These powders were made into the proper form with a little syrup, and the lozenge was then put, under the tongue and allowed to dissolve. To the latter circumstance much impor- tance was attached. Some practitioners gave a scruple of burnt sponge alone, thrice every day, while others added a grain of calomel to each dose. A purge of ca- lomel was ordered about once a week or fortnight, at long as the patient persevered in the use of the cal- cined sponge ; but when mercury was combined with 196 BRONCHOCELE. ach dose of this medicine, no occasional purgative was deemed requisite. External means may very materially assist the above internal remedies. Frequently rubbing the swelling with a dry towel; bathing the part with cold water; rubbing the tumour two or three times a day with the liq. amnion, acet. or the camphor liniment; are the best steps of this kind which the surgeon can take. " In the treatment of bronchocele," says Mr. A. Burns, " repeated topical detraction of blood from the tumour is highly beneficial. Electricity also has sometimes a marked effect; but there is no remedy which I would more strongly advise, than regular and long-continued friction over the tumour. By perseverance in this plan, a bronchocele, treated in London, was materiaUy re- duced in the course of six weeks. Its good effects I have likewise witnessed myself; and it is a remedy highly recommended by Girard in his ' Traite des Loupes' It has also been much used in scrofulous tu- mours by Mr. Grosvenor of Oxford, and by Mr. Rus- sell of Edinburgh.—(Surgical Anatomy of the Head and Neck, p. 204.) Mr, A. Burns recommends the friction to be made with flannel covered with hair-powder, and the part to be rubbed at least three times aday, for twenty minutes. In two cases of bronchocele related by Dr. Clarke, the patients were cured by " the steady use of the compound plaster of ammoniac and mercury, con- joined with the internal exhibition of burnt sponge and occasional purgatives."—(See Edin. Med. and Surgical Journal, vol. 4, p. 280.) We learn from Professor Odier, that, in Geneva, bron- chocele used to be cured by burnt sponge exhibited in powder or infused in wine, and combined with purga- tives to prevent the cramps ofthe stomach, which some- times accompany the disappearance of the swelling. Muriate of barytes has likewise been recommended.— (See Manuel de Midecine Pratique.) Mr. Wilmer, credulously imputing great influence to the changes of the moon, used to begin with an emetic the day after the fuil moon, and to give a purge the ensuing day. The night following and seven nights successively he directed the above-mentioned lozenge to be put under the tongue at. bedtime, and adminis- tered every noon a bitter stomachic powder. On the eighth day the purge was repeated, and in the wane of the succeeding moon, the whole process, except the emetic, was renewed.—(Cases in Surgery, Appendix.) This, which is often called the Coventry plan of treat- ment, is said to be greatly assisted by rubbing the tu- mour with an ointment containing tartar emetic. Prosser succeeded with his medicines, though the patient was nearly twenty-five years old, and the swell- ing had existed more than twelve years. It is said, that no instance of cure has been known after the pa- tient was twenty-five. Prosser orders one of the fol- lowing powders to be taken early in the morning, an hour or two after breakfast and at five or six o'clock in the evening, every day, for a fortnight or three weeks. The powder may be taken in a little syrup or sugar and water: ft. Cinnab. ant. op. levigat. milleped. ppt. et pnlv. aa gr. xv. Spong. calcin. 3j. M. These powders should be taken for two or three weeks, and then left for a week or nine days before a repeti- tion. At bedtime every night, during the second course of the powders, some purgative pUls composed of mer- cury, the extractum colocynthid. comp. and rhubarb, are to be administered; and in general it will be proper to purge the patient with manna or salts, before be- ginning with the powders. Prosser put no faith in external applications. Some have recommended giving two scruples of calcined egg-shells every morning, in a glass of red wine; half a drachm of the sulphuret of potash every day dissolved in water; or ten or fifteen drops of the tinct digit, twice a day, the dose being gradually in- creased Muriated barytes, cicuta, and belladonna have also been exhibited. Postiglione commends the muriate of Ume as a medicine possessing great effi- cacy The remedy is made in a bolus with honey, to which is sometimes added burnt sponge, with cinna- mon in powder. He employs also frictions with flan- nel, liniments, and sometimes purges with calomel. The bolus is placed under the tongue, and allowed to dissolve there.—(P. 59, i-c.) Sir J. Wylic, physician to the emperor of Russia, prescribes three grains of the submuriate of mercury, three ofthe ammoniacal muriate of iron, four of burnC suon-'e, and ten of ihe bark of laurus cassia, divided iri'o Twelve doses, one of which is given twice a week with a gentle anodyne at night. He also directs twenty- four lozenges to be made, by triturating an ounce of burnt sponge with an equal quantity of the powder-of euin arabic, and fifteen grains of cinnamon, first blended with a sufficient quantity of the syrup of orange-peel. One of these lozenges is put under the tongue daily and allowed to dissolve there. Lastly, to the lumour itself he applies a piaster composed of half an ounce of litharge, a drachm of the submuriate of mercury, and 10 grains of antim. tartanz^—(Alibert, Nosol. Nat. t. 1, p. 474.) . , „ • The virtues of burnt sponge in the cure of certain forms of bronchocele are now ascertained to be owing to the iodine which it contains. Iodine was discovered in 1813 by Courtois, manufacturer of saltpetre at Paris; but six years elapsed before it was tried as a medicine. From the first memoir of Dr. Coindet, addressed in 1820 to the Helvetian Society of Natural Sciences, if appears, that as he was searching for a formula in the work of Cadet de Gassicourt, he found that Russel had recommended the ashes of the fucus vesiculosus, or bladder wrack, under the name of a?thiops vegetabilis, for the cure of bronchocele; and he was led from ana- logy between this substance and burnt sponge, so long celebrated for its efficacy in the treatment of broncho- cele, to suspect that iodine was the active principle of both. " The great and uneqnalled success which re- sulted from its use in the treatment of bronchocele, at once indicated the power of iodine as a therapeutic agent, and encouraged Dr. Coindet to pursue his re- searches in rendering it an efficient article of the ma- teria medica; and about tbe close of the same year, when Dr. Coindet had employed iodine in treating goitre for six months at least, his conjecture was confirmed by the discovery which Dr. Fyfe of Edinburgh made, that this substance was actually contained in the ashes of the burnt sponge," &c. " It has been generally understood among the pro- fession, that the happy conjecture which introduced iodine into medica) treatment, originated with Dr. Coin- det, of Geneva; yet we find that his claim to this ho- nour is disputed by one of his countrymen, Dr. J. C. Straub, of Hofwyl, in the canton of Berne. Dr. Straub, whose communication is found in Pro- fessor Meisner's Physical Intelligence of the General Helvetian Society for 1820, states, that before the dis- covery of iodine, attempts had been made to compound a substitute for burnt sponge, but without success; and that this failure and his observation of the simi- larity of smell between iodine, burnt sponge, and other marine productions, led him to suspect the existence of iodine or its salts in these substances, and that its absence in the artificial compounds was the cause of failure in these experiments. This conjecture, which appears to have been made previously to 1819, led Dr. Straub to examine the real burnt sponge, and he in- forms us, that though his time did not permit him to ascertain exact quantities, yet he obtained from IJ oz. of burnt sponge as much iodine as to render his con- jecture probable, and to be astonished that the ingre- dient should have escaped notice. He was therefore at once induced to think of its use in medicine; and in the same paper from which we obtain these facts, im- pressed with the poisonous quality ascribed by Orfila to iodine, he recommended first the trial of its salts, especially the hydriodates of soda and lime, and then that of the substance itself. The communication of Dr. Straub is dated Dec. 1819, and was actually published in Professor Meis- ner's periodical work in February, 1820, five months at least before the first memoir of Dr. Coindet was communicated to the Helvetian Society of Natural Sciences at Geneva. It is unnecessary to have re- course to any supposition of injustice done to Dr. Straub; much less would it be right to deprive Dr. Coindet of the merit of originality in substituting the direct and certain action of iodine, for the irregular and sometimes inert qualities of burnt sponge in the treat- ment of goitre. Coincidence of this kind is not uncom- mon in science; in the present instance, the inge- nuity of Dr. Straub does not diminish the merit of Dr, Coindet."—(See Edin. Med. and Surg. Journal, No. 80, p. 210, i-c.) That iodine is a medicine of considerable efficacy in BRONCHOCELE. 197 bronchocele, nat a doabt can be entertained, after the many cases now recorded in proof of the fact; and that it will be found useful in some other chrome tu- mour*, especially those of a scrofulous nature, seems highly probable,' if such probability be no already con- verted into certainty. In bronchocele, friction with the ointment on the swelling may often be advanta- geously conjoined with the use of one of the prepa- rations for internal exhibition. In the Archives G.n rales de Midecine for July, 1823, Dr. Coster mentions the opportunity which he had had of remaining eight months at Geneva with Dr. Coin- det, and of observing correctly the good effects of iodine in enlargements ofthe thyroid gland and in scrofulous tumours. Dr. Coindet first of all employed this medi- cine under the form of alcoholic tincture, and obtained very surprising effects from its administration in goi- tre. He next tried friction on the tumour itself with an ointment composed of the hydryodate of potass and lard; and the success of this practice was so great,that of nearly one hundred individuals affected with goitre, whose cases Dr. Coster collected, more than two-thirds were com- pletely cured by it. Soon after these successful results, iodine was employed sometimes internally and some- times in the form of friction in scrofula. " I shall not affirm (says Dr. Coster) that success was as uniform in the latter as in the former disease, but it is certain, that scrofulous tumours yield sooner to the action of iodine than to that of any other remedy at present known: when the tumours, whether of the thyroid gland, or of the lymphatic glands, are hard and reni- tent, experience proves, that the effects of iodine are much more prompt when the frictions are preceded by the application of leeches and a low regimen. Not- withstanding these precautions, however, the tumour sometimes continues stationary." In such a case, Dr. Coster put the tumour twice a day, for ten or twelve minutes, under the influence of the positive pole of the voltaic pile, taking care to change sides each time of using it; so that, in the morning, he made use of fric- tion with iodine on the right side and the action of the pile on the left, and in the evening applied the friction to the left side and the galvanism to the right. In twenty days not the least trace of the bronchocele was left. It is stated, that in this instance, the voltaic pile, unassisted with the frictions of iodine, was as ineffec- tual as the friction by itself had been. By the inter- nal and external use of iodine, I lately dispersed a bronchocele which had formed in the neck of a young lady, aged about 12, who was brought to my house by my neighbour Mr. Blair. The disease began to diminish in loss than a week from the commencement of the treatment, and in six weeks the cure was complete. An interesting case, in which a similar plan was at- tended with success, is recorded by Dr. Roots.—(See Med. Chir. Trans, vol. 12, p. 810.) Another instance of its decided efficacy is reported by Dr. Barlow, of Bath (see Edin. Med. Journ. No. 79, p. 337); but who- ever wishes to have a large and convincing body of evidence on this point, should consult the cases and observations published byDr. Manson, of Nottingham, where bronchocele is said to be endemic. He gives the results of one hundred and twenty cases of bron- chocele in which he administered iodine. Fifteen were in males, and one hundred and five in females. When the disease was complicated with diseased lymphatic glands, the thyroid gland first yielded and then the others. In the fourth case a scrofulous swelling of the foot yielded during the use of iodine. Ofthe hundred and twenty cases referred to, eighty-seven were cured, ten much relieved, and only two or three discharged without relief. —(See Manson's Medical Researches on the Effects of Iodine in Bronchocele, Paralysis, Chorea, Scrofula, Fistula Lachrymalis, Deafness, Dysphagia, White Swellings, and Distortions of the Spine. Lond. 1825.) Some farther notice of this gentleman's prac- tice, as well as the results of Mr. Buchanan's expe- rience will be taken in the articles Ear, Iodine, Joints, Scrofula, Vertebra, Sc. For the preparation and doses of Iodine, see this word. In south America, a remedy for bronchocele called aceyte de sal, was found, by M. Roulin, to contain a proportion of iodine.—(See Magendie, Journ. de Physi- ologie, t. 5, p. 273.) The same gentleman has also proposed the trial of chlorine, or the free hydro-chloric Petit, lK-istcr, and S.-hmucker make mention of in- veterate bronchoceles which gradually subsided in consequence of suppuration. Volpi states, that such ulcerations are not unfrequent He has published two facts of this kind which occurred after a nervous fever; and he records a third case, where the swelling in flamed in consequence of a blow, suppurated, and sloughed so as entirely to disappear.—(See Leveill , Nouvelle Doctrine Chir. t. 4, p. 128.) A similar fact is recorded by Zipv.TJSiebold, Samml. Chir. Beob. b 2, p. 229.) The disease in its inveterate form has also been sometimes removed by the application of caustic (Mes- ny in Journ. de M decine, t. 24, p. 75; Timaus, Cos. p. 283); the estabUshment of issues (Jeitteles, Obs. Med.); the making of an incision into the swelling, or the introduction of a seton through it.—(Foderi, Essai sur le Goitre et le Cretinage, p. 75 ; Klein, in v. Sie- bold, Sammlung Chir. Beobacht, b. 2, p. 11; Flajani, Collezione d'Osservazioni di Chirurgia, t. 3, p. 283.) Bronchoceles have sometimes been removed by the part having been accidentally or purposely burnt to a considerable depth (Motte, in Blegny, Zodiac, ann. 2 Febr. Obs. 11; Severinus de Efficaci Medicina,p. 220.) The disappearance of bronchoceles has also been known to follow a wound.—(Schmidmuller uber die Ausfuhrungsgange der Schilddruse, p. 37, Landshut, 1M)5.) A. Burns sometimes employed blisters, and found them useful.—(Surgical Anatomy of the Head and Neck, p. 204.) With respect to caustic, which is spoken of by Celsus (lib. 7, cap. 13), Flajani states, that its operation is tedious and painful, and attended with danger; and what he says about the practice of an incision is not more encouraging. When the disease contains a cyst, he prefers making an opening with a trocar, though he confesses that this plan is apt to be followed by a relapse, when the cyst is very thick and hard; in which circum- stance, it will be necessary to have recourse either to an incision or the seton, for the purpose of ex- citing suppuration. Should the disease, however, be merely composed of one cyst of moderate size, Fla- jani recommends its entire removal. " Of all these methods (says he) proposed for the extirpation of bron- choceles, the seton is *le least dangerous, and by means of it a radical cure may be generally effected without any severe symptoms, as I have found by ex- perience in many cases. On the contrary I have been an eye-witness of the fatal consequences induced by the other plans. I was called to assist a gentleman, about forty years of age, brought to death's door by a bleeding, which arose from the application of caustic to the forepart of the neck. As tourniquets, bandages, &c. proved quite ineffectual, it was indispensable to make pressure on the part with the finger of an assist- ant, for twenty-four hours, ere the hemorrhage could be stopped; a copious suppuration ensued; and it was three months before the parts were healed. I was likewise present (says he) at the opening of a similar, but larger swelling in the same situation, the disease having afflicted an elderly respectable patient for seve- ral years. The incision caused the evacuation of a small quantity of serum, contained in the cellular mem- brane ; but the following day the tumour inflamed, the difficulty of respiration increased, and for some days the patient was in great danger. At length suppuration was established, followed by a destruction of a great deal ofthe cellular membrane and several sinuses, and in five months the patient lost his life. On examina- tion of the body, the lungs were found tuberculated, an effect of the impediment to the circulation of the blood through the smaller vessels of those organs."— (Flajani, Collezione d'Osserv. t. 3, p. 283, Sua. Roma, 1802.) The first proposer of the employment of setons for the cure of diseases of the thyroid gland, is perhaps not exactly known; but it is certain that the method has been known, and occasionally practised, ever since the middle of the last century. " Dr. Monro, senior, (as a well informed writer has observed) mentions in bis lectures that he has seen a dropsy in the centre of the gland, complicated with bronchocele, cured by a seton, although the glandular swelling stUl continued." —(A. Burns on the Surgical Anatomy of the Head and Neck, p. 191.) This statement is given on the authority of some MS. notes taken by Dr. Brown, from Dr. Monro's lectures. According to Girard, many cases iu his time had been communicated tu the Ro>al 198 BRONCHOCELE. Academy of Surgery at Paris, in which the disease had been got rid of either by means of a seton, drawn through the swelUng, or the application of an issue.— (Lupiologie, He. 8vo. Paris, 1775. The occasional success of setons was also adverted to by Richter in the year 178/8.—(Bibliothek, b. 9, p. 478.) And the plan is spoken of in another work, published in 1790, as be- ing eligible where the disease is conjoined with a cyst. — .Encyclopedic Mithod. partie Chir. t. 1, p. 231.) The practice was particularly noticed by Fodere in his valuable treatise on bronchocele; and Alibert mentions the seton as being used at the Hospital St. Louis — (Nosol. Nat. t. 1, p. 466, fol. Paris, 1817.) In November, 1817, Dr. Quadri, of Naples, tried this practice, which he erroneously supposed to be quite new. " By means of a trocar-pointed needle, six and a half inches long, I passed (says he) a seton from above downwards through the gland, at the depth of about four lines from its surface. Suppuration took place in forty-eight hours. On the 18th of November the seton escaped, when the matter was squeezed out; and the irritation occasioned by replacing it, produced an abscess on the right side of the neck, which was opened on the 23d, when it was found that the suppu- ration had effected the destruction of nearly the whole gland." The woman, who was thirty-six years of age, was seen by Dr. Somerville, in AprU, 1818, with the circumference of her neck lessened, from sixteen to thirteen inches, French measure. In another case referred to, a seton was passed through each side of the thyroid gland, and the result was a removal of the tumour on the side where the seton was maintained long enough; but on the opposite side the seton being withdrawn too early, the matter collected in a sac; and at the end of four months a sinus and discharge still continued, the patient refusing to have a counter opening practised. When the seton does not prove stimulating enough, Dr. Quadri sometimes enlarges it, or attaches to it escharotic or irritating substances. He also frequently uses two setons. In one example, in endeavouring to perforate the gland rather deeply, Dr. Quadri appears to have injured the larger branches of the thyroid arteries, as more than an ounce of blood was discharged, and the tumour swelled as if injected with blood. The bleeding, however, ceased spontaneously. He states that the seton has been passed through the tumour not less than sixteen times, the direction being varied in every instance, -without untoward aceident; and he is confident, that unless the needle be pushed deep enough almost to touch the thyroid cartilage, the trunks of the thyroid arteries will not be exposed to injury, while the branches in the track of the needle will not cause any danger. He insists also upon the propriety of retaining the seton in the tumour a considerable time; and observes, that it remains to be ascertained whether this practice will answer in every description of bronchocele ? For these and several other cases and particulars, the profession is indebted to Dr. Somerville.—(See Med. Chir. Trans. vol. 10, p. 16, i-c.) Mr. Gunning applied a seton in a case of broncho- cele in St. George's Hospital; but in this instance the irritation brought ou sloughing, and the patient after a time died. The particulars of this case, and of three successful examples of the practice in England, have been lately recorded. One ofthe successful cases was treated by my friend Mr. James, of Exeter, another by Mr. A. C. Hutchison, who has taken the trouble to collect the history of them, and the third by Dr. A. T. Thomson.—(See Med. Chir. Trans, vol. 11, p. 235.) Percy and Dupuytren have also employed setons in bronchocele with success. The plan, however, is some- times inefficient, as is proved by two cases under Dr. Kennedy, of Glasgow.—(See London Med. Repository, No. 99, Fe»»1822.) The exact nature of cases relieved by this' practice, and their difference from other exam- ples which are benefited by treatment of a different kind, are still desiderata in surgery. The diseased thyroid gland has been successfully extirpated; but the operation is one of so much danger, that it ought never to be attempted except under the most Dressing circumstances. The many large arte- ri™naturally dfctributed to the gland itself; their still OMtar size in bronchocele; and the vicinity of the carotid arteries, and important nerves render the un- dertaking a thing of no common difficulty. Mr G«och relates two oAM, which do not euro,, rage practitioners to have reconrse to the excision of enlarged thyroid glands. In one, so copious an he- morrhage took place, that the surgeon, though equally bold and experienced, was obliged to stop in the middle of the operation. No means availed in entirely sup- pressing the bleeding, and the patient died in a few days. In the other, the same event nearly took place, the patient's life being saved only by compressing the wounded vessels with the hand, day and night, for a whole week, by persons who relieved each other in turn. This was found the only way of stopping the hemorrhage, after many fruitless attempts to tie the vessels. Hemorrhage is not the only risk : Dupuytren re- moved a large bronchocele that caused dangerous pres- sure upon the trachea: the whole gland was taken away, and the four thyroid arteries and many veins secured. Only a few spoonfuls of blood were lost. The woman, however, died soon after the operation, with pale face, hurried respiration, cold akin, sickness, &c, denoting injury of some important nerves. I do not mention these facts to deter surgeons from the operation altogether, because it is proved by modern experience, and especially by six cases in which Dr. Hedenus, of Dresden, has successfully removed the thyroid gland, that not only it is occasionally a neces- sary proceeding, but one that may be well accom- plished by a skilful operator, as will be particularly explained in a future article.—(See Thyroid Gland.) When bronchoceles by their pressure dangerously ob- struct respiration, deglutition, and the return of blood from the head; and when the disease resists the effi- cacy of iodine, a seton, blisters, and every other plan of treatment found deserving of trial; what can be done with the view of saving the patient, but the bold operation of cutting away the swelling, or that of ex- posing and tying one or both of the upper thyroid arte- ries? When the quantity of blood flowing into a tumour is suddenly and greatly lessened, the size ofthe swelling commonly soon undergoes a considerable diminution. The experiment was once made by Sir W. Blizard : he tied the arteries of an enlarged thyroid gland, and, in a week, the tumour was reduced one-third in its size. The ligatures then sloughed off, repeated bleeding took place from the arteries, and by the extension of hos- pital gangrene, the carotid itself was exposed. The patient died; yet, as Mr. A. Burns observes, this does not militate against a repetition of the experiment; as the same thing might have happened from merely opening a vein, and, in the confined air of a hospital, has actually happened.—(Surgical Anatomy of the Head and Neck, p. 202.) In fact, the rationality of the experiment prevented surgeons from being intimidated by the failure in ques- tion ; and, with that laudable spirit for the improve- ment of operative surgery every where diffusing itself through the profession, other gentlemen were soon found who had judgment enough to make farther trials of the practice. In a young man, twenty-four years of age, whose breathing was much impeded by a bron- chocele, and whose upper thyroid arteries were very large, and affected with strong pulsations, Walther, of Landshut, tied the left of these vessels, the left side of the gland being the largest. The operation was done on the 3d of June, 1814. An incision, an inch and a half in length, was made in the direction of the inner edge of the sterno-cleido-mastoid muscle, where the throbbing of the artery was quite distinct. By a second stroke of the knife, the platysma-myoides was divided in the same direction, and to an equal extent. The vessel was then exposed by a cautious dissection, and separated from the surrounding parts, and one arterial branch which was divided was immediately secured. A ligature composed of three silk threads, was then conveyed with an aneurism-needle under the left thy- roid artery, and tied with two simple knots. The wound was then closed with adhesive plaster, and the ends of the ligatures brought out at the angles. The ligature on the large artery came away on the 12th day; and, without any febrile symptoms, or other bad consequences, the wound was perfectly healed on the 23d day. As early as the third day after the applica- tion of the ligature, the left part of the tumour began to be less tense, and the throbbing feel in it soon ceased. By degrees it dwindled away, becoming as it lessened harder, and, as it were, cartilaginous. In a BRONCH' fortnight, the left half of the swelling was one-third smaller than before the operation; and, at length, only one-third of re at present. Even the repre- sentations of the late Dr. Dwight, relative to the great prevalence of the disease, though among the most re- cent with which we have been favoured, are to be re- ceived with allowance. That in particular portions of our western country repeated examples are to be OCELE. 199 found, may be known by any accurate observer. But " in the village of Utica,(says Dr. Francis) which contains between 4 and 5000 inhabitants, no case of bronchocele could be pointed out, and this village oc- cupies the site of old Fort Schuyler, on the Mohawk, the vicinity of which has been referred to as the spot where goitre was peculiarly prevalent. I am strength- ened in the accuracy of this statement relative to the almost total disappearance of goitre in this neighbour- hood, by the testimony of Dr. Coventry. A similar re- mark may be made with regard to the former fre- quency of the disease throughout the extensive region from Utica to Buffalo. The late Uriah Tracy, in his excursion through this country some years since, was led to believe that bronchocele prevailed in the old set- tlements as well as the new, and thought it incidental to the country at large. In my late visit I made spe- cial inquiry as to the present condition of the health of the inhabitants, and am persuaded that the instances of goitre are much more rare than at the period of Mr. Tracy's observations. The number of cases which came under my notice during the tour were twenty- three. These were at Herkimer, Manlius, Syracuse, Onondaga, Batavia, WUliamsville, and Buffalo; and I saw more cases in the neighbourhood of Buffalo than at any other place. In other parts of the state the disease may be seen, particularly in the county of Alle- ghany." To assign a satisfactory cause for this disease is difficult, perhaps impossible. Dr. Barton has endea- voured to show that goitre and intermittent and remit- tent fevers have one common origin, and argues this opinion from the simultaneous prevalence of these dis- eases, from the frequency of glandular affections where intermittents abound, and from the opinion that persons afflicted with goitre are exempt from intermit- tents, though in the midst of these diseases. Dr. Co- ventry inclines to ascribe it to drinking water impreg- nated with alum. Dr. Dwight advocates the more current opinion that these affections originate from the lime contained in the water drank in those regions. Dr. Francis ascribes the production of the disease chiefly to humidity, and hence it prevails most in the vicinity of lakes and rivers where vegetation abounds. He says, it increases with the rainy seasons, and is di- minished when the weather becomes cold and dry, and hence argues the reason of its disappearance as the country becomes cleared. He however does not alto- gether reject the agency of certain waters in aggravat- ing if not producing the disease. Of the 23 cases examined by Dr. Francis, two only were in male subjects, and one of them an adult In- dian, in Niagara county. He saw it in an infant but a few months old, and he subscribes to the opinion that it often depends on constitutional causes, and is sometimes hereditary. In Oneida county, Dr. Francis learned that goitre prevailed among sheep, and Fodere gives us a similar fact of its occurrence among dogs. The doctrines of Hunter and others, in considering the sexual functions connected with this disease, are sustained by its greater prevalence among women, and also according to Dr. F. by some well-known facts connected with parturition. Dr. Coventry has removed several cases of goitre by the simple expedient of the patient wearing the muri- ate of soda about the neck. The recent plan of Mr. Holbrook, of employing steady pressure, has been tried in this country with some success. The efficacy of burnt sponge has often been seen, but instances of its failure are not unfrequent. The iodine has been used of late years with the best effects, and Dr. Cong- don, of Buffalo, has reported its entire success in a number of cases. Dr. Francis informs me, that in a subsequent journey through this state, he found a number of interesting cases, and that the disorder in every instance afflictea the female sex, and in eight or ten cases it was obviously associated with the function of menstruation and par- turition. The left portion of the gland was most fre- quently the seat of the disease, but in no instance was it connected with idiocy. He reports one instance of the entire cure of a formidable case which occurred in a young married female, who, upon leaving the neigh- bourhood of Catskill and removing to the southern states, after a residence of three years, was entirely relieved of her goUre. soo BRO I can add my own testimony to the value ofthe iodin , having witnessed its success in a number of cases which had resisted tbe other remedies ordinarily em- ployed. The operation of removing the gland by the knife has been performed in this country with success, but is seldom advised, and will not be often repeated.—Reese.] Albucasis gave the first good account of bronclio- cele. Wilmer's Cases and Remarks in Surgery, with an Appendix on the Method of curing the Bronchocele in Coventry, 8vo. Lond. 1779. Prosser, An Account and Method of Cure of Bronchocele, or Derby-neck, 800. Lond. 1769. Also, 3d edit. 4to. Lond. 1782. Me- moirs of the Med. Society of London, vol. 1. Gooch's Chirurgical Works, vol. 2, p. 96; vol. 3, p. 157. De- sault's Parisian Chirurgical Journal, vol. 2, p. 292. tEuores Chirurgicales de Desault, par Bichat, I. 2, p. 298. V. Malacarne, Leltre sur VEtat de Cretin; (Frank, Del. Op. 6.) Edin. Med. and Surgical Journ. vol. 4, p. 279. Odier's Manuel de Midecine Pratique, 8vo. Geneve, 1811. Dr. Reeves's Paper on Cretinism, in Edin. Med. and Surg. Journal, vol. 5. Traite du Goitre, et du Cretinisme, par F. E. Fodeui, &»«. Pa- ris, an 8. Richter's Anfangsgriinde der Wundarz- neykunst, b. 4, kap. 13, von Kropfe. Surgical Ana- tomy of the Head and Neck, by A. Burns, p. 191, ire. Larrey, Mimoires de Chirurgie Militaire, torn. 1, p. 123; t. 3, p. 199, i-c. J. F. Ackermann, iiber die Kre- tinen, eine besondere Menchenabart in den Alpen. 8vo. Gotha, 1790. B. S. Barton, A Memoir concerning the Disease of Goitre, as it prevails in different parts of North America, 8vo. Philadelphia, 1800. Memo- ria Patologico Practica sulla Natura di Gozzo, i-c. del Dottor Prospero Postiglione, 12i»o. Fircnze, 1811. Korluin, Comment, de Vitio Scrofuloso, t. 2. Giuseppe Flajani, Collezione d' Osservaxioni e Riflessioni di Chirurgia, t. 3, p. 270, i-c. 8vo. Roma, 1802. Quadri, in Med. Chir. Trans, vol 10, p. 16. Diet, des Sci- ences Med. art. Bronchocele. Ph. Fr. Walther, Neue Heilart des Kropfes durchdie Unterbindung der obern Schildrusen Schlagadern nebst der Gesehichte eines durch die Operation geheilten Aneurismds der Carotis Bvo. Sulzbach, 1817. H. Coates, in Med. Chir. Trans, vol. 10, p. 312, i-c. Gautieri Tyrolicnsium, Carynthiorum, Styriorumque Struma ; Vienna, 1794. Maas, Diss. de Glandula Thyroidea tarn Sana quam Morbosa, i-c. Wirceb. 1810. Hausleutncr, iiber Erkenntniss, i-c. des Kropfes, in Horn's Archiv. b. 13, 1813. Miihh- bach der Kropf. nach seiner Ursache, Vehiitung, und Hciluvg. Wien, 1822. Hedenus, Tractatus de Glan- dula Thyroidea, ire. Lips. 1822. Lassus, Pathologic Chirurg. t. 1, p. 408, i-c. Petit, (Euvres Posthumes, t. l,p. 255. Haller, Opuscula Pathologica, Obs. 5, p. 16. J. L. Alibert, Nosologic Naturelle, I. I, p. 464, i-c. fol. Paris, 1817. A. C. Hutchison, Cases of Bron- chochcle, or Goitre, treated by Seton: Med. Chir. Trans, vol. 11, p- 235, i-c. A. de Humboldt, Observa- tions sur quelques Phenomines peu connus qu' offre le Goitre sous les Tropiques, dans les Plaines et sur les Plateaux des Andes ; in Journ. de Physiologic par F. Magendie, t. 4, p. 109, 8vo. Paris, 1824. Observa- tions on the remarkable Effects of Iodine in Broncho- cele and Scrofula ; being a translation of three Me- moirs published by J. R. Coindet, M. D. Lond. 1821. J. C. Straub, in Naturwissenschaftlicher Anzeiger der Allgemeiner Schweizerischer Gesellschaft, ire. heraus- gegeben von Fr. Meisner, ito. Bern. Feb. 1820. Brer a, Saggio Clinico sull' Iodio, ire. Padova, 1822. W. Gairdner, L. D., Essay on the Effects of Iodine, with Practical Observations on its use in Bronchncele, Scrofula, ire. Lond. 1824. H. S. Roots, in Med. Chir. Trans, vol. 12, p. 310. Coster, in Archives Generates de Midecine, Juillet, 1823. J. Kennedy, in Lond. Med. Repository for Feb. 1822. Dr. A. Manson, Medical Researches on the Effects of Iodine in Bronchocele, i-c. Lond. 1825. M- Roulin, Note sur quelques Faites re- latifsi I'Histoire des Goitres ; in Magendie's Journ. de Physiologic Expir. t. 5, p. 966. J. A. W. Hedenus, Ausrottung der SchiUruse «•*«■"•• %£*"• von C F. GralftundPh. Von Walther, b.2,p. 237, ire or Journ of Foreign Medicine, vol. 5, p. 317, i-c. For the best plates of the disease see Dr. Bailhe's Series of En;ed twenty-three, was in the most urgent danger from an inflammation of his throat. It was thought nothing could save him except bronchotomy. After the longitudinal cut in the skin, and the separa- tion of the muscles, the trachea was opened between two of the cartilages ; but the blood insinuated itself into this canal, and excited so violent a cough, that the cannula could not be kept in by any means, though it was replaced several times. Louis remarks, that in this instance the patient's head should have been turned downwards, in order to keep the Nood from flowing backwards into the trachea. It is asserted, that the opening of this tube was not always opposite the ex- ternal wound, in consequence of the convulsive action of the muscles, and that the patient on this account could hardly breathe. Hence, Vigili was induced to slit open the trachea, down to the sixth cartilaginous ring; and it was only then that he inclined the par tient's head forwards. The bleeding now ceased, the patient breathed with ease, and on the second day the inflammation was so much better, that respira- tion went on without the aid of the opening in the trachea. The most simple and natural mode of obviating all trouble from the entrance of blood into the trachea, is to tie any bleeding branch of the thyroid artery or vein before the windpipe is opened. Sometimes the cannula becomes obstructed with mucus or clots of blood. Such an accident nearly suf- focated a patient at Edinburgh. An ingenious person happening to be at hand, suggested the introduction of a second cannula into the first; the second one being taken out and cleaned as often as necessary, and then replaced. The use of the cannula must be continued as long as the causes obstructing respiration remain. Thus, in one very interesting case of cynanche, detailed in a BRONCHOTOMY. 207 modern publication, the patient, thirteen months after the operation, had not been able to discontinue the tube.- i.sec Med. chir. Journ. vol. 5, p. 7.) This ex- ample was attended in its progress with a singular circumstance, viz. the expulsion through the cannula of several portions of calcareous matter or bone. In the case operated upon by Mr. F. White, the tube had been worn two years; and in the well-known case of Mr. Price of Plymouth, the instrument had been worn ten years.—(See Dublin Hospital Reports, vol. 4, p. 505, 506.) When respiration is suspended by the presence of a foreign body in the trachea, and the extraneous sub- stance does not make its appearance at the opening, a trial may be made to discover its situation by means of a bent probe. When it lies downwards, which it hardly ever does, the wound in the trachea may be enlarged in this direction, and the body extracted with a pair of curved forceps. The extraneous substance is mostly forced out by the air, as soon as the incision in tin; trachea is opened. When it cannot be immediately found, some practitioners (Heister and Raw.) have sue, ceded by keeping the lips of the wound asunder with a leaden cannula, by which means the force of the air in expiration has in a few hours expelled the foreign body. Richter gave the preference to a curved cannula ; and since his time many surgeons have chosen to use Buch an instrument, though if it be double the inner tube cannot be so easily introduced as that of a straight one ; and no doubt the chief disadvantage of the latter has often proceeded from its having been made of too great length. In some instances, like that referred to above, a can- nula has been borne quietly in the trachea; while in others, it has produced so much irritation, cough, and Bense of choking, as to render its immediate removal necessary. Mr. Lawrence, in speaking ofthe obstruc- tion of the glottis from the disease already adverted to in this article, observes, that when the cannula causes inconvenience, he should advise a longitudinal inci- sion, of about half an inch, in the middle of the trachea, and the removal of a thin slip of the tube, which would leave an artificial opening for respiration, equal in size to the natural one.—(See Med. Chir. Trans, vol. 6, p. 249.) The same plan was followed by Mr. F. White, and is also sanctioned by Mr. Carmichael.—(See Dub- lin Hospital Reports, vol. 4, p. 563, cS-c, and Trans, of Assoc. Physicians, vol. 3, p. 174.) When this prac- tice is not adopted, Mr. Carmichael recommends the use of as large a cannula as can be introduced. On the continent the operation of laryngotomy, which was first advised by Vicq d'Azyr, and recom- mended by Desault, is frequently preferred to trache- otomy. The surgeon makes an incision over the ante- rior part of the thyroid cartilage, punctures the cri- co-thyroid membrane, and, if it be necessary, intro- duces a director and slits the thyroid cartilage up- wards. A single opening in the crico-thyroid mem- brane would suffice for the introduction of a cannula for the purpose of enabling the patient to breathe; but for the extraction of foreign bodies it would be neces- sary also to cut the thyroid cartilage. The fact that extraneous substances, when they are loose, are almost always lodged at the upper part of the larynx, proves that laryngotomy, in such cases, must commonly be most advantageous; and according to Desault, even wbeuthe foreign bodies are lower down in the tra- chea, they may in general be most easUy extracted with the aid of a pair of curved forceps. In this country laryngotomy has been less commonly practised, though commended a few > ears since by Mr. Coleman, and more recently by Mr. C. Bell. " Of the three situations (says Mr. Lawrence), in which it has been proposed to make the opeiung, viz. in the th\ roi i cartilage, between that and the cricoid, or in the trachea, I consider the first as the least eligi- ble. Besides the objection from the ossification of the cartilage, and the danger of wounding or otherwise injuring the chorda? vocales, there is the inconvenience in the case of angyna laryngea, arising from the swollen and thickened state of the membrane, which may ac- tually impede the passage of the air. I am not aware of any objection to a transverse opening between the thyroid and cricoid cartilages. The prominence of the former in tho neck serves as a guide to the part which should be opened. W liuher broncliotomy or laryngo- tomy ought to be selected, must of course depend upon the nature of the case : in cases of cynanche, the prox- imity of the inflamed parts would be an objection to laryngotomy; while in examples of foreign bodies within the glottis this operation may generally be most advisable for reasons already explained. It is absurd to think of confining one mode of operating to differ- ent cases."—(See Medico-Chir. Trans, vol. 6, p. 248.) Of the operation performed in the membranous space Mr. C. Bell entertains a favourable opinion. He directs us to slit up the membrane and open the incision with the handle of the knife, when the patient will immedi- ately breathe with ease. Here, says he, there is no- thing to alarm the most timid operator. No great tur- gid veins are opened; the cut is made above the thyroid gland, and above the anastomosing branch of the thy- roid arteries. The part is strongly marked by the pro- minence of the thyroid cartilage above, and the ring of the cricoid cartilage below. " If the occasion be temporary, a simple slit of the membrane will be found sufficient. If necessary, a transverse cut will afford any degree of opening. If a round hole be desired, the four corners left by the incisions may be snipped off," or the edges of the opening may be kept asunder by means of the double wire of a catheter, the middle part of which lies on the wound, while tbe ends are bent round the neck and tied by a ligature behind. In Mr. C. Bell's cases, less annoyance was caused by this contrivance than by a tube LBronchotomy is frequently performed in this coun- try for the removal of foreign bodies from the trachea, but seldom with any other intention. The situation most generally selected is between the thyroid and cricoid cartilages. Sometimes the foreign body es- capes through the wound, or may be extracted by the forceps ; at other times, so soon as the air is admitted into the lungs, the force of the respiration expels it through the mouth. I have known several cases in which, although the operation afforded immediate relief to the respiration, yet the escape of the foreign hody did not take place for several hours; and in one in- stance days had elapsed, when it was coughed up with great violence.—Reese.] Hemn sur les Coips Etrangers qui sont arritis dans les premiiris Voies, et qu'it faut tirer par Inci- sion, in Mem. de l'Acad. Roy ale de Chirurgie, t. 3, p 131, ic. edit. 12mo. I^ouis, Memoire sur une Ques- tion Anatomique relative a la jurisprudence, ou I'on itablit les pnncipes pour distinguer, a. I'inspection d'un corps trouvi pendu, les signes du suicide, d'avec ceux de Vassassinat. Habicot, Question Chirurgi- cale, par laquelle il est demontri que le Chirurgien doit assuriment pratiquer l'Operation de la Broncho- tomie, i-c, 12mo. Paris 1620. Louis, Mi-moire sur la Bronchotomie, in Mem. de l'Acad. de Chirurgie, t. 12, edit. 12mo. Second Memoir on this subject, in- serted by the same -writer in the said volume. De la Rescission des Amygdales, t. 14, p. 283, .ic. Piecis d'Observations sur le Gonflemenl de la I^angue,i-c. par M. de la Malic, t. 14, p. 408. l,escure, sur un por- tion d'Amande de Noyau d'Abricut dans la Trochee Artire, t. 14, p. 427. Suite d'Observations sur les Corps Etrangers dans la Trachie Artire, t. 14, p. 432. Experiences sur les Cos, par M. Favier, t. 14, p. 445. De la Martiniere, sur les Corps Etrangers, dans la Trachie Artire, op. cit. t. 5, ito. Bertrandi, 7 raite des Opirations de Chirurgie, p. 402, ire. edit. 1784. Sabatier, de la Midecine Opiratoire, torn. 2, p. 283, idit. 1. (Euvres Chir. dt Desault, par Bichat, t. 2, p. 236, ira Pelletan, Clinique Chirurgicale, I. 1, first Memoir. Cheyne, Pathology of the Larynx and Bron- chia, Edin. 1809. A. Burns, Surgical Anatomy of the Head and Neck, p. 377—401. J. F. Double, Traite du Crimp, 8vo. Paris, 1811. Richter's Anfangsgrilnde der Wundarzniykunst, b. 4, p. 225, ic, Cottingrn, 1800. Lawrence on some affections of the larynx which require the operation of bronchotomy, in Medico- Chii: Trans, vol. 6, p. 221, *c. Baillie, in Trans, of a Society for the Improvement of Med. and Chir. Knowledge, vol. 3. Ti misselDrelincourt, Corps Etrangers arritis dans Irs Voies aevicnnrs, Nuuvean Journ. de Mid- par Beclard, Se. i- 7, p. 101. Philos. Trans. 1730, .V<. 416, art. 5. Journal de .Medicine t. 38, p. 358. ./. .-*• Albers, Comvi. de Trachitide Infan- tum, vulgo Ci-i'up vocata, 4lu. Lips, lt-16. Cose of Chronic Infl- of the Laryux,in which laryngotomy was performed. Ser .Met. Chir. .hutv. April, 1820. F. J. 208 BUN BUR Bourlant de Bronchotomia Diss, in Coll. Diss. Lo- van. 2, 175. G. Detharding, Epist. Med. de Methodo subveniendi Submersis per Laryngotumiam, Rostochii, 1714. Klein in Chir. Bemerkungen, Stuttgart, 1801 • in V. Siebold's Chiron, b. 2, p. 619; in Graefe's Journ. b. l,p. 441, and b. 6, p. 225. Michaelis, in Hufeland's Journ. b. 9, p. 2, and b. II, p. 3. Flajani, Osberua- ziom, ire, di Chirurgia, t. 3, Roma, 1802. R. Col- lard, Abhandlnng iiber den Croup, 8vo. Hannon. 1814. T. Chevalier's Case of Croup, in Med. Chir. Trans. vol. 6, p. 151, ire. Andree's Case,in vol. 3, same work, p. 335, with the Obs. of Dr. Farre on Cynanche in the same part of the work ; and those of Dr. Percival on the same subject, in vol. 4, p. 297. C. W. Eberhard, De Musculis Bronchialibus in Statu et Morbosa Ac- tione, 8vo. Marpurg. 1817. R. Sprengel, Gesehichte der Chirurgie, th. 1, p. 177, 8vo. Halle, 1805. Diet. des Sciences Mid. art. Bronchotomie, t. 3, 1812. Sur- gical Observations by C. Bell, part 1, p. 14, i-c. 8va. Lond. 1816. Case of Cynanche Laryngea requiring Tracheotomy, and the continued use of a Cannula, ever since the Operation, in Med. Chir. Journ. vol. 5, p. 1, 8vo. Lond. 1818. W. H Porter, Case of Cynan- che Laryngea, in which Tracheotomy and Mercury were successfully employed; Med. Chir. TVans. vol. 11, p. 414. R. Liston, two Cases in which Tracheo- tomy was performed with success; one for oedema glvttidis, i-c, the other on account of an injury of the larynx; Edin. Med. and Swg. Journ. vol. 19. Burgess, in Dublin Hospital Reports, vol. 3. Dr. Hall, in Med. Chir. Trans, vol. 12. W. J. Hunt, Case of Bronchotomy; Med. Chir. Trans, vol. 12, p. 27, ic. R. Carmichael, in. Trans, of Assoc. Physi- cians, Ireland, vol. 3, p. 170, i-c. F. White, in Dublin Hospital Reports, vol. 4. Dr. Cullen on Broncho- tomy, in Edin. Med. Journ. No 94. BUBO. (Bov6u>v, the groin.) Modern surgeons mean by this term a swelling of the lymphatic glands, particularly of those in the groin and axilla. The disease may arise from the mere irritation of a local disorder; from the absorption of some irritating matter, such as the venereal poison ; or from constitu- tional causes. Of the first kind of bubo, that which is named the sympathetic is an instance. Of the second, the vene- real bubo is a remarkable specimen.—(See Venereal Disease.) The pestilential bubo, which is a symptom of the plague, and scrofulous swellings of the inguinal and axillary glands, may be regarded as examples of buboes from constitutional causes.—(See Strofula.) The inguinal glands often become affected with sim- ple phlegmonous inflammation, in consequence of irri- tation in parts from which the absorbent vessels pass- ing to such glands proceed. These swellings ought to be carefully discriminated from others which arise from the absorption of venereal matter. The first cases are simple inflammations, and only demand the application of leeches, the cold saturnine lotion, and the exhibition of a few saline purges; but the latter diseases render the administration of mercury ad- visable. Sympathetic is the epithet usually given to inflamma- tion of glands from mere irritation; and we shall adopt it without entering into the question of its propriety. The sympathetic bubo is mostly occasioned by the irritation of a virulent gonorrhoea. The pain which such a swelling gives is trifling compared with that of a true venereal bube, arising from the absorption of matter, and it seldom suppurates. However, it has been contended that the glands in the groin do sometimes swell and inflame from the actual absorp- tion of venereal matter from the urethra, in cases of gonorrhoea, and if this were true the swellings would be venereal; but this doctrine is now nearly exploded. —(Hunter on the Venereal, p. 57.) The manner in which buboes form from mere irrita- tion will be better understood by referring to the occa- sional consequences of venesecfiou, in the article Bleeding. The distinguishing characters of the vene- real bubo are noticed in the article Venereal Disease. BUBONOCELE. (From j}.,v6i>v. the groin, and Kij\r) a tumour.) A species of hernia, in which the bowels protrude at the abdominal ring. The case is often called an inguinal hernia^ because the tumour takes place in the groin.—(See Hernia.) BUN YON. An inflammation of /.he bursa mucosa, at the inside of the ball of the great toe.—(See Brodit't Pathological and Surgical Obs. on the Joints, p. 356, ed. 2.) , , BURNS are usually divided into three kinds. 1st. Into such as produce an inflammation of the cutaneous texture, but an inflammation which, if it be not im- properly treated, almost always manifests a tendency to resolution. 2dly. Into those which occasion the separation of the cuticle, and produce suppuration on the surface of the cutaneous texture. 3dly. Into others in which the vitality and organization of a greater or less portion of the cutis are either immediately or sub- sequently destroyed, and a soft slough or hard eschar produced.—(See Thomson on Inflammation, p. 585, 586.) Suppuration is not always an unavoidable conse- quence of the vesications in burns; but it is a common and a troublesome one. " In severe cases it may take place by the second or third day; often not till a later period. It often occurs without any appearance of ul- ceration ; continues for a longer or shorter time; and is at last stopped by the formation of a new cuticle In other instances, small ulcerations appear on the sur- face or edges of the burn. These spreading form ex. tensive sores, which are in general long in healing, even where the granulations which form upon them have a healthy appearance."—(Op. cit. p. 595.) Burns present different appearances, according to the degree of violence with which the causes producing them have operated, and according to the kind of ciuse of which they are the effect. Burns which only irritate the surface of the skin are essentially different from those which destroy it; and these latter have a very different aspect from what others present which have at- tacked parts more deeply situated, such as the muscles, tendons, ligaments, jo. Lond. 1822. the cervix uten, may render this practice indispensable. A scirrhous hardness of the neck of the uterus is the most frequent. When the induration is such that the cervix cannot be dilated, and the patient is exhausting herself with unavailing efforts, the parts should be divided in several directions. This has been success- fully done under various circumstances. Cases have been met with, in which the cervix uteri presented no opening at all; and yet the preceding operation proved quite effectual. Such is the example which Dr. Sim- son has inserted in the third volume of the Edinburgh Essays. A woman, forty years of age, became preg- nant, after recovering from a difficult labour, in which the child had remained several days in the passage. She had been in labour sixty hours; but the neck of the womb had no tendency to dilate. Dr. Simson, per- ceiving that its edges were adherent, and left no open- ing between them, determined to practise an incision, with the aid of a speculum uteri. The bistoury pene- trated to the depth of half an inch, before it got quite through the substance which it had to divide, and which seemed as hard as cartilage. As the opening did not dilate, in the efforts which the woman made, it became necessary to introduce a narrow bistoury on the finger, in order to cut this kind of ring in various directions. There was no hemorrhage; and the only additional suffering which the patient encountered, arose from the distention of the vagina. As the child was dead, Dr. Simson perforated the head, in order to render the delivery more easy. Strong convulsions at the moment of parturition, may create a necessity for the vaginal Cesarean ope- ration. These sometimes subside as soon as the mem- branes are ruptured and the waters discharged, so as to lessen the distention of the womb. However, if the convulsions were to continue, and the cervix uteri were sufficiently dilated, the child should be extracted with the forceps or by the feet, according to the kind of presentation. On this subject Baudeloque has re- corded a fact, which was communicated to the Academy of Surgery by Dubocq, professor of surgery at Tou- louse. The woman was forty years of age, and had been in convulsions two days. She was so alarmingly pale, that she could scarcely be known. Her pulse was feeble and almost extinct, and her extremities were cold and covered with a clammy perspiration. The edges of the opening, which was about as large as a crown piece, felt, as it were, callous ; and hardly had this aperture been dilated, when delivery took place spontaneously. The child was dead. The symp« c CESAREAN OPERATION. 215 toms were appeased, and the woman experienced a perfect recovery. Another case, in which the indurated cervix uteri was successfully divided, is recorded by Lambron, a surgeon at Orleans.—(See Diet, des Sci- ences Med. t. 23, p. 297.) A considerable obliquity of the neck of the womb, combined with a pelvis of small dimensions, may also be a reason for the performance of the vaginal Ce- sarean operation. Not that such obliquity always oc- casions that of the rest ofthe uterus; nor is the neck oi this viscus invariably directed towards that side of the pelvis which is opposite to its fundus, although this is sometimes the case. In the latter circumstance, as the contractions ofthe uterus do not produce a dila- tation of its cervix, which rests upon the bones of the pelvis, the adjacent part of that organ is dilated and pushed from ahove downwards, so as to present itself in the form of a round smooth tumour, without any appearance of an aperture. Such a case may have fatal consequences. Baudeloque furnishes us with an instance. A woman in her first pregnancy, not being able to have the attendance of the accoucheur, whom she wished, put herself under the care of a midwife, who let her continue in labour-pains during three days. When the accoucheur came, on being sent for again, the child's head presented itself in the vagina covered with the womb. The portion of the uterus which in- cluded the foetus, was in a state of inflammation. The os tinea? was situated backwards towards the sacrum, hardly dilated to the breadth of a penny-piece, and the waters had been discharged a long time. The patient was bled, and emollient clysters were administered. "All sorts of fomentations were employed. She was laid upon her back with the pelvis considerably raised. The accoucheur had much difficulty in supporting the head of the child, and keeping it from protruding at the vulva, enveloped as it was in the uterus. Notwith- standing such assistance, the patient died. So fatal an event, says Sabatier, might have been prevented, by making the woman lie upon the side op- posite the deviation of the uterus, and employing pres- sure from above. If these proceedings had failed in bringing the os tinea? towards the centre of the pelvis, this opening might have been brought into such posi- tion by means ofthe finger, in the interval of the pains, and kept so until it were sufficiently dilated for the membranes to protrude. This is what was done by Baudeloque in one case, where the womb inclined forwards and to the right. The os tinea? was situated backwards. The waters escaped and the head advanced towards the bottom of the pelvis, included in a portion of uterus The whole of the spherical tumour which presented itself could be felt with the finger; but no opening was distinguish- able ; and the swelling might also be seen on separat- ing the labia from each other and opening the entrance of the vagina. It became necessary to keep the patient continually in bed, and to have the finger incessantly introduced; but she was not sufficiently docile to sub- mit to such treatment. Fortunately, the unexpected appearance of two officers of justice, forty-eight hours after the commencement ofthe labour, had the effect of making her more manageable. It was time for her to become so; for the uterus had now become tense, red, and painful. The abdomen was also so tender, that it could scarcely bear the contact of the clothes. Febrile symptoms had begun, and the ideas were be- ginning to be confused. Baudeloque made her lie down; and he pressed with one hand on the abdomen, for the purpose of raising tbe uterus, while with the other he pushed the head a little way back, in order that he might reach the os tincae, which he now brought with his finger towards the centre of the pelvis, and kept there for some time. The efforts of the pa- tient being thus encouraged, she was delivered in about a quarter of an hour. The infant was of a thriv- ing description, and the case had a most favourable termination. When the obliquity -of the uterus is such, that the os tinea? cannot be found, and the mother and foetus are both in danger of jierishing, it is the duty ofthe prac- titioner to open the portion of the womb that projects towards the vulva. I.auverj it met with a case of this description in his practice. A woman, pregnant with her first child, suffered such extreme pain in her labour, that Lauverjat w:\s solicited to ascertain the real state of thuigs. He w as surprised to find the vulva com- pletely occupied by a body which even protruded ex- ternally and yielded to the pressure ofthe fingers, ex- cept during the labour-pains. In examining this tumour he could only find at its circumference a cul-de-sac, half an inch deep, without any aperture through which the child could pass. Other practitioners, who were consulted about this extraordinary case, were also anxious to learn what had happened. They found in the tumour a laceration, which only affected a part of the thickness of its parietes. This laceration was deemed the proper place for making an incision. The operation having been done, the finger was passed into the cavity in which the child was contained. A large quantity of turbid fluid was discharged. The child presented and passed through the opening, with a tri- vial laceration on the right side. Lauverjat, having passed his hand into the utherus, was unable to find either the os tincae or the cervix. No particular indis- position ensued, and the lochia were discharged through the wound, which gradually closed. In the course of two months the os tinea? and neck of the uterus were in their natural position again.—(Lauverjat, Nouveile Mrthode de pratiquer ''Operation Cisarienne. Paris, 1788.) When the case is a scirrhous induration of the cer- vix uteri, or a laceratiou of the parietes of this viscus at the place where it projects into the vagina, the va- ginal Caesarean operation is attended with no difficulty, It is performed with a blunt-pointed bistoury, the blade of which is wrapped round with lint to within an inch of the point. The instrument is to be introduced, un- der the guidance of the index finger, into the opening presented by the uterus, and the aperture is to be pro- perly enlarged from within outwards, in various direc- tions. But when the scirrhous hardness of the cervix presents no opening at all, or when the part of the ute- rus projecting in the vagina is entire, the incision should be made from without inwards, with the same kind of knife. Too much caution cannot be used in introducing the instrument, in order that no injury may be done to the child, which lies directly beyond the substance which is to be divided. No general di- rection can here be offered, except that of proceeding slowly, and of keeping the index finger extended along the back of the knife, so that it may be immediately known when the substance ofthe womb is cut through, into the cavity of which the finger ought to pass as soon as the knife. If it should be necessary to extend or multiply the incisions, the cutting instrument should be regulated in a similar manner with the same finger. The cervix uteri having been divided, the expulsion of the child is either to be left to nature, or to be pro- moted by the ordinary means. The operation that has been described requires no dressings. If the bleeding should prove troublesome, we are recommended to apply to the incision a dossil of Unt wet with vinegar or spirit of wine.—(See Sabatier, Midecine Opiratoire, t. 1.) The chief object would here be to prevent adhe- sions between the cervix of the uterus and the upper part of the vagina.—(Diet, des Sciences Med. t. 23, p. 298.) ABDOMINAL CESAREAN OPERATION. This is a far more serious operation than that which has just now been treated of, and is the proceeding to which the term Caesarean operation is more particularly applied. There are three cases in which this operation may be necessary. 1. When the foetus is alive and the mo- ther dead, either in labour, or the last two months of pregnancy. 2. When the foetus is dead, but cannot be delivered in the usual way, on account of the deformity of the mother, or the disproportionate size of the child. 3. When both the mother and child are living, but de- livery cannot take place from the same causes, as in the second example. In many instances, both mother and child have lived after the Caesarean operation, and the mother even borne children afterward.—{See Heister's Institutes of Sur- gery, chap. 113. Mem., de l'Acad. de Chirurgie, t. 1, p. 623, t. 2, p. 308, in 4to. Edin. Med. Essays, vol. 5, art. 37, 38. Mil. Med. and Surgical Journal, vol. 4, p. 179. Med. Chir. Trans, vol. 9 and 11, ic.) Very recently an example has been recorded, in which Dr. Mulier, of Lowenburg, in Silesia, performed the Cesarean sec- tion, and saved both the mother and the child.—(Maga- zmfur die gesamvite IleiUcuiule, 1SC8; b. 28, p. 146.) 216 CESAREAN OPERATION. An instance of similar success is reported by C H Graefe—(Journ. fur Chirurgie, sarean operation on the living mother had its defend- ers. Bauhin relates, that in the year 1500 a sow-gelder performed the Cesarean operation on his wife, tarn ft- liciter,ut. eapostea gemellos el quatuor adhvc infantes enixa fuerit. This is said to be the first instance in which the operation was ever done on the living mother with success. Marty other cases were afterward col lected and published. The possibility of operating successfully on tha CESAREAN OPERATION. 217 living mother was proved with great perspicuity and accuracy by Simon,in theJf moires del1 Acad, de Chi- rurgie, l. 1,4to. Here we are presented with a col ec- tion of sixtv-four Cesarean operations, more than a half of which had been done on thirteen women. Some of these had undergone the operation once or twice ; others five or six times. There was one woman in particular who had undergone it seven times, and al- ways with success. This seems to prove, notwith- standing all assertions to the contrary, that the opera- tion for the most part succeeds. But if the life of the mother should not invariably be preserved, the Cesa- rean operation ought not to be rejected on this account; it ought always to be done when relief cannot be ob- tained by other means ; just as amputation and litho- tomy are practised, though they are not constantly fol- lowed by success. Would any thing be more cruel than to abandon a mother and her child, and leave them to perish while there is any hope of saving them both? It is true, that when a pregnant woman dies of any in- ward disorder, and not from the pains and efforts of labour, the foetus is sometimes still alive in the uterus; but in cases of death after difficult labours, and the great efforts made by the uterus to overcome the ob- stacles to parturition, the foetus is generally dead; and the operation therefore is less likely to be availing.— (8ee Bertrandi, Traite des Operations de Chirurgie, chap. 5.) It is the opinion of the best writers upon this sub- ject, that whenever a woman dies at all advanced in pregnancy the performance of the Cesarean opera- tion is highly proper. The propriety of this practice in such circumstances was known to the ancient Ro- mans ; for by a decree of Numa Pompilius, no woman who died pregnant was suffered to be buried, ere her body had been opened, with the view of preserving the infant for the use-of the state.—(Sprengel, Gesehichte der Chir. th. I, p. 371.) Experience has proved, that when the fastus has not attained the period at which parturition commonly happens, it will sometimes sur- vive the operation a considerable time, and that when it is full grown its life may be most happily preserved. Although instances are cited, in which the foetus in utero has been found alive upwards of four-and twenty hours after the death ofthe mother, little stress should be laid on such prodigies. The operation ought to be done without any delay. Even then we are not certain of saving the infant's life. In the greater number of instances the foetus perishes at the same time with the mother, and from the same causes. The cases which are recorded of the foetus being extracted alive after the death of the mother, are numerous: I shall here only refer to three, two of which rest on the unim- peachable authority of Flajani, who was himself the operator.—(Collezione di Osservazioni, i-c. di Chirur- gia, t. 3, p. 144—146.) In one of these instances, the operation was done on a woman killed by violence in the ninth month of pregnancy; the child lived six hours; in the other, a foetus was extracted from a wo- man who had died of typhus fever in the seventh month, and though the operation was not done till she had been dead about an hour, the child was taken out alive, and continued to live full ten minutes. A living child was also taken out of its mother by Vesling, after her death by typhus.—(Welsch. Obs. Med. Epi- sagm. No. 74, p. 47; Sprengel, Gesehichte der Chir. th. 1, p. 374.) On the 15th of April, 1820, Mr. Green, of St. Thomas's Hospital, extracted by the Cesarean ope- ration, from a woman suddenly killed in the ninth mouth of pregnancy by the passage of a stage coach over her, a foetus that lived '.14 hours after its re- moval from the uterus.—(See Med. Chir. Trans, vol. 12, p. 46.) With respect to the statements of Cangia- mila, a SicUian practitioner, I join Sprengel in consi- dering them as incredible exaggerations : five instances are given, in which the foetus was taken out of the mother from fifteen to twenty-four hours after her death, and yet it continued to live. Cangiamila says, that at Syracuse, in the course of eighteen years, the operation had been practised twenty times under the same circumstances; that at Girgenti, thirteen chil- dren were saved out of twenty-two women who had died pregnant; and that in twenty-four years, at Mon- tereali, twenty-one children ware preserved in the same manner. — (Embryologia Sar.ro. Yenet. 1763, fol.) As Sprengel remarks, one might almost sup|>ose from this account, that in Sicily pregnancy was generally fatal. If the mother should happen to die in labour, and the neck of the uterus were sufficiently dUated, or dis- posed to be so, an attempt should be made to accom- plish delivery in the ordinary way; for examples have occurred in which women, supposed to be dead in this circumstance, were in reality alive. Hence we find that the Senate of Venice, in 1608, enacted a law, by which practitioners were liable to punishment in case they neglected to operate with as much caution on a pregnant woman supposed to be dead, as on a living sub- ject ; and rules to be observed were again issued by the same government in 1720.— (Seb. Melli, La Commare levatrice, p. 108,4to. Venez. 1721; Personi, Diss, sopra VOperaz. Cesar, p. 15,8ro. Vinez. 1778.) A law to the same effect was likewise made in 1749, by the lung of Sicily, who decreed the punishment of death to those medical men who omitted to perform the Cesarean operation on such women as died in the advanced stages of pregnancy. In the Journal des Sgavans de Janvier, 1749, the following case, confirming the pro- priety of such caution, was inserted by Rigaudeaux, surgeon to the military hospital at Douay. This prac- titioner having been sent for to a woman, to whose re- sidence he was unable to proceed till two hours after her apparent death, he had the sheet with which she was covered removed, and perceiving that the body retained its suppleness and warmth, he tried whether the foetus could not be extracted in the ordinary way, which was easily effected as soon as the feet were got hold of. The first endeavours to save the child were very unpromising; but after a few hours they had the desired effect.. As the woman continued in the same state five hours afterward, Rigaudeaux recommended that she might not be buried before her limbs were quite cold and stiff. He afterward had the satisfac- tion to learn that she was also restored to life. This remarkable case happened on the 8th of June, 1745, and both the mother and child were living at the period when Rigaudeaux published the observation. Supposing, however, delivery in the ordinary man- ner to be impracticable, at all events the Cesarean ope- ration ought to be performed with the same cautions as if the mother were alive, only one incision being made for the purpose of opening the uterus. Almost all the insurmountable obstacles to delivery originate from the bad conformation of the pelvis, de- pending upon rachitis; though they are not an inva- riable consequence of it, since there are women ex- tremely deformed, in whom no imperfection of the pel- vis exists, while it prevails in others whose shape is but trivially disfigured. An examination of the di- mensions of the pelvis is the right mode of ascertain- ing whether there is really such an impediment to parturition. In order that the dimensions may not be an obstacle to delivery, the distance between the upper edge of the sacrum and the os pubis ought to be three inches and a half; and the distances between the tuberosities of the ischium and between each of these protuberances and the point of the os coccygis, three inches. - Women have indeed been known to be delivered without assistance, although the first of the above distances was only two inches and a half; but then the heads of the children were so elongated, that the great diameter was nearly eight inches, while that which extends from one parietal protuberance to the other was reduced to two inches five or six lines, and the infants were lifeless. If they are to be born alive, they must be taken out of the womb by the Cesarean operation; but the latter proceeding should never be adopted without a certainty that they are actually Uving; for when dead they may be extracted in a way that is attended with much less risk to the mother. It is not always an easy matter to ascertain with certainty whether a foetus in utero be liv- ing or dead. If it has entirely ceased to move, after being affected with a violent motion, the probability is that it is no longer alive. But to be certain, manual examination is necessary, which may be practised in two ways. One consists in pressing upon the uterus, through the parietes of the abdomen. If the child lives, such pressure makes it move, and the motion can be plainly felt and distinguished. In the other method, one hand is employed in pressing upon the uterus externally, whUe with the fingers of the other hand passed up the vagina, corresponding pressure is also to be made. The uterus is likewise to be allowed to. descend as far as possible, in order to induce the OPERATION. 218 CESAREAN < fetus to move. When no decisive indications can be thus obtained, it becomes necessary to rupture the membranes, if they have not already given way, intro- duce the hand into the uterus, and put a finger into the child's mouth, for the purpose of making it move its tongue. The finger may also be applied to the region of the heart, so as to examine whether this organ is beating; and the umbilical cord may be touched, in order to ascertain whether there is still a pulsation in it. When none of these proceedings furnish unequi- vocal information, the conclusion is that the child is dead, and Its extraction is indicated, unless the nar- rowness of the parts be such that the hand cannot be passed into the uterus, in which case, the Cesarean operation is indispensable. But how are we to form a judgment respecting the dimensions of the pelvis 1 And how can we know whether that diameter which extends from the upper edge of the sacrum to the os pubis, is long enough to allow the passage of the child 1 The proper conforma- tion of this part is known by the roundness and equal- ity of the hips, both in the transverse and perpendi- cular direction ; by the projection of the pubes ; by the moderate depression of the sacrum; by an extent of four or five inches from the middle of this depression to the bottom ofthe os coccygis; by an extent of seven or eight inches from the spinous process of the last lumbar vertebra to the highest part of the mons ve- neris, in a woman moderately fat; and by there being an interspace of eight or nine inches between the two anterior superior spinous processes of the ossa ileum. These general calculations, however, are insufficient. In order to acquire more correct opinions, double com- passes have been employed. The branches ofthe first being applied to the top of the sacrum and middle of the mons veneris, three inches are to be deducted from the dimensions indicated by the instrument, viz. two inches and a half for the thickness of the upper part of the sacrum (which is said to be constant in subjects of every size), and half an inch for that of the os pubis. In women who are exceedingly fat, some lines must also be deducted on this account. Hence, when the total thickness of the pelvis measured in this di- rection is seven inches, there will remain four for the distance from the upper part of the sacrum to the os pubis, or for the extent of the lesser diameter of the upper aperture of the pelvis. For taking the measurement internally, a kind of sector was invented by Coutouly. It bears a consider- able resemblance to the instruments employed by shoe- makers for measuring the feet. It is passed into the vagina, with its two branches approximated, until one arrives opposite the anterior and upper part of the sa- crum, when the other is to be drawn outwards, so as to be applied to the pubes. The distance between the branches is judged of by the graduations on the instru- ment. This was named by its inventor a pelvimeter. According to Sabatier, it is not always easy to place it with accuracy; its employment is attended with some pain; and there are particular cases in which it can- not be used. Instead of this contrivance, the celebrated Baude- loque recommended a means which seems to be very safe and simple. The index finger of one hand is to be introduced into the vagina to the upper part of the projection of the sacrum. The finger, having the ra- dial edge turned forwards, is then to be inclined ante- riorly till it touches the arch of the pubes. The point of contact being then marked with tbe opposite hand, the length from the point in question to the end of the finger is to be measured. This length, which indicates the distance between the sacrum and the bottom ofthe symphysis pubis, usually exceeds that of the lesser dia- meter ofthe pelvis by about six lines. Baudeloque ac- knowledges that this measurement is not exactly accu- rate", bat he believes it will do very well, because, un- less the narrowness of the pelvis be extreme, two or three lines hardly make any difference in the facility of parturition. The following is the description of the pelvis of the woman twice operated upon by Dr. Locher: the ossa pubis, which should be on the same level with the pro- montory of the sacrum, were found perpendicularly under it; so that the child necessarily extended the ab- dominal integuments bv its own weight, into a pen- dulous bag overhanging the thighs. For the same rea- son, nothing could be felt of the child by examination per vaginam. The sacrum, instead of closing the pel- vis behind by a semicircular curve, which forms a kind of conductor for the child in parturition, stretched nearly horizontally backwards. A representation of this pelvis, with a few other particulars, may be seen in a modern publication.—(ilfed. Chir. Trans, vol. 11, p. 199.) The pelvis may be every where well formed, and yet present an insurmountable obstacle to delivery, in case an exostosis, lessening its dimensions, should exist on one of the bones which compose this part of the skele- ton. Pineau met with a case of this description in a woman who died undelivered. The tumour originated from one of the ossa pubis. A steatomatous swelling, situated with the head of the child in the upper aper- ture of the pelvis, might produce the same effect unless it were detected, and could be pushed out of the way, so as to make room for the foetus to pass. Baudeloque mentions a swelling of this kind. It was six or seven inches long, and an inch and a half in width. The ex- tremity of it, which was as large as half a hen's egg, had a bony feel, and contained nine well-formed teeth, the rest of" the mass being steatomatous. It had de- scended into the lesser pelvis, below the projection ofthe sacrum, and a little to one side. It might have been taken for an exostosis of this last bone. The labour- pains continued sixty hours, and the propriety of per- forming the Cesarean operation was under considera- tion. Baudeloque was averse to this proceeding. Here- commended turning the child and extracting it by the feet, because he thought that the pelvis was sufficiently ca- pacious to admit of delivery. The event proved that it was three inches nine lines from before backwards, and four inches nine lines transversely. The fostus was soon easily extracted. The assistance of the for- ceps was necessary to get out the head. The child was still-born. The mother, exhausted with numerous unavailing efforts, only survived between fifty and sixty hours. Baudeloque was of opinion that a de- fective regimen also tended to occasion her death. Among the insurmountable obstacles to delivery may be reckoned such a displacement of the uterus that this viscus protrudes from the abdomen and forms a hernia. The records of surgery have preserved some examples of. this extraordinary occurrence. Twice has the Cesarean operation been performed, and in one of the two cases, the woman survived so long that hopes were entertained of her recovery. Indeed, as Sabatier observes, why should not the operation suc- ceed in such a case, where the uterus is only covered by the integuments, and there is no occasion to cut into the abdomen, just as well as other instances in which it is indispensable to divide the muscles, and open the cavity of the belly 1 In the other case on record, de- livery was effected in the ordinary way, either by raising the abdomen and keeping it in this position with towels skilfully placed, or by making pressure on the uterus, which had the beneficial effect of making this organ resume its proper situation. Having shown the absolute necessity for the Cesa- rean operation under certain circumstances, it remains to consider the proper time for performing it, the re- quisite preparatory means, and the method of ope- rating. With regard to the time of operating, practitioners do not agree upon this point: some advising the opera- tion to be done before the membranes have burst and the waters been discharged; others not till afterward. The arguments in favour of the first plan are, the fa- cUity with which the uterus may be opened without any risk of injuring the foetus, and the hope that the viscus wiU contract with sufficient force to prevent he- morrhage. The advocates for the second mode believe, that in operating after the discharge of the waters, there is less danger of. the uterus falling into a state of relaxation, in consequence of becoming suddenly empty after being fully distended, and that this method does not demand so extensive an incision. Hence they recommend, as a preliminary step, to open the membranes. Whatever conduct be adopted, it is es- sential that the labour should be urgent and unequi- vocal, that the cervix uteri should be effaced, and that the os tince should be sufficiently dilated to allow the lochia to be discharged; wit at the same time, says Sa- batier, if the operation is not to be done till after the escape of the waters, there ought not to be too much delay, lest the patient's strength should be exhausted, CESAREAN OPERATION. 219 and the violent efforts of labour should bring on an in- flammatory state of the parietes of ihe uterus'. The propriety of emptying the rectum and bladder is so evident, that it is unnecessary to insist upon it. This precaution is more particularly requisite in regard to the latter of these viscera, which has been known to rise so much over the uterus as to conceal the greater part of it. Baudeloque had occasion to remark this circumstance, in a woman upon whom he was ope- rating. The bladder ascended above the navel, and presented itself through the whole extent of the open- ing made in the parietes of the abdomen. The instruments, dressings, Sec which may be wanted, are two bistouries, one with a convex edge, the other with a probe-point; sjonges, basins of cold water acidulated with a little vinegar; long strips of adhesive plaster; needles and ligatures; lint; long and square compresses; a bandage to be applied round the body, with a scapulary, r- tion of the intestines also, into the abdomen, which had come out of the wound with the child. The surgeon who attended the plantation was sent for, a few hours after the accident happened ; and judging, from the situatiou in which he found her, that some dirt had been put into the wound, by the old midwife, with the intestines, he cut open the stitches that had been made, and carefully washed the parts clean, extracted the placenta at the wound, and then stitched it up again. On the third day, after she had recovered from her low state from the loss of blood, which was considera- ble, a fever came on, which was removed by cooling medicines ; she then took bark for ten days. The wound was fomented and dressed properly, and was soon cured; and the woman was well in six weeks' time from the accident, and able to go to her work. The child died on the sixth day, with the Jaw-falling, as it is called; but came into the world healthy and strong. The woman continued perfectly well, menstruated regularly, and was with child again a year or two afterward. She attempted the same operation again; but was watched and prevented, and had a regular and proper labour. She had borne three children be- fore this affair, all with natural and easy births. She was an impatient and turbulent woman, whose vio- lence of temper was the only cause assigned for her conduct.—(Mosely on Tropical Diseases.)—Reese.] Fr. Rousset; Traite Nouveau de V Hyslerotomoto- kia. Paris, 1581. Lat. C. Append. Bauhivi. Basil. 1582. Also, Casarei Partus Assertio Historiologica, ire. 8vo. Paris, 1590. Fr. Rousselus, Fatus vini ex matre viva sine alterutrius periculo Casura; 12mo. Basil. 1591. Theoph. Raynaud, De Ortu Infantium contra Naturam per Sectionem Casaream, i-c. 12/no. Lugd. 1637. A. Cyprianus, Epistola Historiam exhi- bens Fatus humani post 21 menses ex uteri tuba, matre saloa. ac superstite, excisi. 8vo. Lugd. Bat. 1700. TAt's is the celebrated case, related by Albosius at the end of Bauhin's Trans, of Rousset. J. B. Verdnc, Traiti des Opirations de Chirurgie; nonvelle edit. Vtmo. Par. 1721. Sabatier, Midecine Operatoire, t. 1, ed. 2. Recherches sur V Opiration Cisarienne, par M. Simon, in Mim. de l'Acad. Roy.de de Chirurgie, t. 3, p. 210, i-c. and t. 5 p. 317, i-c. idit. in 12mo. Bertrandi, Traite des Opirations de Chirurgie, chap. 5. G. W. Stein, Praktische Anleitung zur Kaisergeburt. Cassel, 1775. Weissenborn, Obs. dua de Partu Casareo. F.r- ford. 1792. C. Gaillardot, sur I'Opiration Cisarienne, Strasb. 1799. N. Ansiaux, Diss, sur I' Operation Ci- sarienne et la Section de la Symphyse de Pubis. Paris, 1803. J. F. Nettmann, Specimen, Sistens Sectionis Casarea historiam. Hal. 1805. Baudeloque, Traiti des Accour.hf--m.ens. Paris, 1807. Denman's Introduc- tion to Midwifery, 4to. 1805. Also, Obs. on the Rupture of the Uterus, ire. 8vo. 1810. Hull's Defence of the Casarean Operation, 8vo. Manchester, 1798. Also, his letters to Mr. J. W. Simmons. Haighton's In- quiry concerning the true and spurious Casarean Ope ration. P. Berten, du Sectione Sigaultiana el Casa- rea, harumque Sectionum inter se Comparattone: (Cull. Diss. Lovan. 4. 321.) G. Ruellan, Quastio, ire. An ad Servandam pro fatu matrem, obstetricum hamatile minus anceps et aque insons, quam ad servandum cum matre fatum sectio Casarea? (Haller, Disp. Chir. 3, 525. Paris, 1744.) A. Lindemann, De Partu Preter- naturali quern Sine Matris aul Fatus Sectione absolvere non licet, ito. Gott. 1755. Med. Obs. and Inquiries, vol. 4, p. 274, i-c. J. Vanghan, Cases, ire to which is annexed an Account of the Casarean Section, i-c. 8i>o. Lond-. 1778. P. J. F. Walckiers, de Hysterolomotocia, live Sectione Casarea. Lovan. 1785. Edin. Med. and Surgicul Journ. vol. 4, p. 1781 vol. 8, p. 11. Garth- shore's Obs. on Extra-uterine Cases, inserted in the 8lh vol. Lond. Med. Journ. Richter's Ansfingsgr. der Wundarzneykunst, b. 7, kap. 5; Gott. 1804. C. Bell, in Medico-Chirurg. Trans, vol. 4, p. 347, i-c.; J. J. Locher,vol.9;andJ.J. Locher, N. Meyer, F. Spilibarth, and J. Lorinser, in vol. 11 of the same work. J. F. Freymann, De Partu Casareo, \2mo. Marb. Catt. 1797. J. Barlow, in Medical Records and Researches, 1708; and in Essays on Surgery and Midwifery. G. Josephi, iiber die Schwangerschaft ausserhilb der Ge- bdrmuttcr,i-c.8vo. Rostock, 1803. Flajani, Osse-va- zioni, i-c. di Chirurgia, t. 3, p. 144, i-c. Roma, 1802. Rhode, Relatio de Sectione Casarea feliciter peracta. 4to. Dorpati, 1803. K. Sprengel, Gesehichte der Chir. th. 1, p. 369, i-c. 8vo. Halle, 1805. M. Baudrluque, Two Memoirs on the Casarean Operation. Trunsl. with notes, ire. by John Hull; 8vo. Manchester, 18)1. E. L. Heim, Erfahrungen, i-c. iiber Schwangerschufttn ausserhulb der Gebdrmutter, 8vo. Berlin, 1812. A. J. A. Stevens, de Conditionibus qua apud parturientcm Sectionem Casaream, vel potius illam Synchondrosis ossium Pubis, postulant, 4to. Lugd. 1817. Diction- nairedes Sciences Mid. t. 17, p. 419, Pons, 1816; and t. 23, p. 293, i-c. 1818. E. Von Siebotd, Journal /Or Geburlshiilfe, Frauevzimmer und Kinderkrankhtiten, b. 3, 8vo. Francof. 1809. J. H. Green, in Med. Chir. Trans, vol. 12, p. 46, i-c. C. F. Graefe iiber Minde- rung der Gefahr beim Kaiserschnitte, nebst der Ges- ehichte eines Falles, in Welchem Mutter und Kind er- halten wurden; in Journ. fur. Chir. i-c. b. 9. p. 1 CALCULUS. Calculi form in the ducts of the sali- vary glands; in the kidneys, bladder, urethra, gall-blad- der, &c. A paper on calculi formed in the lachrymal sac is contained in Graefe's new Journal.—(Journ.fur die Chir. No. 1, Berlin, 1820.) For an account of stones in the bladder, refer to Urinary Calculi. [CALCULOUS DEGENERATION of tiik SCRO- TUM. The following singular case is communicated by Professor Mott. It was first published in the Phi- ladelphia Journal for 1827. " In the practice of surgery we frequently observe very singular morbid alterations of texture, which are worthy of being recorded notwithstanding our inability to account for their production. None of the works that we have examined contain a description of such a degeneration as that we are about to describe, nor have we ever met with another instance of a similar kind. It may, therefore, be useful to state the fact, as a con- tribution towards a more complete history of the mor- bid anatomy of the scrotum. In the summer of 1824,1 was requested to visit J. R. aged about seventy-three, a wealthy farmer, residing upon Long Island. His health had been declining/or two or three years from an affection of his stomach, accompanied, as he stated, with an uncommon disease of the scrotum. The latter complaint had so far in- creased within the last year, as materially to injure Iria health, in consequence of an ulceration and very fetid discharge therefrom. The constant and severe burning which he expe- rienced in the region of the pylorus, with an ejection of the contents of the stomach shortly after eating, to- gether with frequent acrid eructations and costiveness, led to the fear that there was some organic derange- ment of the lower orifice of the stomach. As the disease of the scrotum was the particular object of my visit, I requested permission to examine it. It exhibited a monstrous, and to me a very unique appearance, reaching fully two-thirds the length of his thighs, being from twelve to fifteen times its ordinary bulk, and studded, particulary on each edge (it being flattened anteriorly and posteriorly) with several dozen tumours, of a stony hardness, covered with the integu- ments, from the size of nutmegs to that of a large pea. It resembled an enormous bunch of grapes, or more closely some morbid conditions of the pancreas and spleen which we have occasionally met with. The tumours had all a very white appearance, and the inte- guments of two or three ofthe largest, having been ul- cerated for upwards of a year, poured forth a constant and very fetid discharge. At these openings white bodies were seen, which, when touched with a probe, felt of a stony hardness. A white substance resem- bling mortar was discharging from these openings, which resulted from the crumbling away ofthe calculi, CAL CAL 225 •nd the combination of this substance with the fluid from tie ulcers. This slate of the scrotum was of upwards of twenty years' duration, and had been pradually increasing, the tumours multiplying as the scrotum augmented in size. The patient knew of no cause to which it could be ■ftcribed. From its size and weight, as well as the loathsome nature of tho discharge, he becam desirous to have it removed if practicable and proper. His health being sufficiently good, and the testes appearing to move freely in the diseased mass, led me to recommend that the operation should be performed. An incision wan made around the root or base ofthe . ncrotum, beginning on each side of the under part of the penis, at a point a little above the scrotum, so that some integument of this part ofthe penis in a diseased state was also removed, and carried down to the peri- neum, leaving an angular portion of the scrotum below of about an inch in length. Cautiously cutting through the diseased integuments and the subcutaneous cellular structure, the vaginal coat of each testis was readUy dis- covered and avoided. The whole of the morbid mass was removed by cautious dissection, leaving the tunica vaginalis on each side sound and unopened. Numerous arteries were secured during the dissection in the integu- ments, as well as several large ones in the septum scroti. The perineal portion of the scrotum was susceptible of very considerable elongation, but it was altogether insufficient to cover the testes. Anew covering for them, therefore, could only be looked for from the granulatory process. Light dressings of lint, compress, and a T bandage were applied for the first two days, followed by emollient poultices to favour the second mode of healing. Suppuration and granulation being well established, the new scrotum was increased and fashioned by the use of adhesive straps. His complete recovery from the operation, and the reproduction of a scrotum, was not interrupted by any circumstance. Three years have now elapsed, and he enjoys excellent health, being occasionally obliged to take for a week or two a few grains of the subnitrate of bismuth, to remove the affection of his stomach, which, before the operation was performed, threatened to become an organic disease."—Reese.] CALCULUS IN THE INTERIOR OF THE EYE. See Eye, ic. CALLUS, new bone, or the substance which serves to join together the ends of a fracture, and for the resto- ration of destroyed portions of bone. 1. The old surgeons believed callus to be a mere inor- ganic concrete, a fluid poured out from the extremities of the ruptured vessels, which was soon hardened into bone. They always described it as au " exudation of the bony juice," and imugined that it oozed from the ends of broken bones, as gum from trees, sometimes too rofusely, sometimes too sparingly. The reunion of roken bones, and the hardening of callus, they com- pared with the glueing together of two pieces of wood, or the soldering of a broken pot.—(A. Pare.) They also conceived, that callus sometimes flowed into the joints, bo as to fhrm a clumsy, prominent protuberance. They imagined that callus was a juice which congealed at a determinate period of time, and they therefore had fixed days for undoing the bandages of each particular frac- ture. They supposed, that its exuberance might be suppressed by a firm and well-rolled bandage, and its knobby deformities corrected by pillows and com- presses ; that it might be softened by frictions and oUs, so as to allow the bone to be set anew. All their no- tions were mechanical; and their absurd doctrines have been the apology for all the contrivers of machines, from Hildunus down to Dr. Aiken and Mr. Gooch. 2. By Galen and Duhamel, however, a second doc- trine was entertained, which imputed the formation of callus altogether to the periosteum and medullary tex- ture, which » ere supposed to produce two solid rings round the fracture, the interspace betw een them heme afterward effaced. 3. A third opinion, maintained by Bordenave, and the best modern observers, is, that the process of nature, in the production of callus, bears a great resemblance to the changes which take place in the reunion ofthe sort parts. A bone is a well-organuad part of the livii.g body ; that matter, which keeps its earthy parts together, is of a gelatinous nature. The phosphate of lime, to which a bone owes its firmness, is deposited in the interstices Vo- I --P ofthe gluten, undergoing a continual change and reno- vation. It is incessantly taken up by the absorbents, and secreted again by the arteries. It is this continual absorption and deposition of earthy matter which forma the bone at first, and enables it to grow with the growth of the body. It is this unceasing activity of the vessels of a bone which enables it to renew itself when it is broken or diseased. In short, it is by various forms of one secreting process, that bone is formed at first, is supported during health, and is renewed on all neces- sary occasions. Bone is a secretion, originally depo- sited by the arteries of the bone, which arteries are con- tinually employed in renewing it. Callus is not a con- crete juice, deposited merely for filling up the interstices between fractured bones, but it is a regeneration of new and perfect bone, furnished with arteries, veins, and ab- sorbents, by which its earthy matter is continually changed, like that of the contiguous bone. Indeed, there could be no connexion between the original bone and callus, were the latter only the inorganic concrete, as it was formerly supposed to be. Notwithstanding the more accurate opinions now en- tertained concerning callus, the supposition is still very common, that tne slightest motion will destroy callus, while it is being formed. But, says Mr. John Bell, it is an ignorant fear, proceeding merely from the state of the parts not having been observed; for, when callus forms, the perfect constitution of the bone is restored; the arteries pour out from each end of a broken bone a gelatinous matter; the vessels by which that gluten is secreted expand and multiply in it, till they form be- tween the broken ends a well-organized and animated mass, ready to begin anew the secretion of bone. Thus, the ends of the bone, when the bony secretion com- mences, are nearly in the same condition, as soft parts wlUch have recently adhered; and it is only when there is a want of continuity in the vessels, or when a want of energetic action incapacitates them from renewing their secretion, that callus is imperfectly formed. This is the reason why, in scorbutic constitutions, in patients infected with syphilis, in pregnancy, in fever, or in any great disorder of the system, or whUe the wound of a compound fracture is open, no callus is generated.— (John Bell's Principles of Surgery, vol. 1, p. 500, 501.) How far some of the latter statement is correct, or not, will be seen in the article Fractures. For some time the secretion of earthy matter is im- perfect ; the young bone is soft, flexible, and of an or- ganization suited for all the purposes of bone; but hitherto delicate and unconfirmed; not a mere con- crete, like the crystallization of a salt, which, if inter- rupted in the moment of forming, wiU never form; not liable to be discomposed by a slight accident, nor to be entirely destroyed by being even roughly moved or shaken. Incipient callus is soft and yielding; it is ligamentous in its consistence, so that it is not very easily injured; and in its organization it is so perfect, that when it is hurt, or the bony secretion interrupted, the breach soon heals, just as soft parts adhere, and thus the callus becomes again entire, and the process is immediately renewed. In consequence of the above circumstances, if a limb be broken a second tune when the first fracture is nearly cured, the bone unites more easily than after the first accident; and Mr. J. Bell even asserts, that when it is broken a third and a fourth time, the union is still quicker. In these cases the limb yields, it bends under the weight of the body which it cannot support; but without any snapping or splintering of the bone, and generally without any over-6hootiirg ofthe ends of the part, and without any crepitation. Callus is found to be more vascular than old bone. Mr. J. Bell mentions an instance of a bone, w hich had been broken twelve years before he injected it, yet the callus was rendered singularly red. When a recently formed callus is broken, many of its vessels are rup- tured, but some are only elongated, and it rarely hap- pens that its whole substance is torn. It is easy to conceive how readily the continuity of the vessels will be renewed in a broken callus, when we reflect on its great vascularity and the vigorous circulation excited by the accident in vessels already accustomed to the secretion of bone. These reasons show why a broken or bent callus is more speedily united than a fractured bone. While the ends of a broken bone are connected to- gether by a flexible substance of cartilaginous consist- ence, Dupuytren calls litis bond of union the pruxi- 226 CAM CAN sional callus, which generally lasts until the thirtieth or fortieth day. In a later stage the intervening cartila- ginous matter ossifies; the swelling of the soft parts subsides; and in from six to twelve months the callus or new bony matter filling the medullary canal is ab- sorbed, whereby the latter is restored. The callus re- maining after the completion of this process, Dupuy- tren terms definitive. When bones granulate, says Mr. Wilson, the granu- lations at first appear exactly similar to those of the soft parts, and, as in the soft parts, take place to restore any loss which the bones may have suffered. This process is very similar to that of the first formation of bone. In the skull membrane was first formed; and here, also, in the process of restoration the granulations change into membrane, and then into bone. In cylin- drical bones, the granulations first produce a species of cartilage, and this is afterward converted into bone. Thus, in the restoration of bone, nature is guided by the same laws which prevail in its first formation. If the granulations thrown out on the surface of a bone be viewed in a microscope, they appear to form a number of small points like villi, the bases of which first become si- milar to cartilage, and then to boue. " The preparations from the surface of granulating stumps show the ex- treme delicacy of the first bony tlireads, and also their mode of uniting laterally with each other."- (On the Structure, Physiology, and Diseases of the Bones, i-c. p. 197, 8vo. Lond. 1820.) And in another place he repeats, " I have examined several skulls on the death of the persons, at different periods, from days to years after pieces of bone had been removed, and before vacancies had been com- pletely filled up ; but I never could in any of them dis- cover the least appearance of cartilage." A membrane here always precedes the formation of bone.--(P. 210.) For additional observations on callus see Frac- ture. N M. Mailer, De Callo Ossium; 4to. Norimb. 1707; Duhamel in Mem. de l'Acad. Royale des Sci- ences, an 1741, p. 92 et 222; Boehmer, De Callo Ossium i rubia tinctorum radicis pasta infectorum, ito. Lips. 1752; Dctlilecf, Diss, eihibens Ossium Colli generationcm et naturam per fracta in animali- bus rubia radicepastis ossa demonstratam. 4to. Goett. 1753; A. Marrigues, Sur la Formation du Cal. Paris, 1783. A. M' Donald, de Necrosi, frc. Edin. 1799 The-works of Trojd, David, Blumenbach, and Kueh- ler, as specified at the conclusion of the article Necro- sis. J- F. Meckel, Handb. der Pathol. Anatomie. Leip- zig, 1818, A. 2, p. 62. G. Breschet, Recherchrs Histo- riques et Exper. sur la Formation du Cal. Paris, 1819. J. Wilson, On the Structure, Physiology, and Diseases of the Bones, p. 208, &eo. i-c. Lond. 1820. CALOMEL. (Submuriate of mercury; hydrargyri submurias, L. P.) Its extensive utility in numerous surgical diseases will be conspicuous in a large pro- portion of the articles in this work. When prescribed as an alterative the common dose is a grain once or twice a day; when ordered as a purgative, from three to eight grains may be given; and when directed with the view of exciting salivation, one or two grains, con- joined with opium, are usually administered night and morning. CAMPHOR is used externally, chiefly as a means of exciting the action of the absorbents, and thus dispersing many kinds of swellings, extravasations, indurations, &c. Hence it is a common ingredient in liniments. It has also tbe property of rousing the action of the nerves and quickening the circulation in parts on which it is rubbed. For this reason, in paralytic affections it is sometimes employed. Perhaps there is no composi- tion that has greater porwer in exciting the absorption of any tumour or hardness than camphorated mercu- rial ointment. In cases of delirium, depending on the irritation of local surgical diseases, and in some descriptions of mortification, camphor is occasionally prescribed. It has also been recommended as singularly useful for the relief of stranguries, even those depending on the ope- tion of cantharides. But although it may occasionally have succeeded, when given with this view, it not only does not always do so, but it has been known to cause an opposite effect, sometimes producing great scalding in voiding the urine, and sometimes pains like those of labour.~ (Medical Trans, vol. \,p. 470.) In chordee its utility is generally acknowledged. Persons who cannot procure rest unless th-y take very large doses of opium, sometimes find smaller ones anKwe-". if combined with camphor.—(See Brande's Manual of Pharmacy, p. 46.) CANCER. (Derived from cancer, a crab, to which a part affected with cancer and surrounded with vHri- cose veins was anciently thought to have some resem- blance.) Carcinoma. The disease has two principal forms, one named srir- rhus or occult cancer ; the other, ulcerated or open can- cer According to the usual definition, as Mr. Pearson observes, an indolent seirrhus is a hard and almost in- sensible tumour, commonly situated in a glandular part and accompanied with little or no discoloration of the surface of the skin. But when the disease has proceeded from the indolent to the malignant state,' the tumour is unequal in its figure, it becomes painftil, the skin acquires a purple or livid hue, and the cutane- ous veins are often varicose.—(Principles of Surgery, § 331. 343.) The pain is remarked to be acute and lan- cinating, and its attacks recur with more or less fre- quency. At length the tumour breaks, and is con- verted into cancer, strictly so called, or the disease in the state of ulceration. The female breast and the uterus are particularly subject to the disease. The breasts of men are bat rarely affected. The testes, lips (especially the lower one of male subjects), the penis, the lachrymal gland and eye, the tongue, the skin (particularly that of the face), the tonsils, the pylorus, the bladder, rectum, prostate, and a variety of other parts, are recorded by surgical writers as having frequently been the seat of seirrhus and cancer. They seem, however, to have comprehended an immense number of different malig- nant diseases under one common name, and in many of the cases called cancerous there are no vestiges of the true scirrhous structure. OF SCIRRHIS, OR CANCER NOT IN THE ULCERATED STATE. Mr. Abernethy has given a matchless history of this affection as it appears in the female breast, where it most frequently occurs, and can be best investigated. Sometimes, as he has remarked, it condenses the sur- rounding substance so as to acquire a capsule; and then it appears, like many sarcomatous tumours, to be a part of new formation. In other cases the mam- mary gland seems to be the nidus for the diseased ac- tion. In the latter case the boundaries of the disease cannot be accurately ascertained, as the carcinomatous structure, having no distinguishable investment, is con- fused with the rest of the gland. Sir Everard Home also remarks, that when the disease originates by a small portion of the glandular structure of the breast becoming hard, which is very commonly the case, it ia readily distinguished by the hard part never having been perfectly circumscribed, and giving more the feel of a knot in the gland itself than of a substance dis- tinct from it. In each of these instances carcinoma begins at a small spot, and extends from it in all directions, like rays from a centre. This is one fta- ture distinguishing this disease from many others, which at their first attack involve a considerable por- tion, if not the whole, of the part in which they occur. '- The progress of carcinoma is more or less quick in dif- ferent instances. When slow, it is in general unre- mitting. Mr. Abernethy thinks, that though the dis- ease may be checked, it cannot be made to recede by the treatment which lessens other swellings. On this point, however, he is not positive; for surgeons have informed him, that diseases which eventually proved to be carcinomatous, have been considerably diminished by local treatment. With great deference to Mr. Aber- nethy, I may be allowed to remark in this place, that every tumour which ends in cancer is not from the first of this nature, though it has in the end become so; consequently, it may at first yield to local applications, but will not do so after the cancerous action has com- menced. Hence Mr. Abernethy's opinion, that a true carcinomatous tumour cannot be partially dispersed, at least remains unweakened by the fact that some tu- mours have at first been lessened by remedies, though they at last ended in cancer. Sir E. Home's observa- tions tend to prove that any sort of tumour may ulti- mately become cancerous. Without risk of inaccuracy we may set down the backwardness of a scirrhous swelling to be dispersed or diminished, as1 one of it* mast confirmed fiaturut CANCER. 227 This obdurate and destructive disease excites the con- tiguous parts, whatever their nature may be, to enter into the same diseased action. The skin, the cellular substance, the muscles, and the periosteum, aU become affected if they are in the vicinity of cancer. This very striking circumstance distinguishes carcinoma, says Mr. Abernethy, from several other diseases. In what this author calls medullary sarcoma, the disease is propagated along the absorbing system; but the parts immediately in contact with the enlarged glands do not assume the same diseased action. Neither in the tuberculated species does the ulceration spread along the skin, but destroys that part only which co- vers the diseased glands. According to Mr. Abernethy, a dis)KMition to cancer existing in the surrounding parts, before the actual occurrence of the diseased ac- tion, was a circumstance noticed by Mr. Hunter. Hence arose the following rule in practice: That a surgeon ought not to becontented with removing merely the indurated or actually diseased part, but that he should also take away some portion ofthe surround- ing substance in which a diseased disposition may probably have been, excited. In consequence of this communication of disease to the contiguous parts, the skin soon becomes indurated, and attached to a carci- nomatous tumour, wnich in like manner is fixed to the muscles or other part over which it is formed. As a carcinomatous tumour increases, it generally, though not constantly, becomes unequal u)L 12, p. 220.) These observations ftiUy agree with those which some atten- tion to the appearances of cancer have enabled mo to make. P 3 Scientific surgeons ought undoubtedly to have a de- finite meaning when they employ the term scirrhm; the word is generally used most vaguely;. and, per- haps, influenced by ita etymology, surgeons call an im- mense number of various morbid indurations scirrhi, which are not at all of a malignant or dangerous cha- racter. I have always considered seirrhus as a diseased hardness, in which there is a propensity to cancerous ulceration, and a greater backwardness to recede than exists in any other kind of diseased hardness, although the skin may occasionally not break during life, and a few scirrhous indurations may have been lessened. Though Richter states that this disposition cannot be discovered till carcinoma has actually taken place; though Mr. J. Burns and Sir E. Home affirm that other indurations and tumours may terminate in cancer; though Mr. Abernethy shows that sarcomatous and encysted tumours may end in most malignant diseases, and such as equal cancer in severity (Chir. Works, p. 83); yet it Is now well ascertained, that in all these instances, the changes which precede cancerous ul- ceration bear no resemblance to those of a true malig- nant seirrhus. The puckering of the skin, the dull, leaden colour of the integuments, the knotted and uneven feel of tbe disease, the occasional darting pains in the part, its fixed attachment to the skin above, and muscles be- neath and in the breast, the retraction of the nipple, form so striking an assemblage of symptoms, that when they are all present, there cannot be the smallest doubt that the tumour is a seirrhus, and that the dis- ease is about to acquire, if it have not already acquired, the power of contaminating the surrounding parts and the lymphatic glands to which the absorbents of the diseased part tend. As Sir Everard Home has observed, the truly scir- rhous tumour, which is known to be capable of chang- ing into the true open cancer, when allowed to increase in size, ia known to be hard, heavy, and connected with the gland of the breast; and, when moved, the whole gland moves along with it. The structure of a scirrhous tumour in the breast is different in the va- rious stages of the disease; and a description of the appearances exhibited in the three principal ones, may give a tolerable idea of what the changes are which it goes through previous to its breaking, or becoming what is termed an open cancer. When a section is made of such a tumour in an early stage, provided the structure can be seen to advantage, it puts on the following appearance: the centre is more compact, harder to the feel, and has a more uniform texture than the rest of the tumour; and is nearly of the consistence of cartilage. This middle part does not exceed the size of a silver penny; and from this, in every direction, like rays, are seen ligamentous bands of a white colour and very narrow, looking, in the section, like so many extremely irregular lines passing to the circumference of the tumour, which is blended with the substance of the surrounding glanU. In the interstices between these bands the substance is different, and becomes less compact towards the outer edge. On a more minute examination, transverse liga- mentous bands, of a fainter appearance, form a kind of net-work, in the meshes of which the new-formed sub- stance is enclosed. This structure accords with what Dr. Baillie describes as presenting itself in cancerous diseases of the stomach and uterus. In a more advanced stage of the tumonr, the whole of the diseased part has a more uniform structure; no central point can be distinguished; the external edge is more defined and distinct from the surrounding gland; and the ligamentous bands in different direc- tions are very appareut, but do not follow any course that can be traced. According to Mr. C. Bell, it is the ligamentous bands which produce the retraction of the nipple, by extend- ing between its ducts and destroying its spongy texture. —(.lfed. Chir. Trans, vol. 12, p. 233.) On dissection, Sir Astley Cooper observes, that the breast is one solid mass like cartilage, with very little vascularity except at its edges, and internally fibrous. When the breast has acquired any magnitude, he says, there is gciierallv an opening in it, in which case it has the appearance internally of being worm-eaten and spongy. In the situation of the ulceration it is very vascul.ir, and bloody seruin is met with. The absorb- "sfcp, CANCER. ' ent glands put on the same character as the scirrhous breast. The cellular membrane, skin, and muscles are also affected. Sometimes the diseased glands above the clavicle press upon the thoracic duct, and thus interrupt the transmission of chyle into the blood. Hence the appetite is sometimes voracious, though the patient is rapidly wasting. In the chest, on tbe same side as the disease, hydrothorax prevails, and the ab- sorbents on the pleura are in a morbid state, and small while spots, like pins' heads, are visible. Traces of scirrhous disorder Sir Astley Cooper likewise repre- sents as occasionally existing in the liver, uterus, &c. —(See Lancet, vol. 2, p. 373.) When the tumour has advanced to what may be called cancerous suppuration (which, however, does not always happen in the centre before it has ap- proached the skin and formed an external sore), it ex- hibits an appearance totally different from what has been described. In the centre is a small irregular ca- vity filled with a bloody fluid, the edges of which are ulcerated, jagged, and spongy. Beyond these there is a radiated appearance of ligamentous bands, diverging towards the circumference; but the tumour near the circumference is more compact, and is made up of distinct portions, each of which has a centre, sur- rounded by ligamentous bands, in concentric circles. It is remarked by Sir Everard Home, that in some instances seirrhus has no appearance of suppuration or ulceration in the centre, but consists of a cyst filled with a transparent fluid and a fungous excrescence, projecting into this cavity, the lining of which is smooth and polished. When a large hydatid of this kind occurs, a number of very small .ones have been found in different parts of the same tumour; and in other cases there are many very small ones, of the size of pins' heads, without a large one. These hydatids are by no means sufficiently frequent in their occurrence to admit of their forming any part of the character of a cancerous tumour.—(Obs. on Cancer, p. 156, i-c. bvo. Lond. 1805.) In the fourth chapter of this work the author relates two coses of hydatids found in the breast. In the first, the contents of the cyst were bloody serum; in the se- cond, a clear fluid. These two cases of simple hyda- tids in the breast, unconnected with any other dis- eased alteration of structure, led Sir E. Home to con- sider more particularly the nature of such hydatids as are sometimes found in cancerous breasts: he believes that they form no real part of the disease, but are acci- dental complaints superadded to it; and that, as they occur in the natural state of the gland, they are much more likely to do so in disease.—(Op. cit. p. 108.159.) These hydatid or encysted swellings of the breast are not always regarded as true scirrhi, and in particular Sir Astley Cooper and Mr. C. Bell describe them, ac- cording to my judgment very correctly, as a different form of disease. Sir E. Home defines what he means by cancer as foUows:—"As cancer is a term too indiscriminately applied to many local diseases for which we have no remedy, though they differ very much among them- selves, it becomes necessary to state what the com- plaints are which I include under this denomination. The present observations respecting cancer apply only to those diseased appearances which are capable of contaminating other parts, either by direct communi- cation or through the medium of the absorbents; and when they approach the skin, produce in it small tu- mours of their own nature, by a mode of contamina- tion with which we are at present unacquainted. There is a disease, by which parts of a glandular structure are very frequently attacked, particularly the os tince, the ale of the nose, the lips, and the glans penis. This has been called cancer, but differs from the species of which we are now treating, in not contaminating the neighbouring parts with which it is hi contact; and neither affecting the absorbent glands nor the skin at a distance from it. It is, properly speaking, an eating sore, which is uniformly pro- gressive ; whereas, in cancer, after the sore has made some progress, a ridge is formed upon the margin, and the ulceration no longer takes that direction. It also differs from a cancer in admitting of a cure in many instances and under different modes of treatment. From the facts which have been stated (see the cases detailed in this gentleman's work), it appears that can- cer is a disease which is local in it? origin. In this respect the cases (alluded to) only confirm an opinion very generally received among medical practitioners; but in favour pf which no scries of facts had been laid before the public of sufficient force entirely to establish the opinion."—(P. 145, ic.) Sir E. Home endeavours to establish a second point, that cancer is not a disease which immediately takes place in a healthy part of the body; but one for the production nf which it is necessary that the part should have undergone some previous change connected with the disease. In proof of this, the first two cases in his work are brought forward, and the innumerable instances in which a pimple, small tumour, or wart upon the nose, cheek, or prepuce may remain for ten, fifteen, or thirty years, without producing the smallest inconvenience ; but at the age of sixty or seventy, upon being cut in shaving, bruised by any accidental violence, or otherwise injured, assumes a cancerous disposition. All the cases of induration of the gland of tho breast, or of indolent tumours in it, which have con- tinued for years without producing any symptom, and after being irritated by accidental violence have as- sumed a new disposition and become cancerous, admit of the same explanation; and are adduced as so many proofs of the truth of this latter position.—(P. 147, ic.} With regard to the common opinion, that the pro- duction of seirrhus of the breast is connected with the cessation of the menses, Sir Astley Cooper also expresses his belief, that if a person has a tumour, not originally of a malignant nature, in the breast, an undue action may afterward be excited in it when the change of life takes place; and the disease then as- sumes the character of seirrhus.—(Lancet, vol. 2, p 376.) However, the doctrine, that certain tumours may change their nature and alter into cancer, is one which is sometimes looked upon with suspicion. " Improper treatment may without doubt exasperate diseases, and render a complaint, which appeared to be rjfild and tractable, dangerous or destructive; but to aggravate the symptoms, and to change the form of the disease, are things that ought not to be confounded. I do not affirm (says Mr. Pearson) that a breast which has been the seat of a mammary abscess, or a gland that has been affected by scrofula, may not become can- cerous ; for they might have suffered from this dis- ease had no previous complaint existed; but these morbid alterations generate no greater propensity to cancer, than if the parts had always retained their na- tural condition. There is no necessary connexion be- tween cancer and any other disease ; nor has it ever been clearly proved that one is convertible into the other."—{Pract. Obs. on Cancerous Complaints, p. 8.) To the latter way of thinking, Mr. Abernethy also in- clines ; for in speaking of the occurrence of cancer in parts previously diseased in another manner, he con- fesses, that his own observations have not led him to believe that this change is common. " Cases of tu- mours, which have remained indolent for twenty or more years, becoming cancerous at an advanced pe- riod of life, are not unfrequently met with ;'* but (says Mr. Abernethy) the patients " might have been liable to the formation of a cancerous disease, even if no diseased structure had previously existed." A degree of indecision, however, appears to be thrown ujion this statement by the admission, that cancer is more likely to begin in parts previously diseased.—(Surg. Works, vol. 2, on Tumours, p. 87.) The following are eome of the most distinguishing characters of seirrhus. A scirrhous induration sel- dom acquires the magnitude to which almost all other tumours are liable to grow, when no steps are taken to retard their growth. According to Sir Astley Cooper, the swelling gradually grows from the size of a marble, until it acquires two or three inches in dia- meter ; " for (says be) it rarely happens that the true scirrhous tubercle increases to a very considerable bulk, and this circumstance is one of its criteria."— (Lectures, ic. vol. 2, p. 177.) Many scirrhi are at- tended even with a diminution or shrunk state of the part affected. Scirrhi are generally more fixed and less moveable than other sorts of tumours; especially, when the lat- ter have never been in a state of inflammation. With the exception of fungus hernatodes, other dis- eases do not involve in their ravages indiscriminatel** CANCER. 229 every kind of structure, skin, muscle, cellular sub- stance, Sec, tinil the integuments seldom become af- fected before the distention produced by the size of such swellings becomes very considerable. In scir- rhous cases, the skin soon becomes contaminated, dis- coloured, and puckered. Some few tumours may be harder and heavier than a few scirrhi, but the reverse is commonly the case. As other indurations and tumours may assume the cancerous action, and even end in cancerous ulcera- tion ; and as some true scirrhi, when not irritated by improper treatment, may continue stationary for years ; the occurrence of actual carcinoma cannot prove that the preceding state was that of seirrhus. The only criterion of the latter disease is deduced from the as- semblage of characters already specified; for except the peculiar puckering, and speedy leaden discolora- tion of the skin, no other appearances, considered se- parately, form any line of discrimination. The white ligamentous bands around a seirrhus form a very characteristic mark of the complaint, at least as it presents itself in the female breast; but these cannot be detected till the disease has been re- moved. 0 Hence, the prudence of taking away a consi- derable portion of the substance surrounding every scirrhous tumour. Were any of these white bands left, the disease would inevitably recur. Mr. Pearson has never yet met with an unequivocal proof of a primary seirrhus in an absorbent gland, and (says he) " if a larger experience shall confirm this observation, and establish it as a general rule, it will afford material assistance in forming the diagnosis of this disease.—(Pract. Obs. on Cancerous Complaints, p. 5.) Sir E. Home, however, has given the particu- lars of one case which seemed to him to have com- menced in one of the lymphatic glands, situated be- tween the nipple and the axilla.—(Obs. on Cancer, p. 161.) The position laid down by Mr. Pearson, that when the disease originates in those glands, it wUl rarely be found to be of a cancerous nature, may yet be generally correct. OF CANCER IN THE STATE OF ULCERATION. According to the observations of Mr. Abernethy, the diseased skin covering a carcinomatous tumour of the breast generally ulcerates before the swelling has attained any great magnitude; a large chasm is then produced in its substance, partly by a sloughing and partly by an ulcerating process. Sometimes, when cells contained in the tumour are by this means laid open, their contentB, which are pulpy matter of differ- ent degrees of consistence and various colours, fall out, and an excoriating ichor issues from their sides. This discharge takes place with a celerity which would almost induce belief, that it can hardly result from the process of secretion. When the diseased actions have, as it were, exhausted themselves, an at- tempt at reparation appears to take place, similar to that which occurs in healthy parts. New flesh is formed, constituting a fungus of peculiar hardness, as it partakes of the diseased actions by which it was produced. This diseased fungus occasionally even cicatrizes. But though the actions of the disease are thus mitigated; though they may be for some time in- dolent and stationary ; they never cease, nor does the part ever become healthy. In the mean whUe, the disease extends through the medium of the absorbing vessels. Their glands be- come affected at a considerable distance from the origi- nal tumour. The progress of carcinoma in an absorb- ent gland is the same as that which has been already described. The disease is communicated from one gland to another, so that after all the axillary glands are affected, those which lie under the collar-bone, at the lower part of the neck, and upper part of the chest, become disordered. Occasionally, a gland or two be- come diseased higher up in the neck, and apparently out of the course which the absorbed fluids would take. As the disease continues, the absorbent glands, in the course of the internal mammary vessels, become affected. In the advanced stage of carcinoma, a num- j very distressing in the occult state of the complain?, her of small tumours, similar in structure to the origi- become now a great deal more so. Notwithstanding nal disease, form at some distance, so as to make a cancerous diseases are not always situated in glandu- kind of irregular circle round it. . ]ar parts, the situation of such sores affords some as- The strongest constitutions now sink under the pain sistance in the diagnois ; for six times as many cancer- Rnd irritation which the disease creates, aggravated bv ous affections occur in the lips and female breasts, as the obstruction which it occasions to the function of, in all the rest of the body together.—(B. Bill.) absorption in those parte to which the vessels leading to the diseased glands belong. Towards the conclu- sion of the disease the patient is generally affected with difficulty of breathing and a cough.—(See Aber- nethy's Surgical Works, vol. 2, p. 72, i-c.) The general condition of the patient is excellently described by Mr. C. Bell. After noticing the hectic fe- ver which preys upon her, he observes, " the counte- nance is pale and anxious, with a slight leaden hue; the features have become pinched, the Ups and nostrils slightly livid; the pulse is frequent; the pains are se- vere. In the hard tumours the pain is stinging or sharp; in the exposed surface it is burning and sore. Pains like those of rheumatism extend over the body, especially to the back and lower part of the spine; the hips and shoulders, oint of a finger, and is not thicker than a sixpence." —(Syme, in Edin. Mid. Journ. v. 31, p. 257.) The venereal disease is sometimes a cause of caries; sometimes of necrosis; frequently of both affections together, and in other instances of exostosis. When it attacks the bones of the nose, its destructive effects arise partly from necrosis, and partly from caries, and the face is sadly disfigured. The bones of the palate are sometimes altered in the same manner; but on other occasions the effect upon them is chiefly necrosis. In cates of cancer of the breast the sternum and ribs are sometimes found carious. I believe that in such cases the disease of the bones has nothing in its own j nature entitling it to be regarded as cancerous. It is a mere effect of the original disorder; and if the cari- ous bone could be removed together with every particle of the disease of the soft parts, a cure would probably follow. Or sup|)Osing the carious bone were the only portion of the disease left, it is conceivable that the case might yet end in a cure. At the same time it is pro- per to recollect what has been mentioned in the article Cancer, that Sir Astley Cooper refers in his Lectures to some bones taken from cancerous subjects, where the scirrhous substance is deposited in their structure. [Under the article 7VepftineI have noticed a very re- markable case of caries from syphilis occurring in the cranium, together with its successful treatment. The celebrated Richerand, of Paris, has several times re- moved carious ribs, and this operation has since been related by Dr. M'Clellan, of Philadelphia, and by Dr M'Dowell, of Virginia—Reese ] Caries arising from syphilis most commonly affects the tibia, cranium, ossa nasi, ossa palati, and sternum ; and I believe is mostly complicated with a greater or less degree of necrosis. Caries of the vertebra? is known by peculiar symp- toms, among which a paralysis of the inferior extremi- ties and lumbar abscesses are the most remarkable. Casteris paribus, caries from an external or a local internal cause is less dangerous than that which pro- ceeds from a constitutional disease, particularly when the latter is difficult of cure. Caries of the spongy part of the bones is more dif- ficult to cure than a similar affection of the compact parts. Caries of the carpal and tarsal bones is par- ticularly obstinate. These bones being in close contact, the affection cannot easily be prevented from spreading from one to the other. Amputation is often the only means of cure. The same is frequently the case when the spongy heads of the long bones forming the large joints become carious. Even tins mode of relief is not practicable when the head of the bone Ues very deeply, like that of the os femoris. Canes of the ossa ileum is also observed to be par- ticularly difficult of removal. Caries from scrofula, the most frequent ease of all the examples of this disorder of the bones (H'iss- mann , is more difficult of cure than that from syphi- lis and scurvy; for some efficacious remedies against the latter diseases are known ; but scrofula cannot be said to be within the reach of medicine. The progno- sis is less favourable in old than young subjects, and much depends on the extent of the disease, the pa- tient's strength, and the state of the soft parts. When caries arises from constitutional disease, inter- nal remedies are of course indicated. Thus mercurial and sudorific medicines put a stop to caries from syphi- lis ; while vegetable diet and acids cure both the scurvy and the caries dependent on it. According to writers the indications in the treatment of canes are, either to produce a change in the action of the diseased portion of bone, whereby it may regain a healthy state, or to destroy it altogether. In the caries from constitutional causes, the first ob- ject seems to be brought about by the operation of such remedies as remove the original disease; and I should much doubt whether, in these cases, any very active local treatment is necessary or free from "objec- tion. Of course, tliis remark is meant to apply only to examples in which we possess some medicine or plan which is known to be a tolerably sure remedy for the general disease. This ia not the case in caries from scrofrila, and here issues, blisters, friction, with other local means, are unquestionably advantageous.—(See Joints and Vertebrae.) But surgeons have proceeded far- ther, and not content withissues, blisters, fomentations, eration for a bubonocele was performed, and as the testicle was found diseased, the surgeon made a complete division of the spermatic cord, tied the sper- matic, arteries, and then left the testicle in its natural situation. After a time, the absorbents had diminished the part to a very small, inconsiderable tumour.—(if. Wemhold, in Journ. der Pract. Heilkunde von C. W. Hufelinduwl K. Himley, 1812, zehntes stuck, p. 112.) This case merits attention, because it is the first in- stance, I believe, in which such practice was ever lied. Subsequently the following work has been pub- lished: Non relit Mtthode de trailer le Sarcocele, sans 0.2 avoir recours a VExtirpation du Testicule; par C. Th. Maunoir, 8vo. Ginive, 1820. The new plan consists in dividing and tying the spermatic arteries, and leaving the rest of the cord and the testis undisturbed. When disease, not merely an cedematous swelling, extends far up the cord, Pott, and the best surgeons of the present day, consider the operation of castra- tion as too late. In such cases, Lisfranc has seen Du- bois pull down the cord and then divide it, and Baron Dupuytren cut up the inguinal canal to the internal ring; but all the patients died.—(C. Averil, Operative Surgery, p. 103, Lond. 1823.) Consult Le Dran's Operations. Sharp's Operations of Surgery, chap. 10. Pott on the Hydrocele, ic. Sa- batier, Deia Med. Oper. torn. 1. Bertrandi, Traite des Opir. de Chirurgie, chap. 11. OSuvres Chirurgicales de Desault, par Bichat, torn. 2, p. 449. Larrey, Mi- moires de Ohirurgie Militaire, torn. 3, p. 423, i-c. Pear- son on Cancerous Complaints. J. L. Petit, Traite des Maladies Chirurgicale, torn. 2, p. 519, i-c. C. Bell's Operative Surgery, vol. 1. RicherancPs Nosographie Chirurgicale, torn. 4, p. 281, i-c. ed. 2, i-c. A long account of the particular sentiments of several emi- nent surgeons is to be found in Rees's Cyclopaedia, art. Castration. Roux, Parallile de la Chirurgie An- gloise avec la Chirurgie Francoise, p. 119, i-c. Law- rence, in Med. Chir. Trans, vol. 6, p. 196, 197. Sketches of the Medical Schools of Paris, by J. Cross, p. 139, i-c. Sir A. Cooper's Lectures on the Principles and Practice of Surgery, vol. 2, p. 159, 8w. London, 1825. CATAPLASMA ACETI. Made by mixing a suffi- cient quantity of vinegar with either oatmeal, linseed meal, or bread-crumb. When Unseed is employed, it is best to add a little oatmeal or bread-crumb, in order to keep the poultice from becoming hard. The vinegar poultice is generally applied cold, and is principally used in cases of bruises and sprains. CATAPLASMA ACETOC.E. Sorrel poultice. R-. Acetosce Ibj. To be beaten in a mortar into a pulp. CATAPLASMA ALUMINIS. Made by stirring the whites of two eggs with a bit of alum, till they are coagulated. In cases of chronic and purulent oph- thalmy, it has been applied to the eye, between two bits of rag, and it has been praised as a good application to chilblains which are not broken. CATAPLASMA BYNES. (Malt.) R. Farina bynes. Spumm cerevisia, q. s. This is applied to cases of gangrene and ill-conditioned extending sores. It is used in instances similar to those in whiah the cata- plasma fermenti is employed, and, by giving out carbonic acid gas, is supposed to operate as a gentle stimulus, and as a corrector of fetid effluvia. CATAPLASMA CARBONIS. Made by mixing pow- dered charcoal with linseed meal and warm water, and is applied to improve the condition of several kinds of unhealthy sores. CATAPLASMA CEREVISLE. Made by stirring some oatmeal or linseed meal in strong beer grounds. It is used in the same cases as the cataplasma fer- menti and cataplasma bynes. CATAPLASMA CONII VEL CICUTiE. R. Her- bee cicutas exfoliates I ij. Aquce fontance Ibij. To be boiled till only a pint remains, when as much linseed meal as necessary is to be added. Hemlock poultice is an excellent application to many cancerous and scrofulous ulcers, and other malignant sores; frequently producing a great diminution of the pain of such diseases, and improving their appearance. Justamond preferred the fresh herb, bruised. CATAPLASMA DAUCI. R. Radicis dauci re- centis Ibj. Some bruise the carrots in a mortar into a pulp; while others recommend the carrots to be first boiled. Carrot poultice is employed as an application to ulcerated cancers, scrofulous sores of an irritable kind, and various inveterate malignant ulcers. CATAPLASMA DIGITALIS. Made by mixing lin- seed meal with a decoction of the leaves of the plant. It is said to have great sedative virtues, to be adapted to the same cases as the cicuta poultice, and even to be more beneficial. CATAPLASMA FARINACEUM. The bread and milk poultice, made by putting some slices of bread- crumb in milk, and letting them gently simmer over the fire in a saucepan, till they are properly softened. The mass is then to be mixed and stirred about with a spoon, and spread on linen, in order to be applied. This 244 CAT poultice, which is of the emollient kind, is with many persons the common one for all ordinary purposes. Most surgeons, however, employ, instead of it, the lin- seed poultice, which is cheaper, more readily made, not apt to turn sour, and, in all common cases, quite as advantageous in every respect. CATAPLASMA FERMENTI. Fermenting poul- tice. R. Farince tritici Ibj. CerevisuB spumas, Yest dicta, Ibss. These are tff be mixed together and ex- posed to a moderate heat, till the effervescence begins. In cases of sloughing, and many ill-conditioned ulcers, this is an application of great repute. CATAPLASMA LINI. Linseed poultice. R. Fa- rince lini Ibss. Aq. ferventis Ibiss. The powder is to be gradually sprinkled into ihe hot water, while they are quickly blended together with a spoon. This is the best and most convenient of all the emollient poultices for common cases, and it has nearly superseded that of bread and milk, which was for- merly much more frequently employed. Mr. Hunter speaks in the following terms of the lin- seed poultice and its uses. " Poultices are commonly made too thin , by which means, the least pressure, or their own gravity, re- moves them from the part: they should be thick enough to support a certain form when applied. They are generally made of stale bread and milk. This composition, in general, makes too brittle an ap- plication ; it breaks easily into different portions from the least motion, and often leaves some part of the wound uncovered, which is frustrating the first inten- tion. The poultice which makes the best application, and continues most nearly the same between each dress- ing, is that formed of the meal of linseed; it is made at once, and when applied, it keeps always in one mass. The kind of wound to which the above applica- tion is best adapted, is a wound made in a sound part, which we intend shall heal by granulation. The same application is equally proper when parts are deprived of life, and consequently will slough. It is therefore the very best dressing for a gunshot wound, and probably for most lacerated wounils; for lint applied to a part that is to throw off a slough, will often be retained till that slough is separated, which will be for eight, ten, or more days." CATAPLASMA MURIATIS SODM. R. Pulveris Lini, Micte panis da. partes aequales. Aq. sodce muriates q. s. This is used for diminishing scrofu- lous tumours and glands. When it excites too much irritation in the skin, a linseed poultice may be substi- tuted for it, until this state has subsided. CATAPLASMA PLUMBI SUBACETATIS. R. Liquoris plumbi subacetatis drach. j. Aqua? distillata? lib. j. Mica? panis q. s.—Misce. Practitioners who place much confidence in the vir- tues of lead, externally applied, often use this poultice in cases of inflammation. CATAPLASMA QUERCUS MARINI. This is pre- pared by bruising a quantity of the marine plant com- monly called sea tang, which is afterwards to be ap- plied by way of a poultice. Its chief use is in cases of scrofula, white swellings, and glandular tumours. When this vegetable could not be obtained in its re- cent state, a common poultice of sea-water and oat- meal was substituted by the late Mr. Hunter and other surgeons of eminence. CATARACT. (From KaraoAow, to confound or dis- turb; because the disease confounds or destroys vision.) rX<£u/co>/ia. Tn6%vpa. Gutta opaca. Suffusio. Der Graue Staar. A cataract is usually defined to be a weakness or impediment to sight, produced by opacity of the crys- talline lens or its capsule. Professor Beer applies the term to every perceptible obstacle to vision, situated in the posterior chamber, between the vitreous humour and the uvea.—(Lehre von den Augenkrankheiten, b. 8, p. 279, %vo. Wien, 1817.) Hippocrates and the ancient Greeks described the ca- taract as a disease of the crystalline lens, under the name of yMvKiopa; but no sooner had Galen promul- gated the doctrine of the lens being the immediate or- gan of sight, than the correct opinion of the ancient founder of medicine began to decline, and for many CAT ages afterward, had no influence in practice. In far?, the seat of the cataract was entirely forgotten, till about 1656, when first Lasnier, and afterward Borel, Bonetus, Blegny, Geoffroi, &c. revived the truth which had been so long extinct; and they and a few others believed that the disease was situated in the crystal- line lens. The bulk of practitioners, however, re- mained ignorant of this fact even as late as the begin- ning of the eighteenth century, when the several pub- lications of Maltre-Jan, Brisseau, St. Ives, and Heis- ter combined to render the truth universally known. In 1708, the celebrated M. Mery, who had hitherto joined in the belief that the cataract was not a diseasa of the lens, communicated to the Academy of Sciences a memoir, in which he acknowledges the correctness of the statement made by Brisseau and Maltre-Jan, that vision can take place without the assistance of tho crystalline lens; and he recommended a clergyman who had a cataract to have the lens extracted, which was successfully done by M. Petit. A cataract, even in its highest degree, does not al- ways produce complete blindness. For the most part, its formation takes place slowly; the cases in which it originates very quickly, being but few, and those in which it is suddenly produced in a complete form still more unusual. The characteristic symptoms commonly remarked when a cataract is slowly formed are the following: 1. All objects, especially white ones, seem to the pa- tient to be covered by a thin smutty or dusty cloud, which, as the late Mr. Ware observed, is gene- rally perceptible by the patient before any opacity is visible in the pupil. 2. The decline of vision bears an exact proportion to the increasing opacity distinguish- able behind the pupil. 3. In most cases, the opacity is first discerned behind the pupil, most plainly also at the central point, the instances in which it first pre- sents itself at the edge of the pupil being less frequent. 4. In eyes with a light-coloured iris, the greater pio- gress a cataract makes, the more clearly can one per- ceive at the edge of the pupil a blackish ring, which partly arises from the shadow ofthe iris felling on the cataract, but chiefly from the dark-coloured pupillary edge of the iris, which, in a clear pupil, cannot be seen, but now that a grayish surface lies behind it, is rendered very manifest. This blackish ring is said by Mr. Guthrie to be very evident in cases of soft cata- racts, and to arise from the back of the pupillary edge of the iris being pushed forwards by the size of the lens. But if the dilatation be increased to its full ex tent, by the application of the extract of belladonna, an internal blacker circle will be seen to surround th* turbid or muddy part behind the iris, and the patient sees better for a short time.—(Operative Surgery of the Eye, p. 197.) 5. As a cataract generally begins at the central point behind the pupil, such objects as are placed directly in front of the eye, are most difficultly seen, even in the early stage of the disease, but those which are latterly placed, especially when the light is not too strong, and of course the pupil a good deal dilated, can yet be seen tolerably well. 6. Hence, when the opacity at the central point behind the pupil is at all considerable, the patient is completely blind in a strong light, while, on the contrary, in a moderately dark room, a degree of vision is yet enjoyed. When the opacity is not far advanced, the eyesight may be improved for a short time by the patient's turning hi* back to the light. 7. Persons with incipient cataracts derive the greatest palliative aid from the use of con- vex glasses, because objects are magnified by them; but they only answer while the opacity is inconsidera- ble. 8. To such patients, the flame of a candle seems to be enveloped in a whitish misty halo which always becomes broader the farther the patient is from the light. When the cataract is far advanced, the flame of the candle cannot be seen, and the patient can only indicate the place near which the light is, or say whe- ther it is close or at a distance 9. Lastly, a cataract which forms slowly produces, in the course of its pro- gress, no change in the mobility of the iris; and if this effect sometimes takes place where the disease is very completely developed, the nature of the case is now so manifest that no surgeon is in any danger of mistak- ing the complaint for amaurosis. The characteristic appearances of amaurosis are en- tirely different. 1. The opacity, perceptible behind tha pupil, is at a consule able distance from this opening, CATARACT. 245 aa may be best seen when the eye is viewed sideways. 2. The opacity is somewhat concave. 3. Its colour in- clines rather to a greenish or reddish cast than to gray. 4. The decline of the eyesight is not at all in a ratio to the degree of opacity, tbe patient being almost blind. 5. The pupil is more or less dUated; the iris nearly or quite motionless, its pupillary edge being here and there thrown into an angle, and of course it is not exactly circular. 6. Even the cornea itself is not quite so clear and transparent as in the natural state. 7. The tempo- rary increase or diminution of blindness, so common in patients with incomplete amaurosis, never depends, as in those with cataracts, upon the degree of dilatation of the pupil or the degree of light, but upon causes which tend either to depress or excita the system. 8. The misty halo which such amaurotic patients perceive around the flame of a candle, is not like a whitish cloud, but has all the hues of the rainbow: indeed, the flame itself presents these colours, and when the patient goes to some distance from it, it generally seems split. 9. At no period ofthe complaint are spectacles of any ser- vice in enabling the patient to see better. Such objects as are situated to one side cannot be seen more plainly than those which are directly in front of the eye.—(See Beer's Lehre von den Augenkr. b. 2, p. 281—284.) 10, The sight is not temporarily improved by the applica- tion of belladonna.—(See Guthrie's Operative Surgery of the Eye, p. 212.) According to this author, the first and most important division of cataract is into the genuine and spurious: for the obstacle to vision, situated in the posterior ch ni- ter, between the vitreous humour and uvea, and mak- ing what is termed a cataract, may be either within the limit of the capsule of the lens, or between the ante- rior layer of that capsule and the uvea. The first case is the genuine, the second the spurious cataract. A genuine cataract, when a primary disease, and un- attended from the first with other morbid effects in the eye, is mostly a single independent affection; on the contrary, as the spurious cataract is generally the con- sequence of internal ophthalmy, it is almost always more or less combined with a partial opacity of the anterior layer ofthe capsule, and, of course, with a ge- nuine cataract. The first variety of genuine cataract noticed by Beer is that which he calls lenticular: it always begins in the centre or very nucleus of the lens, mostly present- ing a dull, yellowish gray colour, which is somewhat deeper at the centre than at the margin of the pupil; a character retained even when the disease is in its most complete stage. The lenticular cataract is always formed very slowly, and, except when the iris is too dark-coloured, it is more or less attended with a black- ish ring at the edge of the pupil, which ring becomes plainer as the disease advances. A genuine lenticular cataract never causes any alteration in the expansion or contraction of the iris; nor does it even in its highest degree deprive the patient of all power of vision, who, in shady places, or when the pupU is artificially dilated with hyosciamus or belladonna, is often capable of dis- tinguishing pretty well many objects which are placed laterally with respect in the eye. A lenticular cataract is usually at some distance from the uvea, so that the extent of the posterior chamber is manifest, while the opacity presents more or less of a convex appearance, and never that of very white cloudy specks. Fre- quently, as Beer observes, the lenticular cataract is un- attended with any change in the capsule, or the liquor of Morgagni In most cases of senUe cataract, not preceded by inflammation, the capsule is said to remain transparent.—(Travers, Synopsis of the Diseases of the Eye, p. 207, 8uo. Lond. 1820.) The second species of genuine cataract noticed by Beer is the capsular, which he thinks should not be called membranous, as the expression may lead to mis- take. The disease seldom commences in the centre of the pupil, and usually arises at its margin in the form ] of distinct, very white, shining points, streaks, or specks; ' its colour, therefore, is always very light, and never al- together uniform, even when the disease is completely formed The dotted or mottled appearance of this ca- taract is also particularly noticed by Mr. Travers.—(Sy- nopsis of the Diseases of the Eye, p. 207.) The black- ish ring' which, when the iris is light-coloured, is even more evident in this than the lenticular cataract, is here not owing to the shadow of the iris, but to its dark border; for this cataract is too near the iris for any sha- dow to be formed. This observation, however, is some- what at variance with what Mr. Travers has remarked; for when a transparent circumference can be seen on dilating the pupil with beUadonna, he has never found the capsule opaque; and he believes that the black rim may be considered as the diagnostic mark of the trans- parency of the capsule. But when the opacity of the lens is diffused, this sign is of course absent.—(Med. Chir. Trans, vol. 4, p. 288.) The disease also has some effect on the motions of the iris, at least their quickness. A capsular cataract never remains long the only affec- tion, but is followed by disease of the lens itself; a feet, says Beer, which cannot surprise us, when we consi- der that it is through the medium of the capsule, that the particles of the lens are incessantly undergoing the changes of removal and reproduction. The capsular cataract is subdivided by Beer into the anterior capsular cataract, the posterior capsular ca- taract, and the complete capsular cataract, in which both the front and back portions of this membrane are opaque. The anterior capsular cataract, which is not at all unfrequent, does not continue long in this form after it has attained a high degree, but, according to Beer, be- comes combined with an opacity, and, according to Mr. Travers, with a slow absorption of the lens itself.— (Synopsis, i-c. p. 207.) " When the capsule is com- pletely opaque (says Mr. Travers), we can hardly judge of the texture of the lens." But in such examples, "the lens is commonly diminished in bulk; it undergoes a waste after the opacity of the capsule, so as in process of time to become a membranous cataract. This I con- ceive to be owing to the obliteration of the vessels of the capsule, from which those of the lens are derived. When the capsular opacity is congenital, it is either purely capsular or only a very small piece of lens re- mains. When the capsule turns opaque from injury, the lens is soon greatly reduced in bulk, as appears from the falling in or concavity of the iris, which loses ita support, and is demonstrated in the operation. This ob- servation renders the operation with the needle appro- priate to the cataract in which the capsule is opaque, in cases which are not very recent."—(Med. Chir. Trans. vol. 4, p. 286.) In the anterior capsular cataract, ac- cording to Mr. Guthrie, the lens does not generally un- dergo any diminution, but, for the most part, an enlarge- ment, in consequence of becoming opaque and soft. But he admits, that the reverse is frequently the case in infants, only a small portion of the lens being left, and the rest of the contents of the capsule fluid.—(See Ope- rative Surgery of the Eye, p. 233.) The anterior cap- sular cataract may be known by its light gray and, in some places, completely chalk-white colour, intersected by shining, mother-of-pearl-like streaks and spots. As the capsule is at the same time thicker than natural, the posterior chamber is lessened, and the cataract is not unfrequently close to the uvea, especially when the lens has also completely lost its transparency. In this stage, the movements of the iris are likewise rendered less quick, and the shadow at the margin of the pupU is en- tirely absent. Hence, vision is not only hurt, but quite impeded, in regard to any correct sensation of Ught, whe- ther the patient be in a Ught or shady situation; and frequently a faint light is completely invisible to him. The posterior capsular cataract belongs to the rarer forms of the disease of the eye; but, says Beer, when it happens, the lens always participates in the opacity much more quickly than occurs in the anterior capsu- | lar cataract. Hence, the disease can never be observed up to its perfect developement. Respecting the state of the lens, some difference prevails between the state- ment of Beer and that of Mr. Travers: the latter gen- tleman informs us, that where the opacity of the poste- rior capsule is met with, which he agrees with Beer in considering as very rare, tlie lens and anterior capsule are usually transparent; "and when this is not the case, and the cataract escapes with a posterior fold of opaque capsule, it is always accompanied with a con- siderable discharge of vitreous humour."—(Synopsis of the Diseases of tbe Eye, p. 209.) And in speaking of the opacity of the posterior capsule, in another work, he informs us, that he has not observed that, in this case, the lens undergoes any diminution.—(Med. Chir. Trans. vol. 4, p. 286.) Like the anterior capsular cataract, it is denoted by a whitish-gray, unequal, variegated co- lour ; but no light-coloured, chalk-white spots and streaks are ever discernible, which, while the lens re- 246 CATAI tains its transparency, may be owing to the distance of the cataract from the pupil. However, the opacity si- tuated behind the pupU always seems concave when the eye is inspected, not from before, but from every side of it. While the posterior half of the capsule is not completely opaque, the lens is not materially affected; the eyesight is only more or less weakened; and sometimes, especially with the aid of a magnifying glass, a tolera- ble degree of vision is enjoyed, notwithstanding the con- siderable opacity behind the pupU. This species of ca- taract has not itself any influence over the motions of the iris, and after the lens becomes opaque, it is not softened. Though the complete capsular cataract is not the rarest species of genuine cataract, it cannot be said to be very common. In addition to the symptoms of the anterior capsular cataract, it presents few, yet decided, characters which indicate it previously to an operation: viz. the iris is nearly motionless, the cataract lying close to that organ; the posterior chamber for the same reason is effaced; and an inexperienced surgeon might really suppose the anterior portion of the capsule were adherent to the uvea, unless he convinced himself of the contrary by producing an artificial dilatation of the pupU with hyosciamus or belladonna. Sometimes the iris even seems thrust out, by this large cataract, to- wards the cornea in a convex form; and the patient can only perceive the strongest kinds of light. Though such is the statement of Beer, I concur with Mr. Guth- rie in regarding the above characters, which may at- tend any large soft cataract, as well as the complete cap- sular one, as by no means a demonstration of the exist- ence of the latter.—(Operative Surgery of the Eye, p. 235.) The third species of genuine cataract is the cataracta Morgagniana, which some term the milk cataract, and others confound with the purulent cataract. It is one of the rarest forms of the disease; so rare, indeed, that Mr. Travers regards the case as purely hypothetical.— (Synopsis of Diseases ofthe Eye,p. 208.) The follow- ing is the form of disease described by Beer under this name; it proceeds from a total conversion of the lens into a milky fluid, or thin jelly, frequently attended with a complete capsular cataract. Its origin is said to be al- ways quick, and an immediate effect of chemical injuries ofthe eye. The following are the symptoms ofthe case, while it is uncomplicated with disease of the lensand cap- sule ; a state which can never continue long. Though the colour is nulk-white, it is delicate and thin, like that of diluted milk. The whole pupil seems cloudy, but when- ever the eyeball moves suddenly and violently, or tbe eyelid is rubbed over the eye, the opaque substances change their shape and position. The posterior cham- ber is nearly annihilated, which may be owing to the quantity of fluid or gelatinous substance collected. While the lens and capsule are not materially changed, the sight suffers only a diminution, though it is very cloudy, and small objects cannot be distinguished at all. When, however, the lens and capsule become opaque, vision is quite abolished, a certain power of knowing light from darkness only remaining. Not unfrequently, says Beer, when the lens itself is in a dissolved state, the capsule is partially opaque, the eye is kept quiet for a few minutes, and the patient stands or sits in an up- right posture, two rows of opaque matter can be plainly seen; the upper being the least white of the two; the lower presenting a chalky whiteness. However, as soon as the patient suddenly or violently moves his eye or head, or the eyelid is rubbed over the eye, both these rows of opaque matter disappear, and the colour of the opacity behind the pupil again seems uniform. The fourth species of genuine cataract described by Beer, is tbe capsulo-lenticular cataract, to which he conceives the Uquor of Morgagni in an altered state may likewise often contribute, as may be inferred from the prodigious size of this cataract. It is by no means un- common, and is attended with the following character- istic symptoms. The colour ofthe opacity, close to the uvea, is partly chalk-white, partly like that of mother-of- pearl, and in many places both these colours can be evi- dently seen disposed one over the other, that of mother- of-pearl, however, being always most superficial. Ex- posure of the eye to the most vivid light scarcely causes any motion ofthe iris, but the pupil is circular, without any angles in it. After the application ofthe extract of henbane or belladonna, the iris contracts again exceed- ingly slowly, and the pupil is long in returning to its former diameter. Besides the obliteration ofthe poste- rior chamber, the anterior one itself is mostly dimi- nished, in consequence of the iris being pushed toward* the cornea by the very large size of the cataract, and hence the sensation of light is very indistinct. The capsulo-lenticular cataract is not unfrequently the consequence of a slow inflammatory process in the iris, the lens, and its capsule; and hence several varie- ties of this case, and its not unfrequent combination with a spurious cataract; all which different modifica- tions, says Beer, should be correctly understood previ- ously to an operation, in order to form a just prognosis of its event, and to know what method of operating ought to be adopted. Of these varieties the first is the capsulo-lenticular cataract, conjoined with slight depositions of new mat- ter upon the anterior capsule of the lens. These after- formations upon the front layer of the capsule, as Beer calls them, put on very different appearances, and ac- cordingly receive various appeUations. For instance, the marbled capsulo-lenticular cataract, when the chalk- white new-formed substances upon the anterior layer of the capsule are so arranged as to resemble the varie gated appearance of marble. The window or lattice capsulo-lenticular cataract, when the new-deposited substances cross each other, leaving darker-coloured in- terspaces. The stellated capsulo-lenticular cataract, when the new matter runs in concentric streaks towards the middle of the pupil. The central capsulo-lenticular cataract, when a single elevated, white, shining point is formed on the anterior capsule, while the rest of this membrane is tolerably clear, and the lens not com- pletely opaque. The dotted capsulo-lenticular cataract, when the front layer of the capsule presents several dis- tinct unconnected depositions on its surface. Tbe half-cataract, or cataracta capsuio-lenticularis dimidi ata, when one-halt ofthe front layer of the capsule is co- vered with a white deposite. In all these, and somt other examples, says Beer, the lens is found to be con verted to its very nucleus into a gelatinous or milky substance. The second variety of the capsulo-lenticular cataract pointed out by Beer, is the encysted, indicated by its snow-white colour; sometimes lying so close to the uvea as to push the iris forwards towards the cornea; and at other times appearing to be at a distance from the uvea. These circumstances, as Beer remarks, almost always depend upon the position of the head; for when this is inclined forwards, the cataract readily assumes a globular form, and projects considerably towards the an terior chamber. Frequently, this variety of the Capsu- lo-lenticular cataract constitutes the kind of case to which the epithets tremulous or shaking, and stw'm- ming or floating are applied. According to Beer, the reason of such unsteadiness in the cataract is owing to the broken or very slight connexion of the capsule of the lens with the neighbouring textures. The same author has never seen any case of this kind, which had not been preceded by a violent concussion of the eye or adjacent part of the head. Both layers of the capsule are opaque, and sometimes considerably thickened. The third variety of the capsulo-lenticular cataract described by Beer, is the pyramidal or conical, which is one of the rarer forms of the disease, and always brought on by violent internal inflammation of the eye, especially af fecting the lens, its capsule, and the iris. It may be known by a white, almost shuiing, conical, more or less projecting, new-formed substance, which grows from the centre ofthe anterior layer of the capsule, and is al- most in close contact with the pupillary margin of the iris. Hence the iris is always quite motionless, and the pupil angular. Sometimes this growth from the capsule extends itself so far into the anterior cham- ber, as nearly to touch the inner surface of the cornea, and sometimes actually to adhere firmly to it: a cir- cumstance, says Beer, which is very constant in the conical staphyloma of the cornea, though not discover- able till the operation is performed. The power of dis- cerning light is feeble and indistinct, and sometimes entirely abolished. Mr. Guihrie (as I think) very cor- rectly regards this case as an advanced degree of the disease presently described under the name given to it by Beer, of lymph-cataract: it ought, indeed to be classed as a spurious cataract.—(See Guthrie's Opera- tive Surgery ofthe Eye, p. 246.) The fourth variety of the capsulo-lenticular cataract is the siliquose. Though principally met with in young CATARACT. 247 children, It ia not one ofthe most uncommon affections In adulta, and in the former it is often falsely regarded as a congenital complaint. When this cataract is ex- tracted either from children or grown-up persons, Beer aays, that the dried shrivelled, capsule is always found round the equally dry nucleus of the lens, like a husk, or shell. In children, however, he says, that the nu- oleus ofthe lens is often scarcely perceptible, while in adults it is always of considerable size, and this may be the reason why this cataract in children does not pre- sent so bright a yellow-white colour as it does in grown- up persons. In infants, in which it is frequently seen in the first weeks of their existence, it is manifestly produced by a slow and neglected inflammation of the lens and its capsule, arising from too strong light. In adults, the inflammation exciting this form of cataract is always owing to external violence; yet Beer sup- poses, that a considerable diminution of cohesion be- tween the capsule and the adjacent textures must like- wise have a principal share in bringing on the disease, which in grown-up persons, is constantly preceded by a concussion ofthe eyeball, from the cut of a whip, the lash of a horse's tail, &c. Professor Schmidt had never seen this kind of cataract, except in boys and girls, who in their early childhood had been afflicted with convulsions; and hence, he thought, that the cause of the disease was owing to a partial loosening of the cap- sule from its natural connexions by the violence of the convulsive paroxysms.—(Abhandlung -iiber Nachstaar und Iritis nach Staar-Operationen. Wien, 1801, 4to.) However, Beer assures us, that he has seen infants, scarcely two months old, affected with this cataract, which had not been preceded or followed by any con- vulsions ; while a much larger number of children with the same kind of cataract had fallen under his notice, where more or less severe blows on the head had been received. With respect to the convulsions, spoken of by Schmidt, he also questions whetherthey and the cataract might not be owing to the same cause, viz. the preced- ing inflammation within the eye? In children, says Beer, this form of cataract may be known by its light- gray, whitish, though seldom very white colour, its di- minutive size and considerable distance from the uvea, and by the freedom with which the iris moves when no adhesions exist at any points between this organ and the cataract, as occasionally happens; a proof of the previous inflammation of the capsule, lens, and neigh- bouring textures. The eyesight is never quite j mpeded, but only much diminished. On the contrary, in adults, as Beer has remarked, this cataract invariably presents a dazzling white hue, and only a few points of it are of a smutty yellowish-white colour, whence the case has been sometimes termed the gypsum-cataract. It is not oonvex, but rather flat; it does not approach the iris; and when free from adhesions to the uvea, which are more likely to happen in adults, it has no effect on the motion of the iris. Vision is generally entirely lost, with the exception ofthe power of discerning the light, and even this faculty is sometimes destroyed in conse- quence ofthe previous violence done to the eye, whereby not merely the lens and its capsule, but also the retina, have suffered. According to Beer, one of the rarest verieties of the capsulo-lenticular cataract is that accompanied with a cyst of purulent matter. It is indicated by a deep le- mon colour, very slow notion of the iris, manifest abo- lition of the posterior chamber, slight convexity of the iris, trivial perception of light, and the weak, unhealthy constitution of the patient. The purulent cyst, which sometimes con tai ns a very fetid matter, and was therefore called by Schiferli the putrid cataract, (Theoretische- Praktische Abhandlung iiber den Grauen Staar, 8vo. Jena and Leipz. 1797), may sometimes be taken out, with- out being broken, together with the whole capsule of the lens, with the aid ofthe forceps, or cataract-tenaculum as was first correctly remarked by Professor Schmidt In one single example, Beer found the cyst of matter between the lens and the anterior portion of its capsule Mr. Travers has likewise seen an example of suppura- tion within the capsule, which projected through the pupil in a globular form, and was filled with pus The case happened in a lad, and had been preceded by a severe blow on the eye.—(Synopsis ofthe Diseases of the Eye, p. 206.) J The sixth and last variety of the capsulo-lenticular cataract mentioned by Beer, is the well-known case de- scribed by the Krench under the name of cataract* barrre the *>ar-catarac<,'and by Schmidt under the appellation of the cataract with a girth or zone. The case, says Beer, is one of the least frequent. The diagnosis is easy; for, behind the diminished, more or less angular pupil, the cataract can be plainly seen, to which is attached, either in a more or less perpendicular or horizontal di- rection, a chalk-white, generally very shining, and thickish kind of bar or girth, which is closely adherent at both its extremities to the pupillary margin of the uvea, and sometimes reaches, but often only on one side, more or less towards the ciliary processes. The iris is therefore completely motionless, the uvea not be- ing merely adherent to the substance forming what is termed the bar or girth, but also closely connected with the whole front portion of the capsule. The perception of light is either very indistinct or quite lost, and not unfrequently the globe of the eye is somewhat smaller than natural. Beer says, that he has never met with this variety of cataract, except after violent internal in- flammation ofthe eye. He describes the substance com- posing the ftaror girth as being of various consistence, and sometimes Arm and almost cartilaginous. In two cataracts of this sort, which he extracted from a boy twelve years of age, he found the bar, strictly speak- ing, ossified, and the capsule, which was nearly cartila- ginous, was adherent to a very small, firm nucleus of the lens, though they were yet capable of separation. In a dead subject Beer also examined such a cataract, in which the outer end of the bar scarcely extended to the greater ring of the uvea, but the inner end reached over the ciliary processes to the ciliary ligament, from which latter part it was inseparable.—(Lehre von den Augenkr. b. 2, p. 302.) OF SPURIOUS CATARACTS. The most frequent, according to Beer, is what he names the lymph-cataract. It is, without exception, the effect of an inflammation which is chiefly situated in the iris, the lens, and its capsule. Hence it is fre- quently combined with a genuine cataract. The na- ture of the disease may be known from the patient's account, that the present blindness has been preceded by a painful tedious affection of his eye and head; and from an examination of the eye itself, in which the pupil will be found more or less diminished and angular; the iris either perfectly motionless or nearly so; the eyesight, and even sometimes the perception of light, more or less impeded or lost, and this not merely in proportion to the quantity of lymph observ- able ipimediately behind the pupil, but also in propor- tion to other morbid effects produced in the organ of inflammation. Lastly, the surgeon may notice, di- rectly behind the pupil, a plastic lymph, either in the form of a delicate kind of net-work, or of a thick web of a snow-white colour. Sometimes in this variety of spurious cataract, though very little coagulating lymph appears upon the anterior portion of the capsule of the lens, and what is effused, as well as the lens itself, is almost clear and transparent, yet the eyesight is con- siderably impaired; and on more careful examination of the pupil, something of a dark-brown colour is per- ceived, which often projects, at several points behind the pupillary edge of the iris, a good way towards the centre of the pupU. In this substance one may discern, with a good magnify in g-glass, new vessels ex- tending from those of the uvea, and formed by the previous inflammation, by means of which yessels this mass and the delicate layer of lymph are con- nected with the capsule of the lens. According to Beer's sentiments, it is only the real lymph-cataract which rightly deserves the epithet membranous, which is sometimes wrongly applied to the capsular cataract; for, says he, the lymph-cataract alone consists of an adventitious membrane, formed by inflammation, of a web of plastic lymph, which may be very thin, and semi transparent, while the lens and its capsule are nearly quite clear, though the patient may be almost or completely bUnd, when the effects of the inflamma- tion have extended to the choroides and retina. The spurious purulent cataract is much less fire- quent than the lymph-cataract. In neglected cases of hypopium (see this word), where the pupil is already quite covered with pus, the greater part of the effused matter is sometimes absorbed, and the pupU can be seen again, but, immediately behind it, a quantity of coagulating lymph can be discerned, as in the lymph- cutaract, sometimes even projecting partly into the an- 248 CATARACT. terior chamber, but blended with particles of purulent matter, so as to give it a light-yellowish tinge and a clustered appearance. The pupil is always diminished, adherent to the morbid substance, and angular; the motionless iris projects towards the cornea; and not only the eyesight, but even the perception of light, is completely lost, or the latter at least much dimi- nished. A rare variety of spurious cataract, described by Beer, is the blood-cataract. Either from some con- siderable injury of the eye, a large quantity of blood is extravasated in the chambers, and slowly absorbed during the ophthalmy caused by the violence, a part of it, however, remaining in the posterior chamber, in the form of small clots encysted in the lymph, which was effused during the inflammation; or else in the course of a more tedious and neglected case of hypo- pium, blood is effused in the chambers of the eye, and not mixing with the pus, still continues in the same form behind the pupil, after the matter has been ab- sorbed. In the first example, this cataract looks like a reddish web, interw-oven with silvery streaks or threads; the pupU, though angular, is seldom con- tracted; the iris nearly or quite motionless; and not only is the light clearly distinguished, but a partial de- gree of vision sometimes retained. On the contrary, in the second instance, the opacity behind the pupil is vety dense, white, studded with reddish or brownish points «r specks, having a clustered appearance, and frequently projecting through the pupil into the ante- rior chamber; while the pupil itself is very small and an- gular, the iris quite incapable of motion, and generally either no perception of light remains, or only a very confined indeterminate sensation of it. Beer says, that this cataract may easily be mistaken for lymph, and that its difference can only be made out with a good magnifying glass. The dendritic cataract of Schmidt, the arborescent cataract of Richter, or the choroid cataract, as Beer ob- serves, is not one of the least frequent of the spurious cataracts, and is invariably the consequence of a vio- lent concussion of the globe of the eye, with or with- out a wound, whereby a portion ofthe tapetum ofthe uvea is loosened, and becomes placed upon the ante- rior layer of the capsule, more or less resembling in its appearance the arborescent, form ofthe stone termed a dendritis. Immediately after such a concussion of the eyeball, the patient complains of a serious diminution and confusion of vision. Whoever examines the eye only superficially, will certainly not discern the pieces of the tapetum lying upon the yet perfectly transparent capsule ofthe lens, for the most careful inspection will be necessary for the purpose, and sometimes the aid of e magnifying-glass will be requisite. But as the lens and its capsule are mostly at the same time loos- ened from their connexions, they likewise generally become deprived of their transparency, and as soon as this has happened, the displaced portion of the tape- tum can be readily seen. When inflammation ensues, the flakes of the tapetum become closely adherent to the front layer ofthe capsule ofthe lens, and even the pupillary edge of the uvea acquires the same kind of connexion, so that the perception of light is diminished. But, says Beer, when inflammation follows, the pupil- lary margin of the uvea remains free, the iris is per- fectly moveable, the light clearly distinguishable, though the lens and its capsule be entirely opaque, and sometimes the flakes of the tapetum resembling the arborescent streaks of the dendritis alter in shape, size, and position, but never completely disappear, though they may not closely adhere to the capsule.—(Lehre von den Augenkr. b. 2, p. 303. 309.) A particular case is described by Mr. Guthrie, as more truly deserving the name of choroid cataract; it arises, without any blow or concussion of the eye, in consequence of a low or anomalous inflammation of the iris. The pupU closes nearly to a point, which remains sufficiently free from opacity for sight to take place with the aid of spectacles. " On the subsidence ofthe inflammation, the iris, by the natural efforts of the part, or under the influence of belladonna, is drawn towards its outer circle or circumference, and the pupil is apparently enlarged; but the uvea, in retract- ing, does not keep pace with its anterior part, or leaves attached to the capsule of the lens so considerable a portion of its pigment as to prevent the passage of the rajs of light through it, while the pupil, at a distance, seems to be of its natural size and blackness." A mi- nute inspection, however, shows that the pupU ia nearly closed. Mr. Guthrie adds, that the operation for closed pupil, by division (the only proper one), is not advisable as long as the patient can see well enough for the common purposes of life.—(See Operative Sur- gery of the Eye, p. 249.) Another classification of cataracts, which is of great importance to an operator, is that which is founded upon their consistence; for, as Beer remarks, this makes not only a great difference in the prognosis, but also in the choice of a method of operating. When the opaque lens is either more indurated than in the natural state, or retains a tolerable degree of firmness, the case is termed a firm or hard cataract. When the substance of the lens seems to be converted into a whitish or other kind of fluid, lodged in the capsule, the case is denominated a milky or fluid cata- ract. When the opaque lens is of a middling consis- tence, neither hard nor fluid, but about as consistent as a thick jelly or curds, the case is named a soft or caseous cataract. When the anterior or posterior layer of the crystalline capsule becomes opaque, after the lens itself has been removed from this little mem- branous sac by a previous operation, the affection is named a secondary cataract. The harder the cataract is, the thinner and smaller it becomes. In this case, the disease presents either artash-coloured, a yellow, or a brownish appearance : according to Beer, its colour is very dark. The inter- space between the cataract and pupil is considerable. The patient distinctly discerns light from darkness, and, when the pupil is dilated, can even plainly per- ceive large bright objects. In the dilated state of the pupil, a black circle surrounding the lens is very per- ceptible. The motions ofthe iris are free and prompt; and the anterior surface of the cataract appears flat, without any degree of convexity —(Richter's Anfangsg. der Wundarzn. p, 177, b. 3. Beer, vol. cit. p. 309.) Beer says, that it is only the genuine lenticular cata- ract which can be hard, and it is chiefly met with in thin, elderly persons; but, with respect to the opinion that all cataracts in old persons are firm, he says, this is frequently contradicted by experience. In cataracts extracted from thin, aged individuals, the lens is sometimes found dwindled, as hard as wood, nearly of a chestnut-brown colour, and with its two surfaces as flat as if they had been compressed. This case has sonctimes been denominated the dark-gray cataract, and is very d fficult to make out previously to an ope- ration, being liable to be mistaken for an incipient amaurosis. Hence, in order to judge of it effectually, the pupil should always be dilated with hyosciamus or belladonna. To the firmish, consistent kind, Beer refers several capsulo-lenticular cataracts, namely, the encysted and conical, or pyramidal cataracts, that to which he ap- plies the epithet dry siliquose, the gypsum cataract in particular, and the bar cataract, which at least is always partly firm, as well as all the varieties of spurious cataract.—(Beer, b. 2, p. 309.) The fluid or milky cataract has usually a white ap- pearance; and irregular spots and streaks, different in colour from the rest of the cataract, are often ob- servable on it. These are apt to change their figure and situation, when frequent and sudden motions of the eyes occur, or when the eyes are rubbed and pressed ; sometimes also these spots and streaks va- nish and then reappear. The lower portion of the pupil seems more opaque than the upper, probably because the untransparent and heavy parts of the milky fluid sink downwards to the bottom of the capsule. The crystalline lens, as It loses its firmness, com- monly acquires an augmented size. Hence, the fluid cataract is thick, and the opacity close behind the pupil. Sometimes, one can perceive no space between the cataract and margin of the pupil. In advanced cases, this aperture is usually very much dilated, and the iris moves slowly and inertly. This happens because the cataract touches the iris and impedes its action. Tha fluid cataract is sometimes of such a thickness, that it protrudes into tbe pupil, and presses the( iris so much forwards as to make it assume a convex appearance. Patients who have milky cataracts, generally distin- guish light from darkness very indistinctly, and some times not at all; partly, because the cataract, when it is thick, lies so close to the iris, that few or no raja CATARACT. 249 of light can enter between them into the eye; partly, because the fluid cataract always assumes, more or less, a globular form, and therefore has no thin edge through winch the rays of light can penetrate—Rich- ter's Anfangsgr. der Wundarzn. b. 3. p. 174, 175.)— Mr. Travers believes, that fluid cataracts are rarely- contained in a transparent capsule, and his experience has taught him, that this membrane is partially opaque, presenting a dotted or mottled surface. The opaque spots are most distinguishable when viewed laterally. —(See Med. Chir. Trans, vol. 4, p. 284.) According to Beer, a fluid cataract is mostly con- joined with a complete opacity of the capsule: its diag- nosis, therefore, is commonly very difficult, and some- times its nature cannot be known with certainty, until an operation is undertaken. When the capsule is opaque only in some places, he states, that the fol- lowing circumstances may be noticed. The cataract lies close to the uvea, and when the patient inclines his head forwards, the cataract presses the iris to- wards the cornea, and the anterior chamber becomes evidently smaller; but when be lies upon his back, the cataract recedes in some degree from the uvea. The power of distinguishing the light is unequivocal. When the head is kept quiet for a long time, a thick sediment and a thinner part can be plainly remarked in the cataract; during which state, that is, while the two substances are undisturbed, the patient can some- times distinguish large well-lighted objects, as through a dense mist; but when the head or eye is qui.'.kly moved, these two substances become confused together again, and the cataract again presents a uniform white colour.—(Vol. cit. p. 312.) It cannot be denied, says Beer, that what is called the congenital cataract, arid which presents itself in infants soon after birth, when their eyes have been exposed to immoderate light, is not unfrequently fluid; but, in such cases, it must not be presumed, that the lens is always in this state; for, in fact, the calnract is often of that sort which Beer describes under the name of dry sili- quose. Sometimu-i the opaque lens is of a middling consist- ence, neither hard nor fluid, but about as consistent as thick jelly, curds, or new cheese. Cases of this de- scription are termed soft or caseous cataracts. The consistence here spoken of may be confined to the two surfaces of the lens, or may exist in its very centre. The first case is the most frequent. The diagnosis is not difficult; for it always has a light-gray, grayish- white, or sea-green colour. When it is far advanced, it quite impedes the eyesight, and sometimes consider- ably interferes with the perception of light.—(Beer, b. 2, p. 310.) As the lens softens in this manner, it com- monly grows thicker and larger, even acquiring a much greater size than the fluid. It is not unfrequent to meet with caseous cataracts of twice the ordinary size of a healthy crystalline lens. The motions of the iris are very sluggish.—(Richler's Anfangsgr. der Wun- darzn. p. 178, b. 3.) Indeed, Beer says that it is sometimes requisite to use the hyosciamus (or rather belladonna) in order to ascertain that no adhesions ex- ist between the uvea and the cataract, for in such cases the posterior chamber is very often completely abo- lished, as the more caseous the lens is, the larger it is; and hence likewise the black ring at the edge of the pupil is not at all owing to the shadow of the iris, but entirely to the dark border of the iris at the margin of that opening. According to Beer, the colour of such cataracts is never uniform, but more or less speckled; the spots, however, either have no determinate outline, or they seem like mother-of-pearl fragments, into which the cataract crumbles when extracted or couched, or else they assume the appearance of clouds.- (Beer, 6. 2, p. 311.) According to Mr. Travers, the caseous cataract has a heavy, dense appearance, uniformly opaque, a clouded, not a fleecy whiteness, and some- times a greenish or dirty wliite tinge.—(Med. Chir. Trans, vol. 4, p. 285.) He farther states, that what he terms the flocculent or fleecy, and the caseous or doughy cataracts, are most frequently met with; the fluid or milky cases, and those called hard, being com- paratively rare. -(Op. tt. loc. cit.) In estimating the consistence of cataracts it is now universally admitted, that their size is a better criterion of it than their colour; and "the larger and more protuberant tho lens pressing forwards into the pupil ami ajalnst the fris, the greater is the certainty of its being soft."— (See Guthries Operative Surgery of the Eye, p. 209.) As Beer observes, a cataract which is recent and has originated suddenly, especially in young subjects, re- quires much more circumspection, ere an operation is determined upon, than a cataract which has already existed a long while, and the formation of which has been only gradual, particularly in an old subject; for the first case is more frequently owing to a concealed slow kind of inflammation than is generally supposed -(Vol. cit. p. 314.) Formerly, cataracts were denominated ripe or unripe; terms which, previously to the time of Mr. Pott, who fully exposed their impropriety, often led to the error of supposing that every cataract must acquire an in- crease of consistence with time, a hardness indicated by a pearly colour, and be thereby rendered more fit to be depressed or extracted. "This opinion (as Mr. Guthrie has observed), founded on the hardness or soft- ness of the cataract, as dependent upon its duration, is contradicted by experience; for cataracts of fifteen or twenty years' duration, and of a pearly colour, have been extracted perfectly soft, while others, of one year's standing and of a milky colour, have been found hard. Neither is the relative state of blindness under these particular circumstances a more just criterion; patients having been found almost entirely blind with a soft cataract, whUe through a hard one they could still distinguish objects and colours.- (Operative Sur- gery of the Eye, p. 190.) A cataract was also called ripe as soon as it was in a state which would admit of no increase, whether the eyesight was completely lost or only diminished, and whether the pupU was entirely occupied by it or not. Thus, says Beer, the siliquose cataract, in its most advanced stage, never totally fills the pupil, and the patient can sometimes even discern colours; nor does the floating capsulo- lenticular cataract fill the pupil in a greater degree; and yet both these cases are completely ripe for an operation. On the other hand, to the unripe cataracts belong the central cataract of the capsule and lens, the posterior capsular cataract and the slight, degree of lymph cataract. Most of these cataracts, after perhaps remaining for years in this state, not unfrequently all of a sudden become complete upon an accidental and slight attack of ophthalmy; but sometimes they remain unchanged during life.—(Beer, b. 2, p. 316.) Anoiher very useful and practical division of cata- racts is into those which are called simple local, and into others which receive the name of complicated. A simple local cataract is so denominated by Beer when the patient is in every other respect perfectly healthy, and no disease prevails in any other part, however dis- tant from the eye. A cataract may be complicated in three ways ; for it may be attended either with other simultaneous disease in the eye itself or its appen- dages, when the case is termed a local complicated ca- taract ; or there is some other disease prevailing in the system, either unconnected or connected with the pro- duction of the cataract, which then has the epithets general complicated applied to it; or, lastly, both de- scriptions of complication exist together, the complete complicated cataract. According to Mr. Guthrie, idio- pathic or constitutional, cataract generally affects both eyes; and the local or accidental form of the disease is more frequently confined to the organ that has been injured either by external violence or active inflamma- tion.—(Op. cit. p. 190.) However, from my being ac- quainted with several cases in which a cataract arose in one eye, without any previous injury or inflamma- tion, and continued many years single, hi one case twenty years, I conclude thai the exceptions to a part ofthe foregoing statement are by no means unfrequent. Among the locally complicated cases is the adhe- rent cataract. The preternatural cohesion may be one of the anterior layer of the capsule with the uvea, pro- duced by effused lymph; it may consist in a very firm connexion of the posterior laver of the capsule with the membrana hyaloidea; or it maybe an unusually close cohesion of the whole of the capsule with the lens; or, says Beer, all the three species of adhesion may exist together.—(P. 318.) The adhesion of the capside of the lens to the uvea (synechia posterior) is generally obvious enough: for, as Beer has observed, tho pupillary margin of the iris is not completely circular, and is more angular the stronger the light is. Th« cataract lies close io ibo lRACT. 250 CAT/ nvea, and is very white. The motions of the iris are more or less obstructed, and when the adhesion is ex- tensive, are quite prevented. The perception of light is indistinct, often very faint, and sometimes entirely lost, for the preternatural adhesion is always the con- sequence of previous internal ophthalmy, which, be- sides occasioning opacity of the lens and its capsule, readily produces other serious effects upon the retina, the choroid coat, and vitreous humour, quite adequate to account for the loss of sight, and the incapacity of distinguishing the rays of light. When the anterior layer of the capsule is adherent only at a single point to the uvea, the extent of the adhesion may be readily ascertained by artificially dilating the pupil with hyo- sciamus or belladonna; and the information thus ob- tained will have great weight in the selection of a me- thod of operating.—(Beer, loco cit.) Some other local complications of cataract are so ob- vious that they cannot fail to be understood ; as, for in- stance, its combination with an adhesion of the iris to the cornea (synechia anterior); with closure of the pupil, unattended by any adhesion of the uvea to the anterior capsule of the lens (synechia posterior); as in watchmakers, and hysterical and hypochondriacal sub- jects, the complications with atrophy, hydrophthal- mia, cirsophthalmia, specks and scars upon tbe cornea, pterygium, and various forms of ophthalmy. According to Beer, the combination of cataract with glaucoma is also readily made out by any body who has once seen the case ; for the cataract always pre- sents a greenish, and sometimes quite a sea-green co- lour ; it is of prodigious size, so as to project through the pupil towards the cornea; .the colour of the iris is more or less changed nearly in the same manner as after iritis; the iris is perfectly motionless ; the pupil very much expanded and drawn into angles, for the most part towards the can thi; the lesser circle of the iris is nowhere visible, because it lies concealed under the far-projecting soft cataract; the light cannot be perceived, though the blinded patient is frequently con- scious of false luminous appearances within the eye (photopsia); and, lastly, the case is invariably accom- panied with more or less of a varicose, state of the blood-vessels of the eye. The origin of this sort of cataract is constantly attended with severe obstinate headache. There are, says Beer, two other local complications which are much more difficult to learn before an ope- ration. The first is a cataract combined with a disso- lution of the vitreous humour (synchysis), the diagno- sis of which, indeed, when the affection prevails in a considerable degree, is tolerably easy, as the cataract trembles, and the iris always swings backwards and forwards upon the slightest motion of the eyeball; the globe itself is somewhat affected with atrophy; the eye is quite spoiled, and feels flaccid and unresisting; the sclerotica immediately around the cornea is bluish, as in infants; and the perception of light is uncertain. On the other hand, when the synchysis is not far ad- vanced, the only symptoms are a suspicious softness of the eyeball, and a swinging of the iris when the eye is suddenly or violently moved. The other complication of cataract, sometimes very difficult to detect previously to an operation, is amauro- sis. When, indeed, the pupU is extraordinarily large, the iris nearly or quite motionless, and the patient cannot distinguish day from night, and of course not the least glimmer of light, no great powers of divina- tion are required to predict with certainty that no ope- ration will restore the eyesight, which is aboUshed, not by the cataract, but by tie existing amaurosis. On the other hand, when the motions-of the -iris are nearly as free as in the natural state, the pupU as small as it usuaUy is in a given degree of light, the patient capable of judging accurately of the strength of the light, and yet the cataract conjoined with amaurosis, which, with the exception af the faculty of perceiving the light, eompletely impedes vision, it is then only by a careful inquiry into the history of the disease, that certain cir- cumstances attending the origin of the cataract, and indicating in "some measure the prevalence of amauro- sis, can be traced: some.imes in consequence of one eye being affected wiih amaurosis, and not with cata- ract, a reasonable suspicion may be deduced, that the eye with cataract is also amaurotic; yet, says Beer, in such a case nothing certain can be known before an operation is done. He considers the general complications of cataract to be as numerous as the diseases of the constitution itself, or as the affections of other organs besides the eye- but tbe most common are scrofula, gout, syphilis, psora, old ulcers of the leg, and an unhealthy constitu- tion. CAUSKS, PROGNOSIS, &C. Persons much exposed to strong fires, as blacksmiths, locksmiths, glassmen, and persons above the age of forty, have been reckoned more liable to cataracts than other subjects.— (Wenzel.) In young persons the dis- ease is by no means unfrequent: even children are often affected, and some are born with it. Beer assents to the general correctness of the opinion that old age is conducive to cataracts, since the disease is most fre- quently observed in old persons. Vet, says he, that age, nay, a very great age, cannot be deemed a regular cause of cataract, is clear from the circumstance of many very old and even decrepit individuals being able, with the aid of spectacles, to read the smallest print: and it would seem that other causes, besides old age, are essential to the production of cataracts, as for in- stance immoderate exertion of the eye during youth, particularly in such employments as expose the organ to a strong reflected light.— (Lelire von den Augenkr. b. 2, p. 325.) Among the circumstances which promote the forma- tion of cataracts, Beer enumerates rooms illuminated only by reflected light; and all kinds of work in which the eyes are employed upon shining, small, microsco- pic objects, especially when, during such labour, a de- termination of blood to the head and eyes is kept up by the compressed state of the abdomen, the cataract often seeming to come on more or less quickly with inflammation of the capsule and lens. And, accord- ing to the manifold experience of the same author, one of the most important though least noticed causes pro- moting the formation of cataract, is allowing very strong light suddenly to enter the eyes of a new-born or very young, delicate infant, the consequence of which is, that the cataracts form more or less quickly, with inflammation of the capsule and lens, or remain for life incomplete, as is the case in the central capsulo- lenticular cataract. The habitual examination of mi- nute objects in a depending position of the head, by which an undue proportion of blood is thrown upon the organ, is said frequently to bring on cataracts.— (See Med. Chir. Trans, vol. 4, p. 279.) In the majo- rity of instances, true cataracts arise spontaneously, without any assignable cause. Sometimes, however, the opacity of the lens is the consequence of external violence; a case which more frequently than any other gets well without an operation. Frequently (says a modern writer) the cataract " proceeds from an hereditary disposition which has existed for several successive generations; while in other cases it attacks several members of the same famUy without any disposition of this kind being re- cognisable in their progenitors. Among others, Janin mentions a whole family of six persons who laboured under this disease."—(Obs. sur l'(Eil, p. 149.) Richter extracted the cataract from a patient whose father and grandfather had been affected with the same malady, and in whose son, at that period, it had begun to manifest itself. He adds, that he had seen three children, all born of the same parents, who acquired cataracts at the age of three years.—(On the different Kinds of Ca- taract, p. 3.) " During my apprenticeship with the late Mr. Hill, of Barnstable, I was present when he operated on two brothers and a sister, all of whom were adults, and who stated that three of four others of their family were affected with symptoms not unlike those which they had experienced at the commence- ment of the complaint. I myself recently operated on two gentlemen advanced in years, who informed me that they had a brother on his return from India, who was similarly affected."—(See Adams's Pract. Obser- vations on Ectropium, Artificial Pupil, and Cataract, p. 101, London, 1812.) Beer speaks of families in which the children all became afflicted with cataracts at a certain age; cases, says he, where an operation, though done by the most skilful practitioner, hardly ever succeeds.—(Lehre von den Augenkr. b. 2, p. 331.) Long exposure of the head and eyes to the rays of the sun, together with a bent position of the body, as in some kinds of field labour, is reckoned by Beer a CATARACT. 251 cause promoting the formation of cataracts on the ap- proach of age ; also hard labour near strong fires, as near ovens and forges, in glass-houses, &c. In Eng- land, little credit is given to these opinions. Beer says, that he has also learned from repeated ob- servation, that exposing the eye to the vapour of con- centrated acids, naphtha, and alcohol, will sometimes bring on a cataract; a statement which will be re- ceived in this country with some hesitation, where the vapour of ether has been occasionally recommended for the dispersion of opacities of the lens and its cap- sule. The dust of lime is also supposed to be condu- cive to the disease, cataracts being said to be frequent among the workmen in Ume-pits and kilns. In such cases, I conceive that the cataract has mostly been the result of inflammation. Wounds of the eye, where the weapon has pierced the capsule and the lens, and especially violent con- cussions of the forepart of the globe of the eye, though no wound may exist, are in general followed by a cataract as an immediate consequence. This is the case, says Beer, even when no inflammation arises from the injury, the cataract often occurring in a few hours, and in so considerable a degree as not to admit of being mistaken. The cause of cataract thus rapidly produced must depend, in Beer's opinion, upon the complete separa- tion of the lens from its connexions with the capsule, and not unfrequently in part upon the detachment of the capsule itself from the neighbouring textures; for in such cases this membrane also gradually becomes opaque. According to Beer, cataracts frequently arise from a slow, insidious inflammation of the lens and its capsule. With respect to the prognosis, it must be evident from what has been premised, that there are many ca- taracts in which the cure is highly problematical, and others in which the impossibility of restoring vision, even in the slightest degree, may be predicted with ab- solute certainty. With the little positive information which surgeons possess concerning the causes of cataracts, scarcely any ex]>cctution can ever be entertained of curing opa- cities of the lens and its capsule, by means of medi- cine, so as to supersede all occasion for an operation. A possibility of success, as Beer remarks, can exist only when the cause of the cataract is ascertained, ad- mits of complete removal, and the disease is in an early stage. And he has learned from manifold and repeated trials, that the attempt to cure an incipient cataract will never succeed, except when some deter- minate and obvious general or local affection of a cu- rable nature has had a chief share in the production of the disease of the eye; as, for instance, scrofula in a mildish form, syplulis, (7) and the sudden cure of erup- tions, or old ulcers of the legs, (?) or a slow insidious inflammation of the iris and capsule of the lens. In some examples of this kind, Beer could only check the flurther progress of the cataract, and even when the eyesight was improved, it was never rendered per- fectly clear. And when the cataract was so far ad- vanced and quite developed, with the exception of the general melioration of tbe health, and an improved state of eye, whereby it was put in a better condition for the operation, not the slightest benefit was de- rived from medicine.—(Lehre, ic b. 2, p. 333.) In this country no faith is put in these notions re- specting the constitutional influence of rheumatism, gout, scrofula, syphilis, &c. in the production of cata- racts, except where such general disorders directly ex- cite inflammation of the eye, and opacity of the lens or its capsule is brought on as a consequence of such inflammation. Indeed, Mr. Guthrie maintains that scrofulous inflammation is rarely propagated to the in- terior of tha eye, and that strumous subjects are not more subject to cataract than other individuals; an opinion in which I perfectly coincide. He also re- marks, that there is no evidence of syphilitic patients being particularly liable to cataracts, and this even when they aavu suffered severely and frequently. In ohort, he absolutely denies the power of this and other constitutional diseases to promote the formation of an opacity of the lens and its capsule, unless inflamma- tion of the eve be excited by them (see Operative Sur- gery of the Eye, p. 191); a sentiment which I think is consonant to every fact revealed to us by daily ex- perience. The principal external remedies thai have been tried for the cure of the cataract are, bleeding, cupping, scarifications, setons, issues, blisters, and fumigations, and the chief internal remedies are aperients, emetics, cathartics, sudorifics, cephalics, and sternutatories. Formerly, preparations of eyebright, millepedes, wild poppy, henbane, and hemlock were credulously ex- tolled as specifics for the disorder. Scultetus asserts that he checked the progress of a cataract by applying to the eye the gall of a pike, mixed with sugar; and Spigelius boasted of having successfully used for this purpose theoU ofthe eelpout (mustela fluviatilis). Cataracts are said to have been cured in venereal patients while under a course of mercury. Probably, however, many such cases might have been mere opa- cities of the cornea, or, at most, only transient opacities of the capsule, or depositions of lymph in the posterior chamber, the consequence of existing or previous in- flammation. Wenzel placed no. reliance whatever on the power of any remedies to dissipate a cataract, and as he had remarked their inefficacy in numerous in- stances, he felt authorized in declaring that internal remedies, either of the mercurial or any other kind, are inadequate to the cure of this disorder; and equally so, whether the opacity be in the crystalline or in the capsule, whether incipient or advanced. Although the late Mr. Ware coincided with Wenzel and Beer in regard to the uncertainty of all known medicines to dissipate an opacity, either in the lens or its capsule, or even to prevent the progress of such opacity when once begun, yet, according to his obser- vations, many cases prove that the powers of nature are often sufficient to accomplish these purposes. The opacities, in particular, which are produced by external violence, Mr. Ware had repeatedly seen dissipated in a short space of time, when no other parts of the eye had been hurt. In such cases the crystalline lens is generally absorbed, as is proved by the benefit which is afterward derived from very convex glasses. In some of these cases, though the crystalline had been dissolved, the greater part of the capsule remained opaque, and the light was transmitted to the retina only through a small aperture which had become trans- parent in its centre. Instances are also recorded, in which cataracts, formed without any violence, have been suddenly dissipated in consequence of an acci- dental blow on the eye. The remedies which Mr. Ware found more effectual than others, were the ap- plication to the eye itself of one or two drops of ether once or twice in the course of the day, and occasionally rubbing the eye over the lid with the point of the fin- ger, first moistened with a weak volatile or mercurial liniment. While Mr. Guthrie admits that opacities perceptible behind the iris have been cured under a course of medicine, he considers such events very rare, and to have been accomplished only when the opacity arose from slight depositions in the capsule, the result of simple inflammation rather than from any affection of the crystalline itself. A haziness of the capsule, caused by the extension of inflammation of the iris to it, he says, may almost always be relieved under the treatment proper for the cure of iritis; but he does not believe that an opacity of the lens, dis- tinctly discerned to be such, has ever been removed by medicine. He expresses his decided opinion, that if any lenticular cataracts have really been cured, they were caused by external violence, and disappeared in consequence of their dissolution in the aqueous hu- mour, and the action of the absorbents, the opacity of the lens having been the result of a rupture of its cap- sule. Mr. Ware, who at one time supposed that inci- pient cataracts might be cured by spirituous applica tions, and particularly the sulphuric ether, latterly abandoned the opinion; and it would seem from a note in the third edition of his book on the cataract, that the cases he published in the first and second, and as proceeding from an external injury, were of the lat- ter description.—(Operative Surgery of the Eye, p. 250.) In short, the operation is now regarded as the only means affording any rational hope of restoring the eyesight of patients afflicted with cataracts. Notwithstanding also the perfection to which the operation, with all its different modifications, is really brought, its performance will not always re-establish vision ; nay, says Beer, it is frequently coumerindi- | catcd; and even in favourable cases the result of tha 252 CATARACT. operation is exposed to so many contingencies, that it is rather a matter of surprise that, on the whole, so much success should attend il as is found to happen. When an operation for a cataract is done apparently under favourable circumstances, and its event is un- expectedly very incomplete or quite unsuccessful, sur- geons in vain ascribe the failure to the particular me- thod of operating which they have hitherto adopted, and uselessly abandon it for another; because none of these methods, including that which is preferred, brought to the highest state of perfection possible, can be applicable to all cataracts. But, says Beer, the rea- son of the Ul success is generally rather owing to the operation not having been' indicated, or to a mode of operating not well calculated for the particular case having been selected He ridicules the idea of adher- ing exclusively to any one plan of operating; and whenever the question was put to him, " what is your plan ?" he answered, that his custom was to operate in the manner which appeared to him the best adapted to each particular case about which he was consulted. A surgeon should be able to distinguish, first, the cases of cataract in which an .operation may be done with the best chance of success; secondly, the examples in which the prognosis is more or less doubtful; and, lastly, the cases in which there is a great probability or an absolute certainty of the operation failing, in which last circumstance the practice is prohibited. According to Beer, the result of an operation will probably be favourable, 1. When the cataract is a genuine local complaint, perfectly free from every spe- cies of complication. 2. When the conformation of the eye and surrounding parts is such, as to allow what- ever method of operating may be most advantageous for the particular case, to be done without difficulty. 3. When the patient is intelligent enough to bebave himself in a manner which will not disturb the preci- sion and safety of the requisite proceedings in the ope- ration or the subsequent treatment. 4 When the ope- rator not only possesses all requisite medical and sur- gical knowledge in general, but is capable of judging correctly what method of operating suits the particular case; and when besides he has derived from nature and acquirement such mental and corporeal qualities as are essential to a skilful operator on the eye; viz. an acute eyesight, a steady, but light, skilful hand, ex- cellently qualified for mechanical artifice in general; long, pliant fingers; a delicate touch; a certain ten- derness in the scientific treatment of this particular organ; complete fearlessness; invmcible presence of mind; and proper circumspection. 5. Wlien the re- quisite instruments are not too complicated; but well adapted to the purpose, and in right order. 6. When the domestic condition of the patient is such as not to occasion any particular disadvantages during or after the operation. Yet, says Beer, even with this fortunate combination of circumstances, uniform success must not be expected; for a patient whose sight is quite pre- vented by this disease, and who, previously to its ori- gin was already far-sighted, will be stUl more so after the removal of the diseased lens, aud, in order to see .distinctly the most common objects which are near, he will be obliged constantly to employ suitable glasses. An individual of this description, though the operation tie done with great success, is apt not to be satisfied. But such patients as were short-sighted previously to the formation of their cataracts, are more pleased with the restoration of vision ; as before the operation their eyesight was much less than what it is now, and in general they can lay aside the glasses which they for- merly made use of, without having occasion for any others. Lastly, as Beer remarks, although patients, who before the origin of their cataracts were neither far nor short sighted, are sensible ofthe important bene- fit of an operation, inasmuch as they now plainly dis- cern all objects again, yet they are usually obliged to employ spectacles in reading, writing, or doing any kind of fine work. On the other hand, the result of an operation Beer considers always more or less doubtful, 1. When the cataract is only locally complicated, as, for instance, with pterygium, which may not form any absolute reason against the experiment. 2. When the confor- | mation of the eye and surrounding parts causes several hindrances to the operator; as is the case when the eye is small, and deep in the orbit, and "the fissure of the eyelids very narrow. 3. When the patient is cither very stupid and obstinate, rough-mannered, i»articu- larly timid, or badly fed. 4. When the surgeon knows how to operate only in one way, in which perhaps he has also not had sufficient experience, and when pos- sibly he is also deficient in the qualities specified above as essential to a good operator on the eyes. 5. When the instruments are bad. 6. When in the patient's domestic affairs there are any circumstances which cannot be removed, and are likely to have a bad effect upon the operation, as an unwholesome, damp room, great uncleanliness, &c. 7. When the origin of the cataract was attended with repeated or tedious head- ache, though this may have subsided a long while. 8. When the patient is particularly subject to catarrhal and rheumatic complaints, especially affecting the eyes. 9. When the patient has often had, or still la- bours under, an attack of erysipelas, notwithstanding the parts inflamed be remote from the eye. 10. When the patient's skin is peculiarly irritable. 11. When in his childhood or youth he has been frequently afflicted with convulsions or epileptic fits, though these com- plaints may have ceased many years. 12. When there is the least tendency to certain constitutional diseases, scrofula, gout, syphilis, &c. Gout, however, does not always make an operation fail, as we learn from Mr. Travers, who, in three cases, extracted the cataract from gouty subjects, and, though a smart attack of the disease followed the operation, the eyes were unaffected, and the sight was well recovered.—(Synopsis of the Diseases of the Eye, p. 297.) 13. When the patient'! habit is bad, though not affected with any.definite dis- order. 14. When the patient in his youth has often been troubled with attacks of ophthalmy. 15. When he cannot perceive the different degrees of light, and correctly describe them, while nothing to account for this state can be detected in the eye itself. 16. The re- sult of an operation is always very doubtful, -when there is the slightest tendency to hysteria or hypochondriasis. 17. When the patient is subject to violent mental emo- tions, mania, iders- on the Diseases of the Eye, p. 153. 155.) Besides Mr. Saunders, several other surgeons of the before his death, strongly recommended the use of the needle in the congenital cataract of infants and children. His mode of operating I shall hereafter notice. The late Mr. Gibson, of Manchester, likewise urged the propri- ety of couching young subjects, and fixed on the age of six months as preferable to that of two years. " What- ever objections (says he) have been urged against the safe and effectual use ofthe couching-needle in inlants, have always appeared to me so slight, and so easily surmountable, that without inquiring particularly into the retl state of the question, I have long concluded that the same motives which would induce an operator to couch a cataract at any period of adult life, would equally lead him to perform that operation at any ear- lier period when a cataract existed. Acting upon this presumption, / have operated upon children of all ages for ten years past.''—(See Edin. Med. and Surgical Journal, vol. 7, p. 394.) Mr. Gibson's paper being dated June, 1811, we are of course given to understand, that he pursued this practice from the year 1801, and he asserts that his experience had embraced a considerable number of cases. "In performing the operation of couching infants, it has always appeared to me (says this gentleman), that the advantages to be gained by restoring v'sion at so early a period, are so important as vO bear down any obstacles which may occasionally be opposed to the safe use of the needle. Even the risk of deranging the figure of the pupil forms no solid objection to its use; and may always be avoided by steadiness and good management. Should even a slight change in its figure be produced, it is seldom in the least detrimental to dis- tinct vision, and can scarcely be considered a blemish Ul the eye of any one; except perhaps in that of-a geo- metrician, who may easily reconcile to himself the pre- sen-e of an oval opening, where one of a circular form should exist. It may farther be observed, that if an operator cannot depend upon his management of the eye, so as to render it steady by the introduction of the couching-needle, he can avail himself of the assistance of a speculum to restrain its motions. The following observations will apply principally to infants under twenty months old. The advantages which an operator possesses in operating upon a child of this age, as compared with a child of three years old or upwards, are important. An infant is not conscious of the operation intended: it is free from the fears created by imagination, and can oppose very feeble re- sistance to the means employed to secure it with stea- diness. At an early age it has not acquired the power of retracting the eye deep in the socket, so that the operator has always a good prospect of introducing the couching-needle with ease by watching a proper oppor- tunity. The eye has not at this time acquired the un- steady rolling motion which, after a few years, is so common and remarkable in children born blind, or re- duced to that state soon after birth. So that this impe- diment to the easy introduction ofthe needle does not ex- ist in infants a few months old. The operator also has it in his power to administer a dose of opium, sufficient to render the steps necessary to expose the eye almost en- tirely disregarded by his patient. With respect to the state of the eye itself, but particularly that of the cataract, this is more favourable for the Operation than at any future period of life. In infants, the cataract is gene- rally fluid, and merely requires the free rupture of its containing capsule, which is in that case generally opaque. The capsule, however, is tender and easily removed by the needle, so as to leave an aperture suf- ficiently large for the admission of light. The milky fluid which escapes from the capsule is soon removed by absorption. If, on the other hand (says Mr. Gibson), the cataract should be soft, it is generally of so pulpy a softness that the free laceration of the anterior part of its capsule, and the consequent admission of the aque- ous humour, ensure its speedy dissolution, and disap- pearance, without the necessity of a second operation Should the cataract happen to be hard, there wiU be no more difficulty in depressing it than in an adult. The advantages (says Mr. Gibson) which an operator will possess, when he attempts the removal of a cata- ract in a child of a few months old, are peculiar to that period. In proportion as the age of the patient advances until he arrives at the age of discretion, and can esti- mate, in some measure, the value of sight by feeling its present day have become zealous advocates for operat- loss, the difficulties opposed to the use of the couching ing upon the cataracts of children Even Mr. Ware, ■ needle increase. His fears of the operation, the unstea- 256 CATARACT. diness of the eye, and his power of retracting it within the orbit, present considerable, but not insuperable ob- stacles ; such, however, as every surgeon would wil- lingly dispense with, if he had it in his power Before an operation at an early age is recommended, the practitioner ought (as at any other age) to ascertain that the cataract is not complicated with a defective state ofthe retina, or with a complete amaurosis. Such cases are by no means uncommon. Some years ago, I recollect to have seen five or six children; the families of two sisters, who were all totally blind, and man idio- tic state, with cataracts accompanied by amaurosis."— (Gibson, op. et loco cit.) I find also iu this gentleman's paper some arguments which have been repeated in Mr. Saunders's work. "Few practitioners, at all conversant with cases of blindness from birth, will deny that it is highly proba- ble that the eye may lose a considerable part of its ori- ginal powers, from the mere circumstance of its haVing so long remained a passive organ. Hence, probably, it happens, that in some cases of congenital cataract, the only benefit conferred on the patient by an operation is that of enabling him to find his way in an awkward man- ner, and to discriminate the more vivid colours. Such pa- tients have never been able to discern small objects, or to judge, in any useful degree, of figure or magnitude : I am well aware, however," says Mr. Gibson, " that in some rare instances, such a defective state of the eye exists from birtb. Another circumstance which must have attracted the attention of oculists is, that in a few years, the eye of a patient born blind acquires a restless and rolling mo- tion, which is at length so firmly established by habit, that he has little control over it. This motion unfortu- nately continues for a considerable time after sight has been restored to such a person, and is a very material obstacle to the early attainment of a knowledge of the objects of vision He cannot fix his eye steadily upon one point for a moment, and the inconvenience which arises from this unsteadiness is, to such a per- son, occasionally as great a bar to the distinct view of an object, as the unsteady motion of the same object would be to one whose vision is perfect. This incon- venience any one can appreciate, and, as far as I know, it is completely avoided by restoring sight at an early age." As a motive for operating on infants, Mr. Gibson also comments on the loss of those years which ought to be spent in education.—(See Edin. Med. and Surgical Journal, vol. 7, p. 394. 400.) Mr. Guthrie also joins in recommending the cure of cataracts in children: he considers the period of denti- tion an unseasonable one for the operation; but except- ing the time of this process, if the child be healthy, he thinks it qualified for the attempt at any age, reckoning from that of six months; and that " even if the opera- tion be delayed until the end of the third or fourth year, little or no inconvenience is found to arise from it."— (Operative Surgery erf the Eye, p. 362.) When once it is decided to operate upon a cataract, the sooner the operation is generally done the better, because the anxiety of the patient increases, as Beer says, with every day, nay, with every hour Just be- fore the operation, care must be taken not to let the pa- tient eat a great deal, nor load his stomach with sub- stances difficult of digestion; and if the stomach and bowels should already be disordered by what they con- tain, their contents ought to be carefully removed pre- viously to the operation. In the same manner, if the surgeon wish to keep off much inflammation, and the patient should be constipated, this state must be obvi- ated by suitable medicines. And, lastly, when, at the request of the patient himself, the operation is deferred for a few days, the greatest caution, must be used not to let him expose himself to any causes likely to bring on catarrhal or rheumatic complaints. — (Beer, b. 2, p. 344.) The following advice, delivered by Scarpa, with respect to the preparation of patients for operations on the eye with the needle is valuable: In ordinary cases, there is not the least occasion for any preparatory treatment previous to the operation; all that prudence requires is, that the patient should abstain from animal food and fermented liquors for a few days before submitting to it, and should take one dose of a gentle purgative. But this, like every other general observation, is liable to particular exceptions. Hypochondriacal men, hysteri- cal women, and patients subject to affections of the 1 stomach and nervous system, should take, for two of three weeks before the operation, tonic bitter medicines, particularly the infusion of quassia, either with or with- out a few drops of sulphuric ether to each dose; or, in other cases, 3 j. of Peruvian bark, with 3j. of valerian, may be administered two or three times a day with par- ticular benefit. It is observed by the most accurate writers upon this subject, that hi such persons the symptoms consequent to operations upon the eyes are often much more -violent than in common cases; and it therefore seems proper to endeavour previously to me- liorate their constitutions. When the patient is timid, it is advisable to give him, half an hour before the time of operating, about fifteen drops of the tinctura opii, with a little wine. Some patients, besides being^afflicted with cataracts, have the edges of the eyelids swollen and gummy, with relaxation and chronic redness of the conjunctiva. In this case, before undertaking to couch, it is advisable to apply a blister to the nape of the neck, and to keep it open for two or three weeks, by means of the savin cerate, and to insinuate, every morning and evening, between- the palpebra? and globe of the eye, a small quantity of the following ointment, the strength of which is to be gradually increased : R. Unguenti hy- drargyri nitratis 5 iv. Adipis suillae 5 viij. Olei oliva? 3 ij. When this ointment does not produce the desired effect, an ointment recommended by Janin (Mimoires sur l'(Eil) should be substituted: it consists of I ss. of hog's lard, 3 ij. of prepared tatty, 3 ij. of Armenian bole, and 3 j. ofthe white precipitate of mercury. At first, care should be taken to use it lowered with twice or thrice its quantity of lard. In the daytime, a collyrium, composed of \ iv. of rose-water, ? ss. ofthe mucilage of quince seeds, and gr v. of the sulphate of zinc, may also be frequently used with considerable advantage. By such means, the morbid secretion from the Meibo- mian glands, and membranous lining of the eyelids, will be checked, and the due action of the vessels and natural flexibility of the eyelids restored.— (Saggio di Osservazioni, i-c. suite principali malattie degli 0,-chi; Venez. 1802.) There are three different operations practised for the cure of cataracts, viz. one termed couching, or de- pression, of which the method called reclination is a modification, as will be hereafter explained ; another named extraction; and a third denominated kera- tonyxis, which consists in puncturing tbe cornea with a needle, the point of which is to be conveyed through the pupil, so as to reach the cataract, which is to be gently broken into fragments. As Beer observes, each of these modes has, in particular cases, manifest ad- vantages over the other two ; but no single method will ever be exclusively preferred, and invariably fol- lowed, by any man of experience or judgment. In every operation for a cataract, the position of the patient, as- sistants, and surgeon is of great importance. In order to enable the assistant, who stands behind the patient, to be conveniently near the head of the latter, Beer prefers letting the patient sit on a stool which has no back. However, as I shall presently notice, some emi- nent surgeons have urged good reasons in favour of employing a chair which is completely perpendicular. When the left eye is to be operated upon, the same assistant is to apply his right hand under the patient's chin, and press the head of the latter against his breast, at the same time that he inclines it and himself more or less forwards towards the operator, who sits upon rather a high stool, in front of the patient. In this country, a music-stool is commonly preferred, the height of which can be regulated in a moment, by simply turning the seat round to the right or left, whereby the screw, with which it is "connected, i* made to rise or descend, as may be found most desira- ble. The same assistant then places his left hand flat upon the left side of the patient's forehead, with the points of the fore and middle fingers somewhat under the edge of the upper eyelid; and, with the fore-finger, he is now to raise the edge of this eyelid as much aa possible, following that finger immediately with the middle one, so as to fix the-eyelid with greater cer- tainty. The ends of these fingers, however, must be so applied as not to touch the globe of the eye m tbe slightest manner, much less make any pressure upon it, yet so that the upper part of the eyeball and cornea may be gently resisted by them, when the eye roUi upwards away from the instrument about to be intra- CATA *»eed, whereby this position, which is extremely in- convenient to the operator, may be immediately recti- fied. The patient should also ait obliquely opposite a clear window, so that a sufficient light may fall ob- liquely upon the eyes, without any rays being reflected to the cornea, and becoming a hindrance to the ope- rator. Nor should Ught from any other quarter be ever allowed to fall upon the eyes. The surgeon should sit in front of the patient, whose head ought to be directly opposite the operator's breast, whereby the latter will be enabled to see from above, with the greatest correctness every thing in the eye- during the operation, and will not be under the necessity of raising his arms too considerably. Supposing it to be the left eye which is to be operated upon, he next ef- fectually draws dow%the lower eyelid with the left fore-finger, the end ol which must be placed over the edge of the eyelid, towards the globe of the eye The middle finger is then to be applied in a similar way over the caruncula lachrymalis. The operator now takes in his right hand the requisite instrument for the operation, viz. the needle or knife, which is to be held like a pen, between the thumb and the fore and middle fingers. By this particular arrangement ofthe fingers of the assistant and operator, which, indeed, is partly ineffectual where the fissure of-the eyelids is very nar- row, and the eyeball is diminutive and sunk in the orbit, the restless eye of the timid patient is fixed ; for a point of the finger is disposed on every side to which the eye can possibly turn away from the in- strument about to be introduced, and when the cornea is gently touched with the extremity of the finger, the wrong position which the eye is about to take is im- mediately prevented. This method of fixing the eye, says Beer, is not merely indispensable for young ope- rators, but is the only perfectly unobjectionable one which can be employed on this delicate organ, since all mechanical inventions for this purpose, like the speculum oculi, which keeps the eye steady by con- siderable pressure, or other contrivances, like Rum- pelt's instrument, which does the same thing by means of a short pointed instrumeo- attached to a kind of thimble, and with which the sclerotica is pierced and held motionless, are found by experience to be worse than useless. ' And, as a proof of this fact, Beer ad- verts to the numerous patients who come out of the hands of such operators as employ these instruments, with a more or less hurtful loss of the vitreous hu- mour, and other ill consequences ; a statement which nearly agrees with the observations of Wenzel and Ware. While the late Mr. Ware coincided with Wenzel and Beer, respecting the general objections to specula, he remarks, that in some instances of children born with cataracts, he had been obliged to fix the eye with a speculum; without the aid of which, he found it loudly impracticable to make the incision through the cornea with any degree of precision or safety. His speculum was an oval ring, the longest diameter of which is about twice as long as the diameter of tbe cornea, and the shortest about half as long again as this tunic. Annexed to the upper rim ofthe speculum is a rest or shoulder, to support the tipper eyelid, and by its lower rim it is fixed to a suitable handle. Beer entertained no higher opinion of other inventions, made for the purpose of enabling surgeons to operate on both eyes with the right hand ; for, says he, the right eye should always be operated upon with the left hand, and the left with the right, and he who cannot learn to be equally skilful with both his hands, must always remain a bungler.—(Lehre von den Augenkr. b. 2, p. 347—350.) Mr. Alexander, whose great skUl in operations on the eye is universally acknowledged, employs no as- sistant for raising the upper eyelid, or fixing the eye, which objects he accomplishes himself; and in Ger- many, this independent mode of proceeding has been particularly commended by Barth.—(Etwas iiber die Auszuhung des grauen Staare,fiir den geubten Ope- ratevr, Svo. Wien, 1797.) .. The preceding directions, respecting the position of the assistant, the seats for the patient and surgeon, and the mode of fixing the eye, are chiefly those of Professor Beer. Whether these instructions are in every respect better than the following, winch com- bine the sentiments of some other writers of expe- rience, the impartial reader must judge for himself \\,l I.—R 257 OF COUCHING, OR DEPRESSION OF THE CATARACT, AND RECLINATION. The operation of couching was once supposed to con- sist altogether in removing the opaque lens out of the axis of vision, by means of a needle, constructed for the purpose ; but it is well known to be frequently ef- fectual on another principle, even when the nature and consistence of the cataract do not admit of the depression of the opaque body. Experience fully proves, that the diseased lens, when broken and dis- turbed, with the needle, and especially when fireely exposed to the contact of the aqueous humour by a proper laceration of its capsule, is gradually dissolved and removed by the action of the absorbents. Indeed, couching now means a variety of operations; for it comprehends not merely the depression of the cataract, not simply its displacement in any direction whatsoever, not only the breaking of it piecemeal and the pushing ofthe fragments into the aqueous humour, but likewise the mere disturbance ofthe opaque body. whereby its absorption is sometimes affected, without any kind of depression or displacement of it at all with the needle. When, therefore, the merits of couching are investigated, it is necessary to define precisely what modification of it is meant, and for what parti- cular kind of case its application is designed ; for no surgeon of the present day would confine himself ex- clusively to one method of operating; and, as Mr Guthrie has remarked," In considering the advantages or disadvantages from any or all of the different opera- tions for cataract, it is absolutely necessary to recol- lect, that no individual operation is applicable to every species of the disease; that each kind requires an ope- ration for its relief or cure, sometimes of a particular nature, and differing essentially from that which is found most advantageous in another. To collect then all the objections which can be urged against any of the operations, from a consideration of every case of cataract to which it is and is not applicable, is The patient should be seated rather low, opposite a window where the light is not vivid, and in such a manner, that the rays may fall laterally upon the eye about to be couched. The other eye, whether in a healthy or diseased state, ought always to be closed, and covered with a handkerchief, or any thing con- venient for the purpose; for, so strong is the sympathy between the two organs, that the motions of the one constantly produce a disturbance of the other. The surgeon should sit upon a seat rather higher than that upon which the patient is placed ; and, in order to give his hand a greater degree of steadiness in the various manoeuvres of the operation, he will find it useftil to place his elbow upon his knee, which must be suffi- ciently raised for this purpose, by a stool placed under the foot. The chair on which the patient sits ought to have a high back, against which his head may be so firmly supported, that he cannot draw it backwards during the operation. The back of the chair must not slope backwards, as that of a common one, but be quite perpendicular, in order that the patient's head may not be too distant from the surgeon's breast.— (Richter's Anfangsgr. der Wundarzn. p. 207, b. 3.) The propriety of supporting the patient's head rather upon the back of the chair on which he sits, than upon an assistant's breast, as Bischoff has observed, is founded upon a consideration, that the least motion of the assistant, even that necessarUy occasioned by re- spiration, causes also a synchronous motion of the part supported on his breast, which cannot fail to be disad- vantageous, both in the operation of extraction and of couching. However, as this is not at present the com- mon practice; the inconvenience of having the back of the chair between the assistant and the patient may more than counterbalance the circumstance in which it seems to be advantageous. In certain casps, where the muscles of the eye and eyelids are incessantly affected -with spasm ; or where the eye is peculiarly diminutive, and sunk, as it were, in the orbit, the elevator for the upper eyelid, invented by Pellier, and approved by Scarpa, may possibly prove serviceable: in young subjects, it materially faciUtates tbe operation. The particular sentiments of Wenzel and Ware, con- cerning the mode of fixing the eye, will be farther ex- plained in the description of the extraction of the cata- ract. 2c/3 CATARACT. merely to confuse the subject, and has generally been done for the purpose of recommending some particular mode of proceeding, rather than to regulate these ope- rations by the general principles of surgery."—(Opera- tive Surgery of the Eye, p. 365.) In this respect, the doctrines of Pott, Callisen, Hey, and Scarpa are un- doubtedly wrong, though their sentiments are blended with many valuable and important truths. Beer, who is by no means a great advocate for depression, ad- mits its utility in particular cases. It is easily com- prehensible, says he, that in this way a firm and large cataract either cannot be removed without injuring the reting, and the attachment of the corpus ciliare to the vitreous humour, or not far enough to prevent the opaque body from rising again at the first opportunity. Hence the former complaints about tbe frequent re- turn of the cataract, and other ill consequences, unap- peaseable vomiting, suddenly produced amaurosis, and severe inflammation, &c. But while Beer acknow- ledges the frequency of these ill effects of depression, he condemns the universal rejection of it, attempted at the present day, and the unlimited substitution for it of reclination, which consists in applying the needle in a certain manner to the anterior surface of the cata- ract, and depressing the opaque body into the vitreous humour, in such a way, that the front surface of the cataract is now the upper one, its back surface the lower one, its upper edge backwards, and its lower edge forwards; a change which, Beer says, cannot be made without an extensive destruction of the cells of the vitreous humour. Hence, with few exceptions, this author flunks the common mode of depression should be preferred.—(Lehre von den Augenkr. b. 2, p. 352.) And in this sentiment he is joined by Mr. Travers, who remarks, that the real objection to couching is the breaking up of the fine texture of the globe of the eye, by the forcible depression of the lens. " Whether it be depressed edgeways or breadthways, makes no dif- ference in the result; it must still occupy a breach in the cells ofthe vitreous humour, and must derange and disorder that delicate texture and those connected with it. A slow, insidious inflammation, marked by a gra- dual developement ofthe symptoms of disorganization, viz. congestion of vessels, turbid humours, flaccid tu- nica, and palsied iris, is too often the consequence. The sight, instead of improving when the immediate effects of the injury are passed away, remains habit- ually weak and dim, or declines and fades altogether. The advocates for reclination seem to forget, that the principle, which is the same in both operations, is the real ground of objection. As to the position of the lens, I suspect less mischief is done by the old method of depression, as less force is required to break a space for the vertical than the horizontal lens, provided the depression be carried to no greater extent than is ne- cessary to clear the inferior border of the pupil."— (Synopsis of the Diseases ofthe Eye, p. 318.) The form of couching-needles should vary according to the object designed to be effected by the operation. The needle used by the late Mr. Hey, that recom- mended by Scarpa, and another employed by Beer, are the principal ones. The length of Mr. Hey's needle is somewhat less than an inch. It would be sufficiently long if it did not exceed seven-eighths of an inch. It is round, except near the point, where it is made flat, by grinding two opposite sides. The flat part is ground gradually thin- ner to tUe extremity of the needle, which is semicir- cular, and ought to be made as sharp as a lancet. The flat part extends in length about an eighth of an inch, and its sides are parallel. From the part where the needle ceases to be flat, its diameter gradually increases towards the handle. The flat part is one-fortieth of an inch in diameter. The part which is nearest the handle; is one-twentieth of an inch. The handle, which is three inches and a half in length, is made of light wood, stained black. It is octagonal, and has a little ivory inlaid in the two sides which correspond with the edge of the needle. Mr. Hey describes the recommendations of this in- strument in the following terms: 1. " It is only half the length ofthe common needle; and this gives the operator a greater command over the motions of its point, in removing the crystalline from its bed, and tearing its capsule. It is also of some consequence that the operator should know how far the point of the needle has penetrated the globe of I the eye, before he has an opportunity of seeing i( through the pupil; as it ought to be brought forwards when it has reached the axis of the pupil. Now he may undoubtedly form a better judgment respecting this circumstance, when the length of his needle does not much exceed the diameter of the eye, than w hen he uses one of the ordinary length, which is nearly two inches. The shortness of the needle is peculiarly useful when the capsule is so opaque that the point cannot be seen through the pupil. 2. As this needle becomes gradually thicker towards the handle, it will remain fixed in that part of the sclerotis, to which the operator has pushed it, while he employs its point in depressing and removing the cata- ract. But the spear-shaped needle, by making a wound larger in diameter than that nart of the instrument which remains in the sclerotis, pecomes unsteady, and is with difficulty prevented fiom sliding forwards against the ciliary processes, while the operator is giving it those motions which are necessary for de- pressing the cataract. On the same account the common spear-shaped needle may suffer some of the vitreous humour to es- cape during the operation, whereby the iris and ciliary processes would be somewhat displaced and rendered flaccid; whereas the needle which I use, making but a small aperture in the sclerotis, and filUng up that aperture completely during the operation, no portion of the vitreous humour can flow out so as to render the iris and ciliary processes flaccid. 3. This needle has no projecting edges; but the spear-shaped needle, having two sharp edges, which grow gradually broader to a certain distance from its point, will be liable to wound the iris, if it be introduced too near the ciliary ligament, with its edges in a hori- zontal position. Besides, in whatever manner tbe needle be introduced, one of its sharp edges must be turned towards the iris in the act of depressing the ca- taract; and in the various motions which are often necessary in this operation, tbe cUiary processes are certainly exposed to more danger than when a needle is used which has no projecting edge. 4. It has no projecting point. In the use of V e spear- shaped needle, the operator's intention is to bring its broadest part over the centre ofthe crystalline. In at- tempting to do this, there is great danger of carrying the point beyond the circumference of the crystalline, and catching hold of the ciliary processes or their in- vesting membrane, the membrana nigra." Mr. Hey asserts, that his needle wUl "pass through the sclerotis with ease; depress a firm cataract readily, and break down the texture of one that is soft. " If the operator finds it of use to bring the point of tin needle into the anterior chamber of the eye (which is often the case), he may do this with the greatest safety, for the edges ofthe needle will not wound the iris. In short, if the operator in the use of this needle does but attend properly to the motion of its point, he will do no avoidable injury to the eye, and this caution becomes the less embarrassing, as the point does not project be- yond that part ofthe needle by which the depression is made, the extreme part of the needle being used for this purpose."—(Hey) Scarpa employs a very slender needle, possessing sufficient firmness to enter the eye without hazard of breaking, and having a point which is slightly curved. The curved extremity of the needle is flat upon its dor- sum or convexity, sharp at its edges, and has a con- cavity, constructed with two oblique surfaces, forming in the middle a gentle eminence, that is continued along to the very point of the instrument; there is a mark on that side ofthe handle which corresponds to the convexity of the point. The surgeons of the Leeds Infirmary have had one advantage in the needle, which they have used in imitation of Baron Hilmer; I mean, having it made of no greater length than the purposes of the operation demand. A couching-needle is suffi- ciently long when it does not exceed, at most, an inch in length: this affords the operator a greater command over the motions of the point, and enables him to judge more accurately how far it has penetrated the globe of the eye, before he has an opportunity of seeing U through the pupil. When Scarpa's needle is preferred, it should therefore be of no greater length than the operation requires. The needle here described will penetrate the sclerotic coat as readily a3 any straight I one of the same diameter, and by reason of its slender CATARACT. 259 •fiess, will impair the internal structure of the eye less in its movements than common couclung-needles. When cautiously pushed in a transverse direction, till its point has reached the upper part of the opaque lens, it becomes situated with its convexity towards the iris and its point in the opposite direction; and, upon the least pressure being made with its convex surface, it removes the cataract a little downwards, by which a space is afforded at the upper part of the pupil, between the cataract and cUiary processes, through which the instrument may be safely conveyed in front of the opaque body and its capsule, which it is prudent to lacerate in the operation. In cases of caseous, milky, and membranous cataracts, the soft pulp of the crystalline may be most readily divided and broken piecemeal by the edges of its curved extremity; and the front layer of the capsule lacerated into numerous membranous flakes, which, by turning the point of the instrument towards the pupU, may be as easily pushed through this aperture into the anterior chamber, where Scarpa finds absorption takes place more quickly than behind the pupil. Beer, and many other skilful operators, give the pre- ference to a straight spear-pointed needle. Scarpa's needle made quite straight is a very eligible instru- ment, and Beer's small spear-pointed needle, which is sold at almost every shop for surgical instruments, de- serves all the reputation which it possesses. As Mr. Travers has observed, in all cases of operation with the needle, the employment of a solution of the extract of belladonna in an equal part of distilled wa- ter, is a point of the first importance. " The space in- cluded between the eyebrow and lash should be thickly painted with the solution once, or oftener, in the twenty-four hours, and this varnish should be pre- served moist for a period of half an hour, in order to admit of its absorption The frequency of the appli- cation must be determined by its effect upon the pupil. The preternatural dilatation should not be permanently maintained; for if it be, the pupil will in all probability be misshapen," when the use of the belladonna is sus- pended, and the iris recovers its power.—(Synopsis of the Diseases ofthe Eye, p. 322.) The couching-needle (if the curved one be used) is to be held with its convexity forwards, its point back- wards, and its handle parallel to the patient's temple. The surgeon, having directed the patient to turn the eye towards the nose, is to introduce the instrument boldly through the sclerotic coat, at the distance of at least one line and a half from the margin of the cornea, for fear of injuring the cUiary processes. Most authors advise the puncture to be made at about one line, and Borne even at the minute distance of l-16th of an inch (Hey) from the union of the cornea with the sclerotica; but as the cUiary processes ought invariably to be avoided, and there is no real cause to dread wounding the aponeurosis of the abductor muscle, as some have conceived, the propriety of puncturing the globe of the eye, at the distance of one line and a half, or two, from the margin of the cornea, as advised by Petit, Platner, Bertrandi, Beer, Sec, must be sufficiently manifest. Nor is it a matter of indifference at what height the needle is introduced, if it be desirable to avoid, as much as possible, effusion of blood in the operation. Anatomy reveals to us, that the long ciliary artery pursues its course to the iris, along the middle ofthe external con- vexity of the eyeball, between the sclerotic and choroid coats; and hence, in order to avoid this vessel, it is prudent to introduce the instrument a full line below the transverse diameter of the pupil, as Dudell, Guntz, Bertrandi, Beer, Scarpa, Sec have directed. If the couching-needle were introduced higher than the track ofthe long ciliary artery, it would be inconvenient for the depression of the cataract. The exact place where the point ofthe needle should next be guided is, no doubt, between the cataract and ciliary processes, in front of the opaque lens and its cap- sule : but as 1 conceive the attempt to hit this delicate invisible mark borders upon impossibility, and, perhaps, in the common manner of bringing the needle from the posterior chamber to the upper edge of the lens, is never effected without injuring those processes, as Mr. Cuthrie positively asserts (Operative Surgery ofthe Eye, p. 270), I cannot refrain from expressing my dis- oent to the common method of passing a couching-nee- dle at once in front of the cataract. On the contrary, il seeuis safer to direct the extremity of the instrii- R 2 mem immediately over the opaque lens, and in the first instance to depress it a little downwards, by means of the flat surface of the needle, in order to make room for the safe conveyance of the instrument between the ca- taract and corpus ciliare, in front of the diseased crys- talline and its capsule; taking care in this latter step of the operation to keep the marked side of the handle for- wards, by which means the point of the needle will be in an opposite direction to the iris, and will come into contact with the diseased body, and the membrane binding it down in the fossula of the vitreous humour. When this has been done, and the case is a firm cata* ract, the instrument will be visible through the pupil. Scarpa now pushes its point transversely, as near as possible the margin of the lens, on the side next the in- ternal angle of the eye, taking strict care to keep it con- tinually turned backwards. He then inclines the han- dle of the instrument towards himself, whereby its point is directed through the capsule into the substance of the opaque lens; and on making a movement of the needle, describing the segment of a circle, at the same instant inclining it downwards and backwards, he lace- rates the former and conveys it in the generality of cases with the latter, deeply into the vitreous humour. Perhaps the greatest inconvenience of Scarpa's method is that Ukely to arise from passing the point of the nee- dle into a firm cataract, whereby the opaque body may become fixed on the end of the instrument, and follow it when it is withdrawn, instead of remaining below the pupil. Indeed, Mr. Guthrie considers it a point of great importance in this operation never to pierce the lens, and that this rule should even be followed, " if necessary, at the expense of the ciliary processes," of which, he thinks, the principal utility terminates With the removal of the lens.—(Operative Surgery of the Eye, p. 271.) To me, who prefer Scarpa's manner of depressing the cataract a little in the first instance, so as to make room lbr the passage of the needle between it and the ciliary processes into the posterior chamber, the necessity of ever wounding those processes, for the pur- pose of avoiding to pierce the lens, seems hardly con- ceivable. At the same time, I believe, with Mr. Guthrie, that in the common practice of moving the needle from the posterior chamber to th'e upper part of the ca- taract, the ciliary processes must suffer more or less injury. Beer, as I have explained, gives the preference to a spear-pointed straight needle, one flat surface of which, at the period of its first introduction into the eye, is turned upwards, the other downwards, one edge di- rected towards the nasal, the other towards the tempo- ral canthus, and the point towards the centre of the eyeball. Beer prefers this mode of proceeding, in order to avoid moving the lens too soon out of its natural si- tuation, whereby the subsequent manoeuvres of depres- sion or reclination, he thinks, would be rendered very uncertain and incomplete. He also recommends the surgeon to support his hand in some measure on the patient's cheek by means of the little finger, so as to have it in his power to check the too sudden and deep entrance of the instrument into the eye, liable to hap- pen when the broadest part of the spear-point has passed through the sclerotica.—(Lehre, i-c. b. 2, p. 354.) It happened, unfortunately for the credit of the ope- ration of depression, that Petit admonished surgeons to beware of wounding the anterior layer of the crys- talline capsule: he had an idea, that when this caution was observed, the vitreous humour would afterward fill up the space previously occupied by the lens, and that thus the refracting powers of the eye might become as strong as in the natural state, and the neces- sity for using spectacles be considerably obviated. But we are now apprized, that leaving this very membrane, from which Petit anticipated such great utility, even were it practicable to leave it constantly uninjured in its natural situation, would be one of the worst incul- cations that could possibly be established; for, in many cases where extraction proves fruitless., in some where depression faUs, the want of success is owing to a sub- sequent opacity of the crystalline capsule; in short, blindness is reproduced by the secondary membranous cataract. It seems more than probable, that in some of the instances where the opaque lens has been said to have risen again, npthing more has happened than the disease in question. Therefore, notwithstanding the whole capsule in the majority of cases may be depressed ! with the lens out of the axis of vision, as it is not a 260 CATARACT. constant occurrence. I cannot too strongly enforce the propriety of extirpating, as it were, ever" source and seat of the cataract in the same operation, and in imita- tion of the celebrated Scarpa, who is entitled to the ho- nour of having first pointed out the greut importance of this practice, I shall presume to recommend, as a ge-. neral rule in couching, always to lacerate the front layer of the capsule, whether in an opaque or transparent state. The capsule of the lens may retain its usual transpa- rency, while the lens itself is in an opaque state. In this case, an inexperienced operator might, from the blackness of the pupU, suppose, not only that he had re- moved the lens, but also the capsule from the axis of sight, and having depressed the cataract, he might un- intentionally leave this membrane entire in its natura] situation. Therefore, if there should be any reason for suspecting that the anterior layer ofthe capsule has es- caped laceration; if, in other words, the resistance made to moving the convexity of the instrument forwards, to- wards the pupil, should give rise to such a suspicion; for the sake of removing all doubt, it is proper to com- municate to the needle a gentle rotatory motion, by which its point will be turned forwards and disengaged through the transparent capsule opposite the pupil: then, by re- peating a few movements downwards and backwards, it will be so freely rent with the needle, as to occasion no future trouble. Beer divides both the operations of couching and re- clination into three stages: the first is that in which the needle is introduced into the eye; the second that in which it is passed Uito the posterior chamber and placed across the anterior surface of the cataract; and the third that in which the depression or reclination ofthe cata- ract is accomplished. If a straight, slender, spear-pointed needle be used, and the second stage of the operation be completed by the introduction of the extremity of the instrument into the posterior chamber (which I particularly recommended to be done in the manner directed by Scarpa), then accord- ing to the directions given by Professor Beer, when de- pression is indicated, the needle is to be immediately carried to the uppermost part of the cataract, with its point directed somewhat obUquely downwards; and with that surface, which, in the first instance, was applied to the front of the lens, now placed upon its su- perior edge; then the opaque body is to be pushed rather obliquely downwards and outwards, so far below the pupil that it can no longer be distinguished. After this has been done, the needle is to be gently raised, in order to see whether the cataract will continue depressed, and if it be found to do so, the needle is to be withdrawn ui fie same direction in which it was introduced. On the other hand, says Beer, when reclination is to be practised, the needle, after being appUed to the front surface of the cataract, is not to be moved farther out of the position of the second stage of the operation, but its handle is merely to be raised diagonally forwards, where- by the cataract wiU be pressed downwards and outwards towards the bottom of the vitreous humour, and turned in the manner already specified. Beer has delivered what appears to me one valuable piece of advice for operators on the eye with the needle: whether depres- sion or recUnation is to be done, says he, a surgeon can only use this instrument -without injurious consequences on the principle of a lever; and every attempt to press with the whole length- of the instrument is not only in- effectual, with respect to the progress of the operation, but so hurtful to the eye that bad effects must follow, as may be readily conceived, when it is recollected how violently the cUiary nerves must be stretched. As for the modifications of the manoeuvres rendered necessary by the varieties of cataracts, they are (says Beer) so unimportant in all cases of depression, that a young operator will easily understand them himself. But things are far otherwise in the practice of reclina- tion ; for when the case is a completely formed capsulo- lenticular cataract, and the opaque capsule is so thin as to be torn during the turning of the lens, the latter body wiU indeed be placed in the intended position at the bottom of the eye, but the capsule itself, which has merely been lacerated, must form a secondary cataract, unless the surgeon, with a sharp double-edged needle, immediately divide it in every direction, and remove it as far as possible from the pupil. When, during reclination, a softish lens, or one which is pulpy to its very nucleus, breaks into several pieces, it is necessary. in order not to have afterward a considerable seoemd- ary lenticular cataract, to put the larger fragments sepa- rately in a state of reclination, while the smaller ones may either be depressed, or (if the pupil he not too much contracted) they may be pushed into the anterior chamber, where they will soon be absorbed. When the cataract is partially adherent to the uvea, Beer recommends an endeavour to be first made with the edge of the needle (which is to be introduced flat between the cataract and the uvea, above or below the adhesion) to separate the adherent parts before the attempt at reclination is made. Should it be a cataract which always rises again as soon as the needle is taken from it, though the instrument has not pierced it at all, the case is termed the ilastic cataract, in which the lens is not only firmly adherent to its own capsule, but this also to the mem- brana hyaloidea. Here Beer thinks that the best plan is first to carry the needle to the uppermost point of the posterior surface of the lens, and, by means of perpendi- cular movements of the cutting part of the instrument, to endeavour completely to loosen this preternatural ad- hesion of the cataract to the vitreous humour, when re- clination may be tried again, and will perhaps succeed. But, says Beer, when the continual rising of the cata- ract is caused by the operator's running the needle into it, the instrument must either be withdrawn far enough out of the eye to let it be again properly brought into the posterior chamber, when recUnation may be effectually repeated; or, if the cataract be firmly fixed on the nee- dle at the bottom of the eye, the instrument should not be raised again, but previously to being withdrawn, it should be rotated a couple of*times on its axis, whereby the pierced lens will be more easUy disengaged from the needle, and at last continue depressed.—(Lehre von dm Augenkr. b. 2, p. 356 358.) In addition to Beer's directions for couching and re- clination, the following observations seem to me to merit attention. When the case is a fluid or milky cataract, the ope- rator frequently finds, that on passing the point of the couching-needle through the anterior layer of the cap- sule, its white milky contents instantly flow out, and, spreading like a cloud over the two chambers of the aqueous humour, completely conceal the pupil, the iris, and the instrument from his view; who, however, ought never to be discouraged at this event. Although it seems to me most prudent to postpone the comple- tion of operations with the needle, in the example of blood concealing the pupU, in the first step of couching, and not to renew any attempt before the aqueous hu- mour has recovered its transparency; I am inclined to adopt tlus sentiment, chiefly because the species of ca- taract is, Ui this circumstance, generally unknown to the operator; consequently, he must be absolutely inca- pable of employing that method of couching which the peculiarities of the case may demand. Speaking of this case, however, Beer says, " the surgeon must has- ten the completion of extraction or recluiation, though possibly the operation may not always admit of being continued, or, if gone on with, it must be done, as it were, bUndfold."—(Lehre, ic. b. 2, p. 361.) When a milky fluid blends itself with the aqueous humour, and prevents the surgeon from seeing the iris and pupU: this event is itself a source of infonnation to him, inas- much as it gives him a perfect insight into the nature of the cataract which he is treating; and instructs him what method of operating it is his duty to adopt. The surgeon, guided by his anatomical knowledge of the eye, should make the curved point of the needle describe the segment of a circle, from the inner towards the outer canthus, and in a direction backwards, as if he had to de- press a firm cataract.—(Scarpa.) Thus he wiU succeed in lacerating, as much as is necessary, the anterior layer of the capsule, upon whith, in a great measure, the perfect success of the operation depends; and, not only in the milky, but almost every other species of cataract The extravasation ofthe mUky fluid in the chambers of the aqueous humour spontaneously disappears very soon after the operation, and leaves the pupil of its accustomed transparency. " In twelve cases of a dissolved lens, on which I have operated," says Latta, " the dissolution was so complete, that on entering the needle into the capsule of the lens, the whole was mixed with the aqueous humour, and all that could be done was to destroy the capsule as comptelely as pos- sible, that all the milky matter might be evacuated. In ten of these cases, vision was almost completely re- CATARACT. 261 stored in four weeks from the operation .** Mr. Pott, in treating of this circumstance, viz. the effusion of the fluid contents of the capsule into the aqueous hu- mour, observes, that so far from being au unlucky one, and preventive of success, it proves, on the contrary, productive of all the benefit which can be derived from the most successful depression or extraction, as he has often and often seen. When the cataract is of a soft or caseous description, the particles of which it is composed will frequently elude all efforts made with the needle to depress them, and will continue behind the pupil in the axis of vi- sion. This has been adduced as one instance that baf- fles the efficacy of couching, and may really seem to the inexperienced an unfortunate circumstance. It often happens in the operation of extraction, that frag- ments of opaque matter are unavoidably overlooked and left behind; yet Richter confesses that such mat- ter is frequently removed by the absorbents. Supposing a caseous cataract were not sufficiently broken and dis- turbed in the first operation, and that consequently the absorbents did not completely remove it, such a state might possibly require a reapplication of the instru- ment ; but this does not generally occur, and is the worst that can happen. It is quite impossible to de- termine, d priori, what effect will result from the most trivial disturbance of a cataract; its entire absorption may, in some instances, follow, while, in others, a re- petition of the operation becomes necessary for the restoration of sight. Even where the whole firm lens has reascended behind the pupil, as Latta and Hey con- firm, the absorbents have superseded the necessity for couching again. The disappearance of the opaque par- ticles of cataracts was, in all times and in all ages, a fact of such conspicuousness, that, as appears from the authority of Barbette and others, it was recorded even previously to the discovery of the system of lymphatic vessels in the body. Indeed, the modern observations of Scarpa and others so strongly corroborate the ac- count which I have given ofthe vigorous action of the absorbents in the two chambers of the aqueous hu- mour, and particularly in the anterior one, that from the moment the case is discovered to be a soft or caseous cataract, it seems quite unnecessary to make any farther attempt to depress it into the vitreous hu- mour. Mr. Pott sometimes in this circumstance made no attempt of this kind, but contented himself with a free laceration of the capsule, and after turning the needle round and round between his finger and thumb within the body of the crystalline, left all the parts in their natural situation, where he hardly ever knew then* fail of dissolving so entirely as not to leave the smallest vestige of a cataract. This eminent sur- geon even practised occasionally what Beer sanctions and Scarpa so strongly recommends at this day; for he sometimes pushed the firm part of such cata- racts through the pupil into the anterior chamber, where it always disappeared, without producing the least inconvenience; we must at the same time add, that he thought this method wrong, not on account of its inefficacy, but an apprehension that it would be apt to produce an irregularity of the pupil, one of the worst inconveniences attending the operation of extrac- tion. But the deformity of the pupil after extraction seems to proceed either from an actual laceration of the iris, or a forcible distention ofthe pupil, by the passage of large cataracts through it, a kind of cause that would not be present in pushing the broken portions of a caseous lens into the anterior chamber. Hence, it does not seem warrantable to reject this very effica- cious plan of treatment. It is well deserving of notice that Mr. Hey, who has several times seen the whole opaque nucleus and very frequently small opaque por- tions fall into the anterior chamber, makes this re- mark : " Indeed, if the cataract could, in all cases, be brought into the anterior chamber of the eye without injury to the iris, it would be the best method of per- forming the operation." What the same author also observes, in a subsequent part ef his work, is strik- ingly corroborative of the efficacy of Scarpa's practice. The practice of the Italian professor consists in lacerat- ing the anterior portion of the crystalline capsule to the exteut of the diameter of the pupU, in a moderately dilated state; in breaking the pappy substance of the diseased lenspiecemeal; and in pushing the fragments through the pupil into the anterior chamber, where thev are gradually absorbed. One great advantage of couching insisted upon by Scarpa depends upon its generally removing the cap- sule at the same time with the lens, from the passage of the rays of Ught to the retina. Sometimes, how- ever, this desirable event, by which the patient is ex- tricated from the danger of a secondary membranous cataract, does not take place. What most frequently constitutes the secondary membranous cataract is the anterior half of the capsule, which, not having been removed, or sufficiently broken in a previous opera- tion, continues more or less entire in its natural situa- tion, afterward becomes opaque, and thus impedes the free transmission of the rays of Ught to the seat of vision. Sometimes the. secondary membranous cata- ract presents itself beyond the pupil, in the form of membranous flakes, apparently floating in the aqueous humour and shutting up the pupil; at other times, it appears in the form of triangular membranes, with their bases affixed to the membrana hyaloidea, and their points directed towards the centre of the pupil. When there is only a minute membranous flake sus- pended in the posterior chamber, Scarpa thinks it by no means necessary for the patient to submit to an- other operation ; vision is tolerably perfect, and in time the smaU particle of opaque matter will spontaneously disappear. But when the secondary membranous cataract consists of a collection of opaque fragments of the capsule, accumulated so as either in a great de- gree or entirely to close the pupil; or when the disease consists of the whole anterior half of the opaque cap- sule, neglected in a prior operation, and continuing adherent in its natural situation, it is indispensable to operate again; for although, in the first case, there may be good reason to hope that the collection of membranous fragments might in time disappear, yet it would be unjustifiable to detain the patient for weeks and months in a state of anxiety and blindness, when a safe and simple operation would restore him, in a very short space of time, to the enjoyment of this most useful of the senses. In the second case, says Scarpa, it is absolutely indispensable; for while the capsule remains adherent to its natural connexions, the opacity seldom disappears, and may even expand over a larger portion of the pupil. He advises the operation to be performed as follows: when the aperture in the iris is obstructed by a collection of membranous flakes detached from the membrana hyaloidea, the curved needle should be introduced with the usual precaution of keeping its convexity forwards, its point backwards, until arrived behind the mass of opaque matter; the surgeon is then to turn the point of the needle towards the pupil, and is to push through this opening regularly, one after another, all the opaque particles into the ante- rior chamber, where, as we have before noticed, ab- sorption seems to be carried on more vigorously than behind the pupil. All endeavours to depress them into the vitreous humour Scarpa has found to be in vain; for scarcely is the couching-needle withdrawn when they all reappear at the pupil, as if (to use his own phrase) carried thither by a current: but wheu forced into the anterior chamber, besides being incapable of blocking up the pupil, they lie without inconvenience at the bottom of that cavity, and in a few weeks are entirely absorbed. When the secondary membranous cataract consists of the whole anterior layer of the crystalline capsule, or of several portions of it connected with the mem- brana hyaloidea, Scarpa, after cautiously turning the point of the needle towards the pupU, pierces the opaque capsule: or, if there be any interspace, he passes the point of the instrument through it; then, having turned it again backwards, he conveys it as near as possible to the attachment of the membranous cataract, and after piercing the capsule, or each portion of it succes- sively, and sometimes carefully rolling the handle of the instrument between his finger and thumb, so as to twist the capsule round its extremity, he thus breaks the cataract, as far as it is practicable, at every point of its circumference. The portions of membrane by this means separated from their adhesions, are next cautiously pushed, with the point of the couching needle turned forwards, through the pupU into the ante rior chamber. In these manoeuvres the operator must use the utmost caution not to injure the ins and cUiary processes, for upon this circumstance depends the avoidance of bad symptoms after the operation, not- I withstanding its duration may be long, aad the neces 262 CATARACT. sary movements of the needle frequently repeated. If a part of the membranous cataract be found adherent to the iris (a complication that will be indicated when, upon moving it backwards or downwards with the needle, the pupil alters its shape, and, from being cir- cular, becomes of an oval or irregular figure), even more caution is required than in the foregoing case, so as to make repeated but delicate movements of the needle, to separate the membranous opacity without injuring the iris. Beer's mode of proceeding in such a ease I have already described. '** Scarpa doss not deem it necessary to vary the plan of operating above explained, if occasionally the cata- ract be formed of the posteripr layer of the capsule. And, according to this author, the same plan also suc- ceeds in those rare instances where the substance itself of the crystalline wastes, and is almost completely ab- sorbed, leaving the capsule opaque, and including, at most, only a small nucleus not larger than a pin's head. Scarpa terms it the primary membranous cataract, and describes it as being met with in children or young peo- ple under the age of twenty ; as being characterized by a certain transparency and similitude to a cobweb; by a whitish opaque point either at its centre or circumfe- rence; and by a streaked and reticulated appearance: he adds, that whosoever attempts to depress such a ca- taraet is baffled, as it reappears behind the pupil soon after the operation: he recommends breaking it freely with the curved extremity of the couching-needle, and pushing its fragments into the anterior chamber, where they are gradually absorbed in the course of about three weeks. No other topical application is generally requisite after the operation, but a small compress of fine linen upon e;ich eye; and the patient ought to be kept in a quiet, moderately darkened room. On the following morning a dose of some mild purgative salt, such as the sulphate of soda or magnesia, may usually be administered with advantage. I shall not enlarge upon the method of treatment when the inflammation subsequent to couch- ing exceeds the ordinary bounds ; in hypochondriacal, hysterical, and irritable constitutions this is more fre- quently met with, and I have already touched upon the propriety of some preparatory measures before operat- ing upon these unfavourable subjects. Beer remarks, that although after extraction very cautious trials of the sight are indispensable, they are by no means proper after depression or reclination; for the action of the muscles of the eye, in the inspec- tion of objects at various distances, is very liable to make the opaque body rise again. Hence, as soon as the pupil is clear, Beer recommends covering both eyes (even when one only has been operated upon) with a plaster, and simple linen compress, which last is to be fastened on the forehead with a common bandage. The. same experienced operator also enjoins perfect quiet- ude ofthe body and head for some days. The patient, he says, may either lie in bed, or sit in an arm-chair, as may be most agreeable, care being taken to avoid all sudden motions. The most proper food for the patient is such as is easily digested, not too nutritious, and does not require much mastication. Every thing must be avoided which has a tendency to excite inflammation in the eye. On the third or fourth day, the eye should be opened, and afterward be merely protected by a green silk eye-screen, which should also be gradually dis- pensed with. The patient should be careful to do what- ever is agreeable to the eye which has been operated upon, and as carefully avoid every thing which irritates it, or causes a disagreeable sensation in it, a difficulty of opening the eyelids, or keeping them open, a dis- charge of tears, or a redness ofthe white ofthe eye,'&c. Of the thrombus under the conjunctiva, sometimes caused by the prick of the needle, and of the readily bleeding granulations which occasionally shoot up at the puncture, I need not here particularly speak. For reUeving the obstinate vomiting sometimes excited by injury of the ciliary nerves, or that of the retina, Beer re- commends castor, musk, and opium, except when the eye is in a state of inflammation, in which circumstance the antiphlogistic treatment is preferable. Such vomit- ing, Beer joins other writers in believing, is often pro- duced by a firm lens being depressed too far, so as to injure the retina; a case, however, which is usually combined with a suddenly produced complete or in- complete amaurosis. Here, unless the position of the lens can be changed by a sudden movement ofthe head, the above class of medicines will be of no use. This kind of amaurosis may also take place without any vomiting, and, as Beer has had opportunitiesof remark- ing, it will not always subside, even though the cata- ract be made to rise again. The same amaurotic affec- tion may also result from the surgeon hurting the retina by pushing the needle too deeply against this membrane. According to Beer, the ophthalmy liable to happen in these cases, as well as after extraction and keratonyxis, is always most severe in the iris and neighbouring textures.—(Von den Augenkr. b. 2, p. 361—363.) I cannot help remarking how judicious it is never to attempt too much at one time in any mode of couching. It happens in this, as in most other branches of opera- tive surgery, that celerity is too often mistaken for skill: the operator should not only be slow and delibe- rate in achieving his purpose; he should be taught to consider, that the repetition of couching may, like the puncture of a vein, be safely and advantageously put in practice again and again; and with far greater security, than if, for the sake of appearing expeditious, or avoid- ing the temporary semblance of failure, a bolder use of the couching-needle should be made than the delicate structure ofthe eye warrants. We read, in Mr. Hey's Practical Observations on Surgery, that he couched one eye seven times, before perfect success was ob- tained : had he been less patient, and endeavoured to effect by one or two rough applications of the instru- ment what he achieved by seven efforts of a gentler description, it is highly probable that the structure of the eye would have been so impaired, as well as the consequent ophthalmy so violent, as to have utterly pre- vented the restoration of sight. All the various methods of couching having now been described, I subjoin the sentiments of Beer, re- specting the circumstances by which the choice of de- pression or reclination ought to be regulated. Accord- ing to this author, when the cataract is very firm, o» moderately so, with a scabrous surface, or the case is what has been already described under the name of en- cysted cataract, or when the cataract consists of any tough membrane, both depression and reclination can oniy be a palliative remedy; for, says he, none of these cataracts after the operation can be dissolved and ab- sorbed, but must remain in the eye, as a foreign unor- ganized body, ready at every opportunity to rise again, and partially or completely blind the patient anew Beer assures us, that he has carefully examined the eyes of persons after death, on whom depression or re- clination had been practised, in some instances, twenty or more years previously; but in almost all the.ex- amples, the lens was found firm and undissolved, or at most only diminished, with or without its capsule. Membranous cataracts were very trivially lessened; though they had quite lost their rough consistence, and were changed into a firmish white mass. In a living person, Beer says, he saw an instance, in which a ca- taract rose again after it had been depressed by Hilmer thirty years previously: it was small, angular, and when the pupil was dilated, it floated from one chamber of the eye into the other. When extracted, which was done with complete success, it was found to be almost ossified. In 1805, Beer extracted from a woman, forty years of age, a very large, hard, yellowish-white lenti- cular cataract, which had been in the anterior chamber twenty-six years. The lens had been thus displaced by a blow received on the eye from the branch of a tree. Nor has Beer ever yet seen a case in which a cataract of a semi-firm consistence was dissolved and absorbed. —(Von den Augenkr. b. 2, p. 363.) Had Beer confined his statements to what happens to certain cataracts, on which depression or reclination, strictly so called, had been practised, I should have been disposed to accede to the general assertion, respecting the great length of time which a firm or tough capsular cataract remains in the vitreous humour undissolved and unabsorbed But if he mean that the same thing is generally the case with cataracts broken piecemeal, and placed in the aqueous humour, we know that such a representation is contradicted by the experience of an infinite number of the highest authorities in surgery. Nay, notwith- standing the case adduced of a bony lens having re- mained in the aqueous humour twenty-six years, I am disposed to think that Beer himself does not intend to question the absorption ofthe fragments of cataracts in the aqueous humour, particularly as at p. 357, b. 2, ha CATARACT. 263 sanctions pushing the fragments of semi-firm cataracts through the pupil into the anterior chamber, where, he con fesses, that they are soon absorbed. Beer thinks that, in general, depression and reclina- tion are indicated only in cases in which extraction is absolutely impracticable, or attended with too great dif- ficulty, as wUl be better understood when this operation is considered. As examples of this kind, Beer specifies an extensive adhesion of the iris to the cornea; a very flat cornea, and, of course, so small an anterior chamber, that an incision of proper size in the cornea cannot be made; a broad arcus senilis ; an habitually con- tracted pupil (incapable of being artificially dilated); an eye much sunk in the orbit, with a small fissure be- tween the eyelids; eyes affected with incessant convul- sive motions; a partial adhesion of the cataract to the uvea; unappeasable timidity in the patient; and an im- possibility of managing him during and after the opera- tion, in consequence of his childhood or stupidity. With regard to the question whether depression or reclination should be preferred, Beer is of opinion that the first method is indicated only when the dimensions of the cataract are small, and, consequently, when there is room enough for it to be placed below the pupU, with- out the ciliary processes being torn from the annulus ciliaris. Such cases are the dry siliquose cataract (the primary membranous cataract of Scarpa), when per- fectly free from adhesions to the uvea; the true lenticu- lar secondary cataract, produced by the small but firm fragments of the lens having been left, or risen again; and the genuine secondary membranous or capsular cataract. On the other hand, reclination is to be pre- ferred, when, together with the above objections to ex- traction, the surgeon has to deal with a fully formed, very hard lenticular, or capsulo-lenticular cataract; or with a case of the latter kind, complicated with partial adhesions to the uvea; or when the case is a secondary capsular cataract, similarly circumstanced; a second- ary cataract, of lymph; a gypsum cataract; or there is reason to apprehend a considerable tendency in the blood-vessels of the interior of the eye to become vari- cose.—(Lehre von den Augenkr. b. 2, p. 365.) The manner of operating with the needle upon the congenital cataracts of children will be hereafter ex- plained. EXTRACTION Or THE CATARACT. From some passages in the works of Rhazes, Haly, and Avicenna, specified by Mr. Guthrie, it is suffi- ciently clear, that the practice of opening the cornea for the removal of cataracts was not unknown to the an- cients. Rhazes says, that about the end of the first cen- tury, Antyllus opened the cornea, and drew the cataract out of the eye with a fine needle, in which practice he was followed by Lathyrion. However, while doubts were entertained respecting the true seat of the cata- ract, it is hardly to be supposed, that this mode of treat- ment could have been frequently adopted; but as soon as it was fully proved that the true cataract was an opacity of the crystalline lens; that the loss of sight would not be occasioned by the removal of this body; that the cornea might be divided without danger; and that the aqueous humour would be quickly regenerated; the mode of cure by extracting the cataract out of the eye would naturally present itself.—(Wenzel.) Freytag is perhaps the first in modern times who made an attempt to extract the cataract: this was about the close of the 17th century. After him, Lotterius, of Turin, performed the operation. But nobody has so strong a claim as M. Daviel to the honour of bringing the merits of the practice before the public; and he not only adopted it himself, but published the first good de- scription of it.—(Sur une Nouvelle Mithode de guerir la Caturacte par VExtraction du Cristallin, 1747. Also, M moires de PAcad. Royale de Chirurgie, t. 2, 4to. 1753.) Two cases in which the cataract had accident- ally slipped through the pupU into the anterior chamber, whence they were extracted in the years 1707 and 1708 by MM. Mery and Petit, as related by St. Ives, seem to have had considerable influence in bringing about the regular performance of this method of removing the ca- taract ; for they served as an encouragement to Daviel by whom the practice was completely established. The operation was afterward brought considerably nearer to perfection by the ingenuity and industry of Wenzel. —(Brambilla, Instrumentarium Chir. Austriacum 1782.p. 71.) Indeed, with the valuable instructions which Ware and Beer have still more recently furnished, the extrac- tion of the cataract may now be regarded as brought to the highest state of improvement. According to Beer, it admits of division into three stages, the first of which, as in depression and reclination, is the most important, because, unless it be performed exactly as it ought to be, the operation will be very liable to fail, and it is ex- ceedingly difficult to make amends for any fault com- mitted in this early part of the proceedings. The first stage consists in making an effectual opening in the cornea with a suitable knife. The second, in dividing the anterior layer of the capsule, which, says Beer, should not be merely punctured, or torn with a bluntish instrument, but cut with a sharp two-edged lance- pointed needle; and, as much as possible, annihilated. In the third stage, the expulsion of the cataract from the eye is effected either by the well-regulated action of the eyeball itself, or by the assistance of art. But, as Beer remarks, they who have learned the manner of effect- ually and skUfuUy cutting the cornea, will frequently have the pleasure to find the last two stagfes beneficially converted into one, and the operation in general soon and expeditiously completed.—(Vonden Augenkr. b. 2, p. 366.) The knives used by Richter, Wenzel, Ware, and Beer are all of them more or less different; but they agree in the common quality of completely filling up the wound, as it is extended, so that none of the vitreous humour can escape before the division of the cornea is finished. Wenzel's knife resembles the common lancet employed in bleeding, excepting that its blade is a little longer, and not quite so broad. Its edges are straight, and the blade is an inch and a half (eighteen lines) long, and a quarter of an inch (three lines) broad, in the widest part of it, which is at the base. From tins part it gradually becomes narrower towards the point; so that this breadth of a quarter of an inch extends only to the space of about one-third of an inch from the base; and for the space of half an inch fronj the point, it is no more than one-eighth of an inch broad. The knife employed by the late Mr. Ware is, in re- gard to its dimensions, not unlike that employed by Wenzel. The principal difference is, that Mr. Ware's knife is less spear-pointed; in consequence of which when this latter instrument has transfixed the cornea, its lower or cutting edge will sooner pass below the inferior margin of the pupil, than the knife used by Wenzel. On this account, Mr. Ware believed that the iris would be less Ukely to be entangled under the knife which he recommended, than under Wenzel's, when the instrument begins to cut its way down- wards, and the aqueous humour is discharged. Mr. Ware particularly advises great care to be taken to let the knife increase gradually in thickness from the point to the handle; by which means, if it be con- ducted steadily through the cornea, it will be next to an impossibUity, that any part of the aqueous humour can escape, before the section is begun downwards: and, consequently, during this time, the cornea will preserve its due convexity. But if the blade should not increase in thickness from the point; or if it be in- curvated much in its back or edge, the aqueous humour will unavoidably escape before the puncture is com- pleted ; and the iris, being brought under the edge of the knife, will be in great danger of being woundeJ by it. But a better knife than any other which has yet been proposed, is that employed by Beer. A very in- genious double cataract-knife is used by Jaeger. " The instrument is composed of a Beer's blade affixed to a handle; a smaller blade of the same form, having its flat side in contact with the other knife; and a button screw. When not in use, the second blade is situated within the outline of the first, with which the cprnea is transfixed. It is introduced in the same way as Beer's knife, not parallel, but nearly perpendicular to the cornea, and afterward carried across the eye, ex- actly like the single knife, with the posterior surface of the fixed blade parallel to the iris, at the usual dis- tance from the junction of the cornea with the sclero- tica. When the point of the greatw knife has trans- fixed the cornea at the inner side, pressure is made on the button head of the smaller Wade, which slides in a groove, in the upper part of the handle with the thumb, with which it it pushed steadily forwards, while the I greater blade keeps the b&ll tinnly fixed, and thus the 264 CATARACT. section of the cornea is completed," mea complete, and from this moment the substance ofthe lens begins to be absorbed. The experience of Mr. Saunders proves, that m the congenital cataract, the lens may be either solid, soft, or fluid, but that more frequently it is partially or com- bletely absorbed, and the cataract is capsular. The circumstance of Mr. Gibson's never having met with a simple membranous cataract in an infant, a fact so much at variance with Mr. Saunders's account, is conceived by Mr. (Juthrie to admit of satisfactory ex- planation by the inference, that Mr. Gibson, in Man- chester, probably saw all the children there with con- genital cataract soon after they were born, and before the absorption of the lens had proceeded far; while a great number of .Mr. Saunders's congenital cases were brought to him in London from distant places, and not seen by him till the children were older, and the disease had made greater progress.—(Operative Surgery ofthe Eye, p. 359.) Indeed, Mr. Gibson states himself, that simple membranous cataracts are by no means uncom- mon at the age of eight or ten, as well as in adults who have been bom blind—(See Edin. Med. and Surg. Jour. vol. 8, p. 399.) . „ The following table of forty-four cases is given in Mr. Saunders's work, for the purpose of showing in what proportion each species of cataract has been found to prevail in congenital cases. Solid opaque lens, with or without opacity of the capsule. Three single, two double cataracts--- 5 Solid lens, opaque in the centre, transparent in the circumference, with capsule in the same state. Five double................................... 5 Soft opaque lene, with or without opacity of the cap- sule. Two single, two double................. 4 Soft opaque lens, with solid nucleus. One single, two double.................................. 3 Soft opaque lens, with dotted capsule, the spots white, the spaces transparent. Two double..... 2 Fluid cataract, with opacity of the capsule. Two single........................................ 2 Fluid cataract, with opacity of the capsule, and closed pupU. Two double...................... 2 Opaque and thickened capsule, the lens being com- pletely absorbed. or the remains of it being thin and squamose. Six single, twelve double....... 18 Opaque and thickened capsule, with only a very small nucleus ofthe lens unabsorbed in the centre. Two single.................................. 2 Opaque and thickened capsule in the centre, remains < of the lens in the circumference. One double... 1 Here the corresponding character of congenital cata- racts in the eyes of each individual is exhibited b^ the number of double cases, and we are informed that the same character was preserved in the cataracts of several children of the same family.—(Saunders on Diseases of the Eye, edit, by Dr. Farre, p. 135, 136.) The congenital cataract appears frequently to afflict several children of the same parents. In the course of the present article, I have already had occasion to advert to two striking examples of this fact. The first is re- lated by Mr. Lucas, who attended five children of a clergyman at Leaven, near Beverley, all born with cata- racts.—(See Mrd. Obs. and Inquiries, vol. 6.) The second is mentioned bv Mr. Gibson, who, some years ago, saw five or six children, the families of two sisters, who were all totally blind, and in an idiotic state, having cataracts accompanied with amaurosis.—(Edin. Med. and Surgical Journal, vol. 8, p. 398.) Several instances occurred to the late Mr. Saunders. In one family, two brothers were thus afflicted. In a second family, two brothers, twins, became blind with cataracts at the age of twenty-one months, each within a few days of the other. It is remarkable, that the four cata- racts had precisely the same character. In a third family, a brother and two sisters were born with this disease. The eldest sister was affected with it only in one eye, the brother and youngest sister in both eyes. In a fourth family, three brothers and a sister had aU congenital cataracts.—(Saunders on the Diseases of the Eye, p. 134, 135.) J ChUdrcn with congenital cataracts possess various degrees of vision ; but when they are totally blind, their eyes not being attracted by external objects, voli- tion is not exercised over the muscles of these organs, which roll about with an irregular, rapid, and trembling motion. Vol. 1—8 I shall now proceed W speak of the manner of opetfa' ting upon children. Until the time of Mr. Pott, the intention of surgeons, in couching or depressing the cataract (as indeed the expression itself implies), was to push the opaque crystalline downwards, away from the pupU. Mr. Pott, conscious that the cataract often existed in a fluid or soft state, was aware that it could not then be depressed; and therefore, in such cases, he recommended using the couching-needle for the express purpose of breaking down the cataract, and of making a large aperture in the capsule, so that the aqueous hu- mour, which he believed to be a solvent for the opaque crystalline, might come into immediate contact with this body. This operation, subsequently to Mr. Pott, has been strongly and ably recommended by Mr. Hey, of Leeds, and Professor Scarpa, of Pavia. In the cases of children, it even received the approbation of the late Mr. Ware.—(On the Operation of Puncturing the Cap- sule of the Crystalline Humour, p. 9.) But, notwithstanding the utility and efficacy of lace- rating the front layer of the crystaUine capsule had been so much insisted upon by Scarpa and others, their obeeW- ations were confined to the cataract in the adult subject, and, before the example set by the late Mr. Saunders, no one (excepting, perhaps, Mr. Gibson of Manchester) ventured to apply, as a regular and successful practice, such an operation to the eyes of infants and children. Indeed, it seems highly probable that even Mr. Gibson himself would have remained sUent upon the subject, had not his attention been roused by the reports of the London Institution for curing diseases of the eye, which reports, he says, were dispersed and exhibited in the public news-rooms of Manchester. For the creation and perfection of this beneficial practice, therefore, I am disposed to give the memory of Mr. Saunders great honour. The propriety of operating for the cataracts of children had long ago been insisted upon by a few writers, and the attempt even now and then made ; but the method never gained any ground, until Mr. Saunders led the way. It only remains for me to describe the plans of opera- ting, as executed by Mr. Saunders, Mr. Gibson, and Mr. Ware. The principle on which Mr. Saunders proceeded hi his operations on the congenital cataract, was founded on the opinion, that the only obstacle to the absorption of the opaque lens is the capsule; and that, as the latter also is most generally opaque, " the business of art is to effect a permanent aperture in the centre of this membrane. This applies to every case of congenital cataract which can occur." Mr. Saunders used to over- come the difficulty of operating upon children, by fixing the eyeball with Pellier'g elevator, having the patient held by four or five assistants, dilating the pupil with belladonna, and employing a very slender needle, armed with a cutting edge from its shoulders to its point, and furnished with a very sharp point, calculated to pene- trate with the utmost facility. Before the operation, the extract of belladonna, diluted with water to the consistence of cream, is to be dropped into the eye, or, to avoid irritation, the extract itself may be smeared in considerable quantity over the eye- Ud and brow. In less than an hour, if there be no ad- hesions, it produces a fUll dilatation of the pupil, ex- posing to view nearly the whole anterior surface of the cataract. The application should then be washed from the appendages of the eye. In using the needle, Mr. Saunders most carefldly ab- stained from doing any injury to the vitreous humour, or its capsule, and it was an essential point with him to avoid displacing the lens. In directing the extremity of the instrument to the centre of the capsule, he passed it either through the cornea, near the edge of this mem- brane (the operation now called keratonyxis), or through the sclerotica, a little way behind the iris. By the first, which is called the anterior operation, Mr. Saunders conceived that less injury would be inflicted, and less irritation excited, than by introducing the needle behind the iris, through all the tunics of the eye. In every case, the first thing aimed at was the permanent de- struction of the central portion of the capsule to an extent equal to that of the natural size of the pupU. If the capsule contained an opaque lens, Mr. Saunders used next to sink the needle gently into the body of the crystalline, and moderately open its texture; cautiously observing not to move the lens at all out of its natural situation. 274 CATARACT. When the case was a fluid cataract, Mr. Saunders was content in the first operation with simply lace- l at ing the centre of the capsule, being desirous of avoiding to increase the irritation foUowing the diffusion of the matter of the cataract in the aqueous humour. When the cataract was entirely capsular, Mr. Saun- ders acted with rather more freedom, as he entertained in this case less fear of inflammation : but in other re- spects, he proceeded with the same objects in view which have been already related, and of which the principal consisted in effecting a permanent aperture in the centre of the capsule, without detaching this mem- brane at its circumference; for then the pupil would have been more or less covered by it, and the operation imperfect, "because this thickened capsule is never absorbed, and the pendulous flap is Uicapable of pre- senting a sufficient resistance to the needle to admit of being removed by a second operation."—(P. 145.) I have already explained, that Mr. Saunders found that the greatest success attended the operation between the ages of eighteen months and four years. One ojie- ration frequently accomplished a cure; as many as five were seldom requisite. The only particularity in Mr. Saunders's treatment of the eye after the operation, was that of applying the belladonna externally, for the purpose of making the pupil remain dilated, tUl the inflammation had ceased, so as to keep the edge of the iris from contracting adhe- sions with the margin of the torn capsule. This last practice is found to be so important, that it is never neglected by any good operator of the present day. In leaving this part of the subject, I must advise every surgeon to read the interesting account of Mr. Saunders's practice, published by his friend and colleague, Dr. Farre. Many minute particulars will be found in this work, highly worthy of the practitioner's attention and imitation. Mr. Gibson appears to have been unacquainted with the usefulness of the extract of belladonna in preparing the eye for the operation. A few hours before operating, he was in the habit of ordering an opiate, sufficient to produce a considerable degree of drowsiness, so that the infant generally allowed its eyelids to be opened and properly secured without re- sistance, and was Uttle inclined to offer any impediment to the introduction of the couching-needle; but, on the contrary, presented the sclerotica to view, naturally turning up the white of its eye. If the infant was more than a year old, and whenever it was necessary, Mr. Gibson used to introduce its body and arms into a kind of sack, open at both ends, and furnished with strings to draw round the neck, and tie sufficiently tight round the legs, so that its hands were effectually se- cured, and the assistants had only to steady its body, and fix its head, while the child was laid on a table, upon a pillow. Mr. Gibson never found it necessary to use a speculum, having uniformly experienced that, after the couching-needle was introduced, he had no difficulty in commanding the eye, aided by a slight de- gree of pressure upon the eyeball with the index and middle fingers of his left hand, which were employed hi depressing the lower eyelid. He admits, however, that the speculum can easily be applied, if an operator prefer'it. He generally used Scarpa's needle, because, in infants, the free rupture of the capsule of the lens ought commonly to be aimed at, in order that the mUky cataract may escape, and mix with the aqueous hu- mour; or, if the cataract be soft, that the aqueous humour may be freely admitted to its pulpy substance which has been previously broken down with the needle. He thinks that no peculiarity is necessary in depressing the hard cataract of infants. Before Scarpa's needle was known in this country, Mr. Gibson used Mr. Hey's, which was generally effectual, and, as he conceives, possesses the recommendation of being less liable to have its points entangled in the iris. He says, that when a milky cataract has been thus evacuated, it ren- ders the aqueous humour turbid; but that within the space of two days, the eye generally acquires its natural transparency, and vision commences. When the cap- sule and substance of the soft cataract have been broken down, and the aqueous humour has come into contact with the lens, the solution and disappearance of the cataract, in all the cases upon which Mr. Gibson has operated have uniformly taken place in a short time. — (See Edin. Med. and Surgical Journal,vol.8, p. 398, 399) For the purpose of fixing er acknowledges the fact of insulated por- li.n.s of skin being sometimes seen in the middle of sores, he maintains, that such appearance is produced in consequence of the whole of the skin not having been destroyed by ulceration, and granulations having arisen from the part of the skin which was left. This, he says, only happens in irregularly formed sores, where, after the healing process has gone on to the centre, the sore breaks out again at the circumference.—(See Lan- cet, vol. 1, p. 225.) Whatever change the granulations undergo to form new skin, they are generally guided to it by the sur- rounding skin, which gives this disposition to the sur- face of the adjoining granulations. The new-formed skin is never so large as the sore was on which it is formed, owing to the contraction of the granulations, and the yielding of the surrounding old skin. If the sore is situated where the adjoining skin is loose, as in tbe scrotum, then the contractile power of the granulations being quite free from ob- struction, a very little new skin is formed; but if the sore is situated where the skin is fixed or tense, the new skin is nearly as large as the sore. The new skin is at first commonly on the same level with the old. This, however, is not the case with scalds and bums, which frequently heal with a cicatrix higher than the skin, although the granulations may have been kept from rising higher than this part. The new-formed cutis is neither so yielding nor so elastic as the original is; it is also less moveable. It gradually becomes, however, more flexible and loose. At first it is very thin and tender, but it afterward be- comes firmer and thicker. It is a smooth continued skin, not formed with those insensible indentations which are observed in the natural or original skin, and by which the latter admits of any distention which the cellular membrane itself will allow of. This new cutis, and indeed all the substance which had formerly been granulations, is not nearly so strong, nor endowed with such lasting and proper actions, as the originally formed parts. The living principle itself is less active; for when an old sore breaks out, it con- tinues to yield, till almost the whole of the new-formed matter has been absorbed, or has mortified. The young cutis is extremely full of vessels-; but they afterward disappear, and the part becomes white. Hence the white appearance of the cicatrices or marks of small-pox. The surrounding old skin being drawn towards the centre by the contraction of the granulations, is thrown into loose folds, while the new skin itself seems to be upon the stretch, having a smooth shining appearance. Tbe new cuticle is more easily formed from the cutis, than the cutis itself from granulations. Every point of the surface i-f the cutis is concerned in forming cuticle, so that this s forming equally every where at once; but the formation ofthe cutis is principally, if not entirely, progressive from the adjoining skin. The new cuticle is at first very thin, and rather pulpy than horny. As it becomes stronger, it looks smooth and shining, and is more transparent than the old cu- ticle. The rete mucosum is later in forming than the cuticle, and in some cases never forms at all. In blacks, who have been wounded or blistered, the cicatrix is a con- siderable time before it becomes dark; and in one black whom Mr. Hunter saw, the scar of a sore, which had been upon his leg when young, remained white when he was old. This case, however, must have been an unusual one; for it is now ascertained that the new skin of a negro does not become white, but is at first red, and after a little time turns blacker than the original skin.—{Sir A. Cooper, Lancet, vol. 1, p. 227.) According to this gentleman's observations, muscle and cartilage are the only two parts of the body incapable of being reproduced in the processes of cicatrization: when a muscle is divided, it unites by means of a ten- dinous substance; and, except in very young subjects, the cartilages of the ribs invariably unite with the in- tervention of bone.—-(Hunter, On the Blood, Inflamma- tion, i-c. Thomson's Lectures on Inflammation, p. 399, .Vc.) CICUTA. See Conium Maculatum. CINCHONA. As one of the designs of this Diction- ary is to embrace the subjects of a surgical pharmaco- peia, Peruvian bark, which is administered in a very great number of surgical cases, cannot be passed over in silence. | Its great repute for its virtues in stopping mortiflca- 284 CINCHONA. turns, and accelerating the separation of the sloughs, every person, whether of the medical profession or not, has frequently heard of. Indeed, so high is the character of the medicine, that many practitioners or- der it in some stage or another of almost every distem- per, often prescribe it when it is totally useless, give it when it actually does harm, and make their patients swallow such quantities as operate perniciously, when smaller doses would effect striking benefit. Some men are credulous enough to think, that from the Peruvian bark vigour and strength are directly extricated and in- fused into the constitution, in exact proportion to the quantity of the medicine which the stomach will keep down and digest. While a doctrine of this sort prevails, we must ex- pect to see indiscriminate and erroneous practice. The generality of diseases will always be attended with an appearance of languor and weakness, and certainly, while there exists a supposition that a drug is at hand, possessing the quality of evolving and communicating strength, it would be absurd to fancy that so important an article will not be largely exhibited in a multiplicity of surgical cases. I shall not presume to hazard an idea of the powers of the Peruvian bark in the practice of physic; but I have not the least doubt that they have been unwarrantably exaggerated in surgery, so as to blind and prejudice many a practitioner of good abi- lities, and lead him to adopt injudicious and hurtful me- thods of treatment. Under particular circumstances, bark has undoubtedly the quality of increasing the tone of the digestive or- gans ; and, of course, whenever the indication is to strengthen the system by nourishing food, and the ap- petite fails, this medicine may prove of the highest uti- lity, provided it be given in moderate doses, and it be found to agree with the stomach and bowels. But the plan of making the patient swallow as much of it as can be got into his stomach, must, in my opinion, be Invariably followed by bad instead of good effects. How can it be reasonably expected that the stomach, which is already out of order, can be set right by hav- ing an immoderate quantity of any drug whatever forced into it ? In fact, if the alimentary canal were in a healthy state, must not such practice be likely to throw it into a disordered condition ? Bark is an excellent medicine when judiciously ad- ministered ; but, like every other good medicine in bad hands, it may be the means of producing the worst consequences. How much good does mercury effect in an infinite number of surgical diseases, when prescribed i>y a surgeon of understanding; what a poison it be- comes under the direction of an ignorant practitioner! With respect to cases of mortification, bark is often most strongly indicated when the sloughing is not sur- rounded with active inflammation, when the patient is debilitated, and his stomach cannot take nutritious food. I have always regarded the notion of giving bark as a specific for gangrene as totally unfounded and absurd. I have watched its effects in these cases, and could never dis em that it had the least peculiar power of .operating directly upon the parts which are distempered. Whatever good it does is by its improving the tone of the digestive organs, and making them more capable of conveying nourishment, and of course strength into the .constitution. I should feel myself guilty of a degree of presump- ''on in speaking thus freely upon this subject, were not .ny sentiments in some measure supported by those of certain surgical writers, the remembrance of whom will always be hailed with unfeigned veneration and esteem. Mr. Samuel Sharp was not bigoted to bark, and while he allowed it to possess a share of efficacy, he would riot admit that it was capable of miraculously accom- plishing every thing which the ignorant or prejudiced alleged. " i know," says he, " it will be looked upon ,by many as a kind of skepticism, to doubt the efficacy Of a remedy so well attested by such an infinity of cases; and yet I shall frankly own I have never clearly to my satisfaction met with any evident proofs of its prefer- ence to the cordial medicines usually prescribed; though I have a long a time made experiment of it with a view to search into the truth. Perhaps it may seem strange thus to dispute a doctrine established on what is called matter of fact; but I shall here observe, that in the practice of physic and surgery it is often exceedingly difficult to ascertain a fact. "Prejudice or want of abilities sometimes mis- leads us in our judgment, where there is evidently a right and a w rong; but in certain cases to distinguish how far the remedy and how far nature operate, is pro- bably above our discernment. In gangrenes particu- larly, there is frequently such a complication of un known circumstances as cannot but tend to deceive an unwary observer. Mortifications arising from mere cold, compression, or stricture, generally cease upon re- moving the cause, and are, therefore, seldom proper cases for proving the power of the bark. However, there are two kinds of gangrene where internals have a fairer trial; those are a spreading gangrene from an internal cause, and a spreading gangrene from violent external accidents, such as gun-shot wounds, compound fractures, &c. Yet even here we cannot judge of their effect with absolute certainty; for sometimes a morti- fication from internal causes is a kind of critical disor- der. There seems to be a certain portion of the body destined to perish, and no more; of this we have an in- finity of examples brought into our hospitals, where the gangrene stops at a particular point without the least assistance from art. The same thing happens in the other species of gangrene from violent accidents, where the injury appears to be communicated to a cer- tain distance and no farther; though, by-the-way, I shall remark in this place, contrary to the received opi- nion, that gangrenes from these accidents (where there has been no previous straitness of bandage) are as often fatal as those from internal causes. As I have here stated the fact, we see how difficult it is to ascertain the real efficacy of this medicine; but had bark in any degree those wonderful effects in gan- grenes which it has in periodical complaints, its pre- eminence would no more be doubted in the one case than in the other. What, in my judgment, seems to have raised its character so high, are the great numbers of single observations published on this subject, the au- thors of which, not having frequent opportunities of seeing the issue of this disorder under the use of cor- dials, Sec, and some of them, perhaps, prejudiced with the common supposition, that every gangrene is of it- self mortal, have therefore ascribed a marvellous influ- ence to the bark, when the event has proved success- ful."— (Sharp's Crit. Inq. chap. 8, on Amputation.) Some farther remarks on this subject wUl be reserved for the article Mortification. According to Mr. Bromfield, bark is a specific for old ulcers, where the inflammation seems circumscribed at the distance of an inch round the sore, the surface of the ulcer looks glossy, and the discharge is extremely thin and very offensive, with little or no sleep from the violence of the pain. He farther observes, that the addition of opium, as circumstances may require, wtil often be found necessary.—(Chirurgical Observations and Cases, vol. 1, p. 132.) Bark is given so extensively in the practice of sur- gery, that there are few important cases in which, in certain circumstances, and at some period or another, it is not indicated. When persons have been weakened by a course of mercury, or by the effects of any disease what soever, moderate doses of bark will frequently be found of great service. But it only becomes so on the princi- ples above suggested, and, as far as my judgment ex- tends, this medicine should never be prescribed in any surgical cases in excessive and unreasonable quantities. [The use of charcoal, in combination with one-fourth part of pulverized myrrh, is found of essential service as a tonic in the debility and constitutional irritation which are induced in some habits by the excessive use of mercury, and I learn from my friend Dr. Francis, that he has recently tested its efficacy to his entire sa- tisfaction. In the mercurial sore-throat of long stand- ing, it has proved an effective remedy, and its use may be alternated or combined with bark and other corrobo- rants in fulfilling the indications required in the eczema mercuriale.—Reese.] The yellow bark, or the cortex cinchona? cordifolia? of the new pharmacopoeia, is said to possess more efficacy than the other kinds. One desirable result of the com- plete establishment of the modern doctrine, that the vir- tues of the various kinds of cinchona reside in two sa- lifiable bases, or alkaline elements, termed cinchonine, and quinine, is that of being able to prescribe prepara- tions which -wUl concentrate all the efficacy of the me- dicine in formula? of moderate bulk, not Ukely at least to disorder the alimentary canal by the mechanical effects of quantity. CIR The sulphate of quinine, or quina, as Dr. Paris terms It, "appears to be the most efficient of all the salts of bark. We must be careful not to combine it with sub- stances that form insoluble compounds with it. The infusum rosa? comp is objectionable as a vehicle, on ac- count of the astringent matter which it contains, and which therefore precipitates the quina from its solution." The form in which Dr. Paris prefers to prescribe it is that of solution, with a minim of sulphuric acid to every grain ofthe salt.—(Pharmacologia, vol.2, p. 163.) It is frequently made into pills, with the conserve of roses, or joined with hyosciamus, squills, opium, and other medicines. Professor Brande does not agree with Dr. Paris, respecting the compound infusion of roses being an unlit velucle for sulphate of quinine, and re- commends the subjoined formula: ft. Quinia? sulpha- tis gr. ij. Infas. rosa? comp. 3 xi. Tinct. cort. aurant. ayrupi ejusdem aft 3 ss. M. ft. haustus bis in die su- lnendus. CINNABAR, ARTIFICIAL (Hydrargyri sulphu- rttum rubrum), is chiefly employed by surgeons for fu- migating venereal ulcers. An apparatus is sold in the ■hops for this purpose. The powder is thrown upon a heated iron, and the smoke is conducted by means of a tube to the part affected. CIRCUMCISION. (From circwmcido, to cut round.) The operation of cutting off a circular piece of the pre- puce, sometimes practised in cases of phymosis.—(See Phymosis.) CIRSOCELR. (From Ktpiric, a varix, and ktj\v, a tu- mour.) Cirsoeule is a varicose distention and enlarge- ment of the spermatic vein; and whether considered on account of the pain which it sometimes occasions, or on account of a wasting of the testicle, which now and then follows, it may truly be called a disease. It is fre- quently mistaken for a descent of a small portion of omentum. The uneasiness which it occasions is a dull kind of pain in the back, generally relieved by suspen- sion of the scrotum. It has been fancied to resemble a collection of earth-worms; but whoever has an idea of a varicose vessel, wUl not stand in need of an illustra-1 tion by comparison. It is most frequently confined to | that part of the spermatic process, which is below the opening in the abdominal tendon; and the vessels ge- nerally become rather larger as they approach the tes- tis. Mr. Pott never knew good effects arise from exter- nal applicationa of any kind. In general the testicle is perfectly unconcerned in, and unaffected by, this disease; but it sometimes hap- pens, that it makes its appearance very suddenly, and with acute pain, requiring rest and ease; and sometimes after such symptoms have been removed, Mr. Pott has seen the testicle so wasted as hardly to be discernible. He has also observed the same effect from the injudi- cious application of a truss to a true cirsocele; the ves- sels, by means of the pressure, became enlarged to a prodigious size, but the testicle shrunk to almost no- thing. --(Pott's Works, vol. 2.) Morgagni has remarked, that the disease is more fre- quent in the left than in the right spermatic cord; a circumstance which he refers to the left spermatic vein terminating in the renal.—(De Sedibus et Caus. Morb Epist. 43, art. 34.) Cirsocele is, more frequently than any other disorder, mistaken for an omental hernia. As Sir Astley Cooper •emarks, when large it dilates upon coughing; and it swells in an erect, and retires in a recumbent posture of the body. There is only one sure method of distin- guishing the two complaints: place the patient in a ho- rizontal posture, and empty the swelling by pressure upon the scrotum; then pul the fingers firmly upon the upper part of the abdominal ring, and desire the patient to rise: if it is a hernia, the tumour cannot reappear, as long as tho pressure is continued at the ring; but if a cirsocele, the swelling returns with increased size, on account of the return of blood into the abdomen bein» prevented by the pressure.-(A. Cooper on Inguinal Hernia.) Cirsocele can, for the most part, only be palliated, and seldom radically cured. \\Txen the complaint is at- tended with pain, cold saturnine and alum lotions may be applied to the testicle and spermatic cord At the same tune, blood should be repeatedly taken away by means of leeches; the bowels should be kept eentlv open; the patient should be placed in a horizontal dos- ture, and the testicle should be supported in a bag- col, 285 In general, the patient only finds it necessary to keep up the testicle with this kind of suspensory bandage. [I learn from Dr. H. G. Jameson, of Baltimore, that he has been favoured with singular success in treating cir- socele, by tying the spermatic artery. He has thus proved that this painful and disagreeable disease may be radically cured by this simple operation. The first pubUc account I can find of this operation, is that per- formed by Dr. J. in 1821, and published in the Am. Med. Recorder for 1825. He reports, that in neither of the cases in which this operation was performed, did the patient suffer in the integrity of the testis, nor, so far as could be ascertained, did the ligature interfere with the important functions of that organ, although both these effects had been feared, and even predicted. Dr. Stephen Brown, of New-York, has succeeded in curing varicocele by a similar operation, viz. tying the spermatic vein. Although no evil consequences resulted in this case from the ligature, yet, after the facts before the profession, of the dangerous and fatal results of tying the veins, the propriety of performing this opera- tion for the cure of varicocele_may be justly questioned, unless in cases of so much suffering and danger as to warrant this hazard.—(See N. Y. Med. and Phys. Jour- nalfor 1824.)—Reese.] Gooch and other writers have related cases of cir- socele, in which the pain was so intolerable and incura- ble, that nothing but castration could afford the patient any relief.—(J. A. Murray de Cirsocele, Upsal, 1784. Pott on Hydrocele, i-c. Richter in Nov. Comment, Goett. No. 4, and in Obs. Chir. Fasc. 2, p. 22. Gooch, Chir. Works. Most, Diss, de Cirsocele, Halas, 1796.) CIRSOPHTHALM1A. (From xtpobs, a varix, and 6, to fall down.) A bearing or faffing down ofthe vagina.—(See Vagina, Prolapsus of.) COMMINUTED. (From comminuo, to break in pieces.) A fracture is termed comminuted when the bone is broken into several pieces. COMPRESS. (From comprimo to press upon.) Folded linen, lint, or other materials, making a sort of pad, which surgeons place over those parts of the body on which they wish to make particular pressure; and for this purpose a bandage is usually applied over the compress. Compresses are also frequently applied to prevent the ill effects which the pressure of hard bodies or tight bandages would otherwise occasion. COMPRESSION OF THE BRAIN. See Head, In- juries of. CONCUSSION OF THE BRAIN. See Head, Inju- ries of. CONDYLOMA. (From k6vSv\oc, a tubercle or knot.) A small, very hard tumour. The term is generally ap- plied to excrescences of this description about the anus. The practitioner may either destroy them with caustic, tie their base with a ligature, or remove them at once with a knife; the first is generally the worst, the last the best and most speedy method. CONIUM MACULATUM. Hemlock. Cicuta. This is a medicine to which my observations in practice in- cline me to impute considerable efficacy in several sur- gical diseases. However, there is no doubt, that when it is represented as a certain cure for cancer and scro- fula, exaggeration is employed. It is an excellent re- medy for irritable painful sores of the scrofulous kind, and it wtil complete the cure of many ulcers in which the venereal action has been destroyed by mercury, though the healing does not proceed in a favourable way. Hemlock is likewise beneficial to several inve- terate malignant sores, particularly some which are every now and then met with upon the tongue. It is an eligible alterative in cases of noli me tangere, porrigo, and various herpetic affections. I have seen several enlargements of the female breast give way to hemlock conjoined with calomel. Some swellings of the testes also yield to the same medicines. Hemlock certainly has not the power of curing cancer; but its narcotic ano- dyne qualities tend to lessen the pain of that distemper, so as to render it by no means a contemptible remedy in that intractable kind of case. Respecting hemlock, Mr. Pearson observes, that the extract and powder may be sometimes given with evi- dently good effect in spreading irritable sores; whether they are connected wdth the active state of the venereal virus, or whether they remain after the completion of the mercurial course; and it would seem, that the be- nefit conferred by this drug ought not to be ascribed solely to its anodyne qualities, since the same advan- tages cannot always be obtained by the liberal exhibi- tion of opium, even where it does not disagree with the stomach. He states that cicuta is almost a spe- cific for the venereal ulcers which attack the toes at their line of junction with the foot, and which fre- quently become gangrenous. Also, in spreading sores which are accompanied with great pain, and no appear- ance of remarkable debility, hemlock will often do more than bark, vitriol, or cordials. The common mode of exhibiting hemlock is in the form of pills, made of the extractum conU, five grains to each. However, I have always thought three grains sufficient to begin with, the dose being afterward gradually augmented. It is curious how large a quantity may at last be taken in this manner. Mr. J. Wilson, in his Pharmacopoeia Chirurgica, informs us of a remarkable case of cancer- ous ulcer, for which the patient took a hundred and twenty pills, each consisting of five grains of the ex- tractum conii, in twenty-four hours, and this without any benefit being produced, or any inconvenience to the patient. The stomach being a little disordered, and the head somewhat giddy, is a sign of the dose being sufficiently strong. "According to some writers, but more particularly Dr. Withering, there are several ways in winch the views of a medical practitioner, in prescribing this remedy, may be frustrated. The plant chosen for pre- paring the extract may not be the true conium macula- turn, which is distinguished by red spots along the stalk. It may not be gathered when in perfection, namely, when beginning to flower. The inspissation of the juice may not have been performed in a water- bath, but, for the sake of despatch, over a common fire. The leaves, of which the powder is made, may not have been cautiously dried and preserved in a well-stopped bottle; or, if so, may still not have been guarded from the Ul effects of exposure to light. Or lastly, the whole medicine may have suffered from the mere effects of long keeping. From any of these causes, it is evident, the powers of cicuta may have suffered; and it happens, no doubt, very frequently, that the failure of it ought, in fact, to be attributed to one or other of them."—(Phar- macopoeia Chirurgica, published in 1802, p. 174.) The activity of hemlock is now found to reside in a resinous element, obtained separately, by evaporating an ethereal tincture of the leaves on the surface of water. A dose of*half a grain will produce vertigo and headache. The watery extract of this plant has been proved by Orfila to have but little power.—(/. A. Paris, in Pharmacologia, vol. 2, p. 180, ed. 6.) I have sometimes prescribed as an alterative, with manifest benefit in several surgical diseases, a pill con- taining three grains of extractum conii, or, what is preferable, the dried leaves, one of hydrargyri submu- rias (calomel); and one of antimonii sulphuretum prte- cipitatum. In various cases of scrofulous diseases, and -also in several very painful irritable ulcers and swell- ings, it is occasionally employed in the form of foment- ations and poultices. The latter are generally made by mixing the powder with the common bread and water cataplasm. F. Hoffman, Of Hemlock, 8vo. Lond. 1763. A. Storck, Libellus, quo demonstratur cicutam non solum usu interno tutissimi exhiberi, sed et esse simul remedium valdi utile, ic.; editio altera, Svo. Vindob. 1761. Also, Supplementum Necessarium de Cicuta, Svo. Vindob. 1761. J. Pearson, On Various Articles of the Materia Medica, i-c. 2d edit. Svo. London, 1807. J. A. Paris, Pharmacologia, ed. 6. CONJUNCTIVA, GRANULAR. The following ac count of this subject is given by Dr. Frick. This dis ease is mostly the sequel of purulent ophthalmy. It is characterized by a rough, scabrous, or granulated state of the palpebral conjunctiva, with a gleety or puriform discharge from its surface. The constant friction of the eyelids upon the globe brings on a varicose state of the sclerotic conjunctiva, and a dusky appearance of the cornea. The patient complains of a sensation simi- lar to that produced by sand, or other extraneous matter, under the eyelids; the eye cannot endure the light, and there is a troublesome epiphora. In the re- cent stage, a cure is easily accomplished by the applica- tion of a few leeches to the eyebrows, and pencilling the part once or twice a day with the vinous tincture of opium, or the ung. hydrarg. nitrat. When these means fail, the sulphate of copper or nitrate of silver may be used, though not so freely as to produce a slough, bnt only to change the diseased condition of the part.—(See Frick, On Dis. of the Eye, p. 240, ed. 2.) Mr. R. Wel- bank recommends the use of these means to be followed by ablution with tepid water, and the application of a few leeches. He also recommends counter-irritation and active aperients. The upper eyelid, he says, should be completely everted in examination, as there is sometimes, at the angle where the conjunctiva passes from the globe to the lid, a crescentic fringed fold, not unlike a cock's comb, apt to keep up a tedious inflam- mation of the cornea. Dr. Frick considers excision of the granular surface proper only when it is hard, insen- sible, and prominent, or tbe excrescences hang like peduncles from the surface of the eyelids. In this state, Dr. Vetch recommends the application of a little burnt alum, or verdigris, and then washing it off with a syringe.—(See the article Cornea, and Frick, Vetch, and Travers on Diseases ofthe Eye.) CONTUSED WOUNDS. See Wounds. CONTUSION. (From contundo, to bruise.) A bruise. Slight bruises seldom meet with much attention; but when they are severe, very bad consequences may ensue; and these are the more likely to occur, when such cases are not taken proper care of. In all severe bruises, besides the inflammation which the violence necessarily occasions, there is an instanta- neous extravasation, in consequence of the rupture of many of the small vessels of the part. In no other way can we account for those very considerable tumours, which often rise immediately after injuries of this na- ture. The black and blue appearance instantly follow- ing many bruises can only be explained by there being COP an actual effusion of blood from the small arteries and veins which have been ruptured. Even largish vessels are frequently burst in this manner, and considerable collections of blood are the consequence. Blows on the head very often cause a large effusion of blood under the scalp. I have seen many ounces thus extra- vasated. Besides the rupture of an infinite number of small vessels, and an extravasation of blood, which attend all bruises in a greater or less degree, the tone of the fibres and vessels which have suffered contusion is considerably disordered. Nay, the violence may have been so great, that the parts are from the first deprived of vitality, and must slough. Parts at some distance from such as are actually struck may suffer greatly from the violence ofthe con tusion. This effect is what the Fench have named a contrecoup. The bad consequences of bruises are not invariably proportioned to the force which has operated; much depends on the nature and situation of the part. When a contusion takes place on a bone which is thinly covered with soft parts, the latter always suffer very severely, in consequence of being pressed, at the time of the accident, between two hard bodies. Hence, bruises of the shin so frequently cause sloughing and troublesome sores. Contusions affecting the large joints are M ways serious cases; the inflammation oc- casioned is generally obstinate; and abscesses and other diseases, which may follow, are proper grounds for serious alarm. In the treatment of bruises, the practitioner has three indications, which ought successively to claim his attention. The first is to prevent and diminish the inflamma- tion which, from the violence done, must be expected to arise. The bruised parts should be kept perfectly at rest, and be covered with linen, constantly wet with the liquor plumbi acetatis dilutus, or the lotio ammon. acetatis. When muscles are bruised, they are to be kept in a relaxed position, and as quiet as possible. If the bruise be very violent, it will be proper to apply leeches, and this repeatedly; and even in some cases, particularly when the joints are contused, to take blood from the arm. In every instance, the bowels should be kept well open with saline purgatives. A second object in the cure of contusions is to pro- mote the absorption of the extravasated fluid by discu- tient applications. These may at once be employed in all ordinary contusions, not attended with too much violence: for then nothing is so beneficial as maintain- ing a continual evaporation from the bruised part, by means of the cold saturnine lotion, and at the same time repeatedly applying leeches. In common braises, however, the lotio ammonia muriata (see this article) is an excellent discutient application; but most sur- geons are in the habit of ordering liniments for all or- dinary contusions; and certainly they do so much good in accelerating the absorption of the extravasated blood, that the practice is highly praiseworthy. The tini- inentum saponis or the linimentum camphors? are as good as any that can be employed.—(See Linimen- tum.) In many cases unattended with any threatening appearances of inflammation, but in which there is a good deal of blood and fluid extravasated, bandages act very beneficially, by the remarkable power which they have of exciting the action ofthe lymphatics, by means of the pressure which they produce. A third object in the treatment of contusions is to restore the tone of the parts. Rubbing the parts with liniments has a good deal of effect in this way But notwithstanding such applications, it is often observed that bruised parts continue for a long while weak, and even swell and become cedematous, when the patient takes exercise, or allows them to hang down, as their Amotions in life may require. Pumping cold water two or three times a day on a part thus cireumstanced, is the very best measure which can be adopted. A bandage should also be worn, if the situation of the part will permit. These step*, together with perseve- rance in the use of liniments, and in exercise gradually increased, wUl soon bring every thing into its natural state ?igam. Ct »PPER The subacetate and sulphate are used in surgery. The first, often called a?rugo, or prepared verdigris, is employed as an escharotic. Mixed with COR 287 an equal quantity of powdered cantharides, it is some* times applied for the removal of warts and other ex- crescences. At present, the old practice of destroying the surface of chancres with it, with the view of hin- dering the absorption of venereal matter, and rendering the exhibition of mercury needless, may be said to be completely abandoned. CORNEA. (From cornu, a horn.) The anterior transparent convex part ofthe eye, which in texture is tough, like horn. It has a structure peculiar to itself, being composed of a number of concentric cellular lamella?, in the cells of which is deposited a particular sort of fluid. It is covered externally by a continuation of the conjunctiva, which belongs to the class of mu- cous membranes: and it is lined.by a membrane, the tunica humoris aquei, which seems to belong to the serous class. FLESHY EXCRESCENCES OF THE CORNEA. Mr. Wardrop, in his Essays on the Morbid Anatomy of the Human Eye, has published an excellent chapter on this subject. Besides pterygia, which are treated of in another part of this Dictionary, Mr. Wardrop states that the cornea is subject to two kinds of caruncles, or fleshy excrescences. One appears at birth, or soon after it, and resembles the na?vi materni, so frequent on the skin of various parts of the body. The second is described as having a greater analogy to the fungi which grow from mucous surfaces, and being in gene- ral preceded by ulceration. Of the congenital excrescence of the cornea, Mr. Wardrop has seen two remarkable instances. The first was in a girl eight or ten years of age, on whose left eye there was a conical mass; the base of which grew from about two-thirds of the cornea, and a small portion of the adjoining sclerotic coat. The second example occurred in a patient upwards of fifty years old. The tumour had been observed from birth, was about as large as a horse-bean, and only a small portion of it seemed to grow from the cornea. The other part was situated on the white of the eye, next the temporal angle of the orbit. From the middle ofthe excrescence, upwards of twelve long firm hairs grew, and hung over the cheek. Mr. Wardrop acquaints us, that a similar tumour, with two hairs growing out of it, was seen at Lisbon by Dr. Barron, of St. Andrew's. Mr. Crampton also mentions, that he once saw a " tuft of very strong hairs proceeding from the sclerotica."—(Essay on the Entro- peon, p. 7.) And De Gazelles met with an instance, in which a single hair grew from the cornea.—(Journ. de Midecine, torn. 24.) According to Mr. Wardrop, this species of excrescence of the cornea greatly resem- bles the spots covered with hair, which are frequent on various parts of the surface of the body. With regard to the second kind of tumour growing from the cornea, a fungus, proceeding from an ulcer of this part of the eye, is stated to be very uncommon. However, it is said that when a portion of the iris' protrudes through an ulcer of the cornea, the growth of a large excrescence from the projecting part is not so unusual. Of such a disease, Mr. Wardrop has cited examples from Maitre-Jean's Traiti des Maladies des Yeux, Voigttl, Beer, and Plaichner. Excrescences growing from the cornea are also quoted from the fol- lowing works: Handbuch der Patliologischen Anato- mie, von F. G. Voigtel, Halle, 1604. Praktische Beo- bachtungen uber den grauen Staar und die Krankheiten der Hornhaut, von Joseph Beer, Wien, 1791. Plaich- ner's Dissertatio de Fungo Oculi.—(See Wardrop's Essays on the Morbid Anatomy of the Human Eye, vol. 1, chap. 4.) Others are likewise described by Mery, in Mi m. de l'Acad. des Sciences, 1703; by Dupre, in Phil. Trans, vol. 19; and Home, in the same work, vol. 81. The only treatment Which excrescences of the cor- nea admit of, is that of removing them with a scal- pel and a pair of forceps, or destroying them with caustic. ABSCESSES OF THE CORNEA. When the matter is collected between the lamella? of the cornea, it first appears like a small spot; and instead of resembling a speck in colour, it is of the yellow hue of common pus. As the quantity of the matter increases, this spot becomes broader, and it does not alter its situation from the position of the 588 CORNEA. head. If it be situated among the external layers of the cornea, or immediately below the corneal conjunc- tiva, a tumour is formed anteriorly, and if touched with the point of a probe, the contained fluid can be felt fluctuating within, or if the eye be looked at side- ways, an alteration in the form of the cornea may be readily perceived. When the matter collects between the interior la- mellie, it does not produce any evident alteration in the external form of the cornea; but if it be touched with the point of a probe, a fluctuation can be more or less distinctly perceived, and the spot alters its form, and becomes somewhat broader. Such collections of matter appear on every part of the cornea. Sometimes they alter their situation by degrees, and sink downwards; and sometimes they change both their situation and form. They very sel- dom cover more than one-fourth or one-third of the cornea. When the quantity of matter is small, it is often completely absorbed during the abatement of the in- flammatory symptoms, and it generally leaves no ves- tige behind it. In other cases, the cornea is eroded ex- ternally, producing an ulcer and subsequent opacity. In some few instances, the internal lamella? ofthe cor- nea give way, and the matter escapes into the anterior chamber. When an artificial opening is made, the matter often does not readily flow out; and it is some- times so tenacious, and contained in a cavity so irre- gular, that it neither escapes spontaneously, nor can it be evacuated by art. It is particularly to the cases in which matter col- lects between the layers of the cornea, that the terms unguis and onyx are applied.—(See Wardrop's Essays on the Morbid Anatomy of the Human Eye, vol. 1, chap. 6.) According to a late writer, these words should be restricted to what he names " crescentic in- terlamellar depositions.''—(Travers's Synopsis of the Diseases of the Eye, p. 115.) Where the cornea is af- fected with onyx, this gentleman commends antiphlo- gistic treatment.—(P. 278.) And with respect to a large collection of matter in the cornea, whether the puriform onyx or central abscess, he observes, that it requires " a supporting constitutional treatment, mild cathartics, and the application of blisters: calomel should be avoided, and the cornea can seldom be punc- tured with advantage."—(P. 280.) OPACITIES OF THE CORNEA. Opacity of the cornea is one of the worst conse- quences of obstinate chronic ophthalmy. The term opacity is used when the loss of transparency extends over the whole or the greater part of the cornea; while other cases of a more limited kind are named specks. The distinction, as Beer observes, is chiefly important in respect to the prognosis.—(Lehre von den Augenkr. b. 2, p. 77.) Scarpa distinguishes the superficial and recent spe- cies of opacity from the albugo and leucoma (see these words), which are not in general attended with inflam- mation, assume a clear and pearl colour, affect the very substance of the cornea, and form a dense speck upon this coat of the eye. The nebula, or slight opacity, here to be treated of, is preceded and accompanied by chronic ophthalmy; it allows the iris and pupil to be discerned through a Kind of cloudiness, and conse- quently does not entirely bereave the patient of vision, but permits him to distinguish objects, as it were, through a mist. The nebula is an effect of protracted or ill-treated chronic ophthalmy. The veins of the conjunctiva, much relaxed by the long continuance ofthe inflammation, become preternaturaily turgid and pro- minent : afterward they begin to appear irregular and knotty, first in their trunks, then in their ramifications, near the union of the cornea with the sclerotica, and lastly in their most minute ramifications, returning from the delicate layer of the conjunctiva, spread over the cornea. It is only, however, in extreme relaxation of the veins of the conjunctiva, that these very small branches of the cornea become enlarged. When this happens, some reddish streaks begin to be perceptible, in the interspaces of which, very soon afterward, a thin, milky, albuminous fluid is effused, which dims the diaphanous state of tlie cornea. The whitish, delicate, superficial speck thence resulting forms precisely what is termed nebula, or the kind of opacity here to be considered. And since this extrava- sation may happen only at one point of the cornea, or in more places, the opacity may be in one speck or In several distinct ones, but which altogether diminish more or less the transparency of this membrane. The cloudiness of the comea, which sometimes takes place in the inflammatory stage of violent acute oph- thalmy, especially differs from the species of opacity expressed by the term nebula. The first is a deep ex- travasation of coagulating lymph in the internal cel- lular texture of the cornea, or else the opacity pro- ceeds from an abscess between the layers of this mem- brane about to end in ulceration. On the other hand, the nebula forms slowly uiion the superflces of the cornea, in long-protracted chronic ophthalmy; is pre- ceded first by a varicose enlargement of the veins in the conjunctiva, next of those in the delicate lamina of this tunic, continued over the front of the cornea; and filially it is followed by an effusion of albuminous lymph in the texture of this thin layer, expanded over the transparent part of the eye. This effusion never elevates itself in the shape of a pustule. Wherever the cornea is affected with nebula, the part of the con- junctiva corresponding to it is constantly occupied by net-work of varicose veins, more knotty and prominent than other vessels of the same description; and though the cornea be clouded at more points than one, there are distinct corresponding fasciculi of varicose veins in the white of the eye. Scarpa injected an eye affected with chronic ophthalmy and nebula, and he found that the wax easily passed, both into the enlarged veins of the conjunctiva, and those of that part of the surface of the cornea where the opacity existed; the inosculations all round the margin of the cornea were beautifully variegated, without trespassing that line which bounds the sclerotica, except on that side where the cornea was affected with the species of opacity. Mr. Travers does not adopt precisely the same defi- nition of nebula as Scarpa; for he describes it as a thickening of the conjunctiva, and an effusion of adhe- sive matter between it and the cornea, or between the lamella of the latter, commonly the product of acute strumous ophthalmy.—(Synopsis, A c. p. 118.) According to Scarpa, the superficial opacity, which alone he calls nebula, demands, from its very origin, active treatment; for though at first it may only oc- cupy a small portion of the cornea, when left to itself it advances towards the centre of this jnembrane, and the ramifications of the dilated veins upon this coat growing still larger, at length convert the delicate con- tinuation of the conjunctiva upon the surface of the cornea, into a dense opaque membrane, obstructing vision. The curative indication in this disease is to make the varicose vessels resume their natural diameters, or if that be impracticable, to cut off all communication between the trunk of the most prominent varicose veins of the conjunctiva, and the ramifications coming from the surface of the cornea, the seat of the opacity. The first mode of treatment is executed by means of topical astringents and corroborants, especially Janin's ophthalmic ointment, and success attends it when the opacity is in an early state, and not extensive. But when advanced to the centre ofthe cornea, the most in- fallible treatment is the excision of the fasciculus of varicose veins near their ramifications, that is, near the seat of the opacity. By means of this excision, the blood retarded in the dilated veins of the cornea is voided; the varicose veins of the conjunctiva have an opportunity to contract and regain their tone, no longer having blood impelled into them; and the turbid secre- tion effused in the texture of the layer of the conjunc- tiva continued over the cornea, or in the cellular sub- stance connecting these two membranes, becomes ab- sorbed. The celerity with which the nebula disap- pears after this operation is surprising, commonly in twenty-four hours. The extent to which the excision of the varicose veins of the conjunctiva must be per- formed depends upon the extent of the opacity of the cornea. Thus, should there be only one set of varicose vessels, corresponding to an opacity of moderate ex- tent, it is sufficient to cut a portion of them away. Should there appear several dim specks upon the cor- nea, with as many distinct sets of varicose vessels, ar- ranged round upon the white of the eye, the surgeon must make a circular incision into the conjunctiva, near the margin of the cornea, by which he will cer- tainly divide every plexu* of varicose vessels. But let CORNEA. 289 k be observed, that a simple incision through tjie van- cose vessels is not permanently effectual in destroying all direct communication between the trunks and rami- fications of these vessels upon the cornea, after such an incision made, for instance, with a lancet; though It be true that a separation of the mouths of the di- vided vessels follows in opposite directions, it is no less true, that in the course of a few days after the in- cision, the mouths of the same vessels approximate each other, and inosculate, so as to resume their for- mer continuity. Hence, to derive from this operation all jHissible advantage, it is essential to extirpate with the knife a small portion of the varicose plexus, to- gether with the adherent particle of the tunica con- junctiva. The eyelids are to be separated from the affected eye by a skilful assistant, who is, at the same moment, to support the patient's head upon his breast. The sur- geon is then te take hold of the varicose vessels with a pair of small forceps, near the edge of the cornea, and to lift them a little urj, which the lax state of the conjunctiva renders easy; then, with a pair of small, curved scissors, he is to cut away the plexus of vari- cose vessels, together with a smaU piece of the con- junctiva, making the wound of a semilunar form, and as near as possible to the cornea. If it should be ne- cessary to operate upon more than one plexus of vari- cose vessels, situated at some distance apart, the sur- geon must elevate them one after the other with the forceps, and remove them. But when they are very close together, and occupy every side of the eye, he must make ,an uiunterrupted circular incision in the conjunctiva, guiding it closely to the margin of the cor- nea all around, so as to divide with the conjunctiva all the varicose vessels. This boing done, he may allow the cut vessels to bleed fteely, even promoting the hemorrhage by fo- menting the eyelids untU the blood discontinues to flow. Scarpa then covers the eye with an ova] piece of the emplastrum saponis and a retentive bandage. The eye ought not to be opened till twenty-four hours after the operation, when, usually, the opacity of the cornea will be found completely dispersed; and, dur- ing the ensuing days, the patient is to be enjoined to keep the eye shut, and covered with a bit of fine rag. A collyrium of milk and rose-water, warm, may be ap- plied two or three times a day. When the inflamma- tion of the conjunctiva happens, about the second or third day after the operation, particularly in cases in which the incision is made all round, while the greater part of the sphere of the eye reddens, a whitish circle, in the place of the incision, forms a line of boundary to the redness which does not extend farther upon the cornea. This inflammation of the conjunctiva, with the aid of internal antiphlogistic remedies and topical emollients, abates in a few days, and then pus is se- creted along the track of the incision in the conjunc- tiva. The wound contracts, and, growing smaller and smaller, soon cicatrizes. Bathing the eye with warm milk nnd rose-water is the only local treatment neces- sary in this stage of the complaint. Thus, not only the transparency of the cornea is re- vived, but also the preternatural laxity of the conjunc- tiva is diminished, or even removed. When the con- junctiva subsequently appears yellowish and wrinkled, the use of topical astringents and corroborants, and of Janin's ophthalmic ointment, may be highly beneficial in preventing the recurrence of the varicose state of the vessels.—(Scarpa suite Malattie degli Orchi, c. 8.) According to the experience of Dr. Vetch, Scarpa's plan of removing the plexus of varicose vessels, toge- ther with a portion of the conjunctiva, produces no good effect, " except in cases of great relaxation ofthe membrane covering the eye." He asserts, that new vessels immediately appear in the room of those re- moved, and tbe good derived from the bleeding does not compensate for the irritation produced by the ope- ration.-(.4 Practical Treatise on the Diseaset of the Eye, p. H>.) However, when it is reflected, that Scarpa advises this practice only for advanced cases and par- ticularly recommends topical astringents for the more recent stages of the disease, he nearly agrees with Dr V. tch, as for as this point is concerned. But Scarpa's account of the disease and its treatment is left im- perfect by the omission of any notice of the connexion frequently existing between opacity of the cornea and a rough, scabrous, granulated state of the lining ofthe V jl 1 --T eyelids. Yet, perhaps, Searpa was not to be expected to treat of this combination in his chapter on nebula, because his definition of this superficial opacity will not altogether suit the affection ofthe same membrane referred to in the following observations. It is re- marked by Dr. Vetch, that after the complete cessation of conjunctival ophthalmia, as far as regards that por tion of the membrane which covers the eye, the vUlous elongation of the vessels of the lining of the eyelids, instead of recovering their natural state, acquire a farther increase of size, so as to produce a rough, sca- brous, or granulated surface, with a secretion of puri- form matter. The irritation of this unequal surface gradually induces an inflammatory state of the sclerotic vessels, and, consequently, a greater flow of blood to- wards the cornea: the superficial vessels become va- ricose ; the conjunctiva assumes a dusky and loaded appearance; and-the cornea becomes opaque, not par- tially, but throughout the whole extent of its structure. This affection, says Dr. Vetch, is essentially different from those nebulous or partial opacities which take place in primary sclerotic inflammation, and which consist in slight extravasations, accompanied by in- tolerance of light, and in which any affection of the pal- pebral linings is a secondary instead of a primary cir- cumstance. The cornea is of the green colour pre- sented by a broken gun-flint; and while it is sufficiently diaplianous to permit the perception of light, it is yet too opaque to allow the patient to discern external ob- jects, except by their shades. Nor can the colour of the iris and limits of the pupU be seen. Dr. Vetch also describes the conjunctiva as being sometimes so much relaxed, and its vessels so generally loaded, as to give it a dusky appearance similar to that of the cornea; and, in other instances, without much alteration of its thickness or transparency, it is said to lose for a con- siderable extent its close attachment to the subjacent lamina of the cornea. Along with the opaque state of the cornea, there is more generally an enlargement of individual vessels, which penetrate almost to its cen- tre, increase as they come outwards, and terminate in trunks, which run to the duplicature of the conjunc- tiva. Dr. Vetch represents this disease of the pal- pebra? as consisting at first in a highly villous state of their membranous lining. This state, if not rectified by proper treatment, gives birth to granulations, which in time become more deeply sulcated, hard, or warty, accompanied by an oozing of purulent matter- Dr. Vetch has explained, that the use of the actual cautery, excision, and friction, for the purpose of curing the dis- eased state of the eyelids, may be traced back to Hip- pocrates, who prefers escharotics. Dr. Vetch ascribes their first employment in these cases to St. Ives. Mr. Saunders, he observes, took an early and a just view ofthe relations existing between the diseased conditions of the palpebral linings, and the opaque state of the cornea; and he succeeded in establishing the cure of the latter by the removal of the former. In short, Dr. Vetch admits, that in the case, which more especially formed the claim of Mr. Saunders to the discovery of the nature of the disease, the practice of excision was attended with complete success. Dr. Vetch contends, however, that this method is for the most part inade- quate to the. cure ofthe disease; and that there are very few cases, in which the more certain and consis- tent process of gradually repressing the diseased sur- face by escharotic substances wUl not produce a more complete and permanent cure. After giving a fair trial to a great variety of escharotics made into oint- ments, and applied to the inside of the upper eyelid, Dr. Vetch found the direct application of the escha- rotic substances themselves was preferable. When there is too much increased action of the vessels of the sclerotic coat, Dr. Vetch recommends the use of escha- rotics to be preceded by cupping the temples; or, when there is any risk of a slough, the application of a leech to the inside of the lower eyelid. Whatever will bring on a determination of blood to the head is to be avoided, and a low regimen observed. The escharotics preferred by Dr. Vetch, are the sul- phate of copper and nitrate of silver, scraped in the form of a pencil and fixed in a portcrayon. In this way, Dr. Vetch says, they should be applied, not, as some have con- ceived, with the view of producing a slough over the whole surface, but with great delicacy, and in so many points only as will produce a gradual change in the condi tion and disposition of the part. As long as there is any 290 COR] secretion of pus, the above application may be mate- rially assisted by the daily use of the undiluted Uquor plumbi acetatis. When the disease resists these reme- dies, and its surface is hard and warty, Dr. Vetch ap- plies to the everted surface powder of verdigris or burnt alum, finely levigated; or even lightly touches the dis- eased surface with the kali purum. In employing these remedies, he enjoins confining their operation to the point of contact, so as to prevent them from hurting the eye. Hence, they are to be applied in -very minute quantities with a fine camel's hair pencil, and to be washed off with an elastic gum syringe, before the eyelid is returned. Of the employment of astringent collyria in conjunction with escharotics, Dr. Vetch dis- approves.—(See A Practical Treatise on the Diseases of the Eye, p. 67, i-c.) With respect to the treatment by excision, as first practised by Mr. Saunders with scis- sors, and afterward by Sir W. Adams with a knife, the principle of cure does not appear to me different from that aimed at with escharotics, unless these latter be supposed not always to destroy, but sometimes to cause an absorption of the fungous granulations. At present, the last method is considered most effectual, and during the operation the eyelids should be everted over a probe. For the form of disease termed by Mr. Travers " strumous nebula, with vessels overshooting the cor- nea," this gentleman recommends ptyalism. He says, that " the hydrargyrus cum creta or oxymuriate, in small but frequent doses, will sometimes succeed bet- ter in this case, than the other forms of Jnercury, and the combination of calomel with antimony, better than that with opium." When the internal exhibition of mercury either disorders the bowels or has no effect on the constitution, frictions are to be preferred.—(Sy- nopsis of tlie Diseases of the Eye, p. 282.) In the par- ticular form of opacity, to which he alludes, he disap- proves of dividing the vessels of the conjunctiva be- fore the inflammation has declined.—(P. 285.) From some observations published by Mr. Wardrop, it would appear, that certain opacities of the cornea are produced by an increase in the quantity of the contents of the eyeball, and not by the deposition of an albu- minous fluid in the texture of the cornea, as takes place in the common speck. He considers this fact proved, by cases in which the cornea regained its transparency the instant the aqueous humour was evacuated. Some cases are detailed by this gentleman, with the view of recommending the practice of punc- turing the cornea, and discharging the aqueous humour, for the relief of the kind of opacity to which we have here al'uded.—(See Med. Chir. Trans, vol. 4,p. 180,i-c.) For other opacities of the cornea, refer to Albugo, Leucoma, and Staphyloma. ULCERS OF THE CORNEA. An ulcer is a common consequence of the bursting of a small abscess, which not unfrequently forms be- neath the delicate layer of the conjunctiva continued over the comea, or in the very substance of the cornea itself, after violent ophthalmy. At other times, the ulceris produced by the contact of corroding matter, or sharp pointed bodies insinuated into the eyes, such as quicklime, pieces of glass or iron, thorns, Sec. As Dr. Vetch has observed, ulceration ofthe cornea is a very frequent consequence of purulent ophthalmy. The little abscess of the cornea is attended with the same symptoms as the severe acute ophthalmy; especially with a troublesome sensation of tension in the eye, eyebrow, and nape ofthe neck; with ardent heat; co- pious secretion of tears; aversion to light; intense red- ness of the conjunctiva, particularly near the point of suppuration. The inflammatory pustule, compared with similar ones in any other part of the body, is slow in bursting after matter is formed. Scarpa deems it improper, however, to puncture the small abscess; for, though it assumes the appearance of being per- fectly maturated, the matter contained in it is so tena- cious and adherent to the substance ofthe cornea, that not a particle issues out of the artificial aperture, and. the wound exasperates the disease, increases the opa- city of the cornea, and often occasions another small abscess to form in the vicinity of the first. Indeed, if the observations of Mr. Travers be correct, " the ulcer of the cornea begins not in abscess, but in a cir- cumscribed deposite of lymph, or in pure ulcerative ab- sorption without pus."— Synopsis of the Diseases of the Eye, p. 106.) And Dr. Vetch takes notice, that (tit observation with respect to fluid matter never forming in the cornea, he invariably found true in several cases, where the whole of the eyeball had been de- stroyed by inflammation.—(Practical Treatise on the Diseases ofthe Eye, p. 52.) This author differs from Scarpa, however, respecting the question of opening pustules or abscesses of the cornea; for he remarks, that whenever the matter or slough is removed, the ulcer, however deep and extensive, will fill up with- out leucoma being the consequence. By a little ad- dress, he says, it may in most instances be removed in a mass upon the point of a lancet or couching- needle.—(Op. cit. p. 50.) This remark applies both to cases where lymph or tenacious matter more or less protrudes, and to instances in which it is quite con- fined between the lamella? of the cornea. Scarpa thinks that the safest plan is to temporize, until the pustule spontaneously bursts, promoting it by means of frequent fomentations, batlung the eye with warm milk and water, and applying emollient poultices. The spontaneous bursting of the little abscess is usually denoted by a sudden increase of all the symp- toms of ophthalmy; particularly by an intolerable burning pain at the point of the cornea, where the ab- scess first began, greatly increased by motion of the eye or eyelid. The event is confirmed by ocular in- spection, and at the spot where the white pustule ex- isted a cavity appears, as may best be seen when the eye is viewed in the profile. Extraneous bodies in tha eye, which have simply divided a part of the comea, or lodged in it, when soon extracted do not in general cause ulceration, as the injured part heals by the first intention. Those which destroy or burn the surface of this membrane, or which, when lodged, are hot soon extracted, excite acute ophthalmy, suppuration at the injured part, and at length ulceration. As Dr. Vetch has observed, the appearance of ulcer- ation varies according to the degree of apostemation, or tendency towards it in the surrounding cornea: when this part is clear, the case is doing well, but when opacity comes on, the ulcer is increasing. The soft middle lamina, he says, is destroyed with great rapidity when the inflammation is violent, but as seoa as the ulcer reaches the internal coat, it often proceeds no farther.—(Practical Treatise on Diseases ofthe Eye, p. 52.) The ulcer of the cornea, as Scarpa remarks, has this in common with all solutions of continuity in the skin, where this is delicate, tense, and endowed with exqui- site sensibility, that at its first appearance, it is of a pale ash colour; has its edges high and irregular; creates sharp pain; discharges, instead of pus, an acrid serum, and tends to spread widely and deeply. Such is the precise character of ulcers upon the cornea, and such is the nature of those upon the nipples of the mamma?, the glans penis, lips, apex of the tongue, th* tarsi, the entrance of the meatus auditorius externus; nostrils, ecially the smarting and burning pain at the ulcer- ated part of the comea; the effusion of tears; the re- straint in moving the eye and eyelids; and the aversion to light; but all these inconveniences are less in degree than before. At their recurrence the surgeon, without delay, must renew the application of the argentum ni- tratum, making a good eschar, as at first, upon the whole surface of the ulcer, which wUl, as before, be followed by perfect ease in the eye. Tlie application of the caustic is, if required, to be repeated a third time; that is, if, upon the separation of the eschar, the extreme irritabiUty in the ulcer is not exhausted, and its pro- gressive mischief checked. When the case goes on ftvourably, it is a constant phenomenon in the cure T2 of this disease, that at every separation of the eschar, the diseased sensibility of the eye is decreased; the ulcer also, abandoning its pale ash-co!our, assumes a delicate, fleshy tint, a certain sign that the destructive process which prevailed is turned into a healing one. The turgid state of the vessels of the conjunctiva, and the degree of ophthalmy, disappear in proportion as the ulcer draws near to a cure. At this epoch, when the formation of granulations has begun, the surgeon would act very wrongly were he to continue the use of the argentum nitratum; it would now reproduce pain, effusion of tears, and inflammation of the eye; and the ulcer would take on that foul, ash-coloured aspect, with swelled and irregular edges, which it had in the beginning. Platner has noticed this fact. Ne- cesse est, ut hoc temperatd manu, nee crebrius flat, ne nova inflammatio, novaque lachrymatio hie acrioribus concitetur.--(Ihst. Chirurg. 6314.) As soon as ease is felt in the eye, and granulations begin to rise, whether after the first, second, or third application of the caus- tic, the surgeon must refrain from the use of every strong caustic, and use only the following collyrium: \y.Zinci sulphatis gr. iv. Aq. rosa, ?iv. Mucil. sem. cydon mali\ ss. M. This is to be used every two hours, the efe in the intervals being defended from the air and light by means of a gentle compress and retentive bandage. When, besides the ulcer of the comea, a sUght relaxation of the conjunctiva remains, Janin's ointment, towards the end of the treatment, introduced between the eye and eyelids, morning and evening, proved serviceable. It must be adapted in strength and quantity to the particular sensibility of the pa- tient. To cure those superficial excoriations of the cornea which make no excavation in the substance of this membrane, and which, in reality, are only a detach- ment of the cuticle, covering the layer of the conjunc- tiva continued over the cornea, the use of caustic is not requisite. The same collyrium, combined with mu- cilage, is sufficient. The symptoms which accompany these slight excoriations or detachments of the cuticle are unimportant, and when the patient takes care to bathe his eye every two or three hours with the solu- tion of sulphate of zinc, and to avoid too much light and exposure to the air, they soon get well. According to Dr. Vetch, when the ulcerative process is likely to destroy the membrane which lines the cor- nea, it can only be checked by measures calculated to subdue the inflammation upon which it depends. "As long, therefore, as there is an appearance of activity in the disease, or recurrence of pain, local blood-letting by cupping or leeches must be steadily adhered to. The indication of the ulcer healing is easUy seen in the diminished activity of the inflammation, relief from pain, and the clean aspect of the ulcerated part. The injection of vegetable, tepid, astringent infusions may be used, or milk and water only. When called upon in extreme cases, where the immediate perforation of the inner membrane is threatened, we may, with great propriety, resort to the operation of puncturing the cor- nea at a place as remote as possible from the ulcer. Next in importance to a diminution of the action on which the ulcer depends, is the removal by scarification of any slough thrown out from its surface, or imbed- ded in the adjoining part of the comea. Sometimes, but always subordinate to these indications, we may add some topical applications to the ulcer; a solution of nitrate of silver, the infusion of tobacco or calomel in powder, applied with a camel's hair pencil."—(Prac- tical Treatise on Diseases of the Eye, p. 57.) In inci- pient protrusions of the inner membrane of the cornea, this author decidedly condemns the use of the argen- tum nitratum in the free manner proposed by Scarpa; observing that, " if the caustic touches by accident the edge of the ulcer, or any part but the apex of the pro- jecting vesicle, it.will often produce much mischief." Thus far of ulcers of the cornea, and the best me- thod of curing them in ordinary cases. However, sometimes, says Scarpa, in consequence of ill-treat- ment, the ulcer, already very extensive, assumes the form of a fungous excrescence upon the cornea, ap- pearing to derive its nourishment from a band of blood-vessels of the conjunctiva; and on this account it occasions, not unfrequently, a serious mistake in being taken for a real pterygium. Left to itself, or treated with slight astringonts, it produces, in general, a loss of the whole eye. It requires the speedy adop- .202 CORNEA. tion of some active and efficacious plan to destroy all the fungus upon the comea, to annihilate the vessels of the conjunctiva tending to it, and to impede the pro- gress of ulceration. This consists first in cutting away the fungus with a pair of small scissors to a level with the cornea, continuing the incision far enough upon the conjunctiva to remove with the excrescence that string of blood-vessels from which it seems to derive its sup- ply. Having effected this, and allowed the blood to flow freely, Scarpa appUes the argentum nitratum to all the space of the cornea which appears to have been the seat of the fungus, so as to make a complete eschar; and if, upon its separation, the whole morbid surface should not be destroyed, he repeats the caustic until the ulcerative process changes into a healing one. To execute commodiously such a fuU application of the caustic, it is not in general enough to have the upper eyelid raised by au assistant, and the lower one de- pressed ; it is also farther requisite, that the operator should evert the upper eyelid completely, and keep it so, whUe a deep eschar is made with the caustic. The action of the caustic cannot always be calculated with precision, and therefore a portion of the whole thickness of the cornea may be destroyed with the fungus, which never fails to be followed by a prolapsus of the part of the iris through the aperture made in the cornea. This accident may seem grievous, yet it is not irreparable, as wUl be shown in the article Iris, Pro- lapsus of; and when the surgeon can produce a firm cicatrix at the point where the excrescence was situ- ated, which prevents a reproduction of the fungus and a total destruction of the eye, he has fulfilled the indi- cations required.—(Scarpa, sidle Malattie dcgli Occhi.) In a late publication, two cases of ulcer of the cornea are recorded, which were benefited by Mr. Wardrop's operation of puncturing the cornea and discharging the aqueous humour. In the first example, there was an ulcer on the central part of the cornea, and a cluster of blood-vessels passing towards it. The whole eye- ball was also much inflamed. .The puncture was made at the place where the vessels passed. The patient's severe headache was relieved, and under the use of fo- mentations and the vinous tincture of opium, all the other symptoms rapidly subsided. In the second case, there were two or three erosions, with a good deal of- muddiness of the comea, headache, ^td^ehrevon den Augenkr. b. 2, Wien, 1817. M. J. Chehus, Ueber die durihsichtige Hornhaut des Auges, litre Function, und ihre Krankhaften Veranderungen, 8yo. Karls- ruhe, 1818. A. Clemens, Diss, sistens Tunica Cornea rt Humoris Aquei Monographiam Physiologico-patho- Umiciitn, 4to. Gott. 1816. J. Wardrop's Essays on the Morbid Anatomy of the Human Eye, vol. 1, Svo. edit. 1 &06. B. Travers, Synopsis of the Diseases of the Eye, torn Lond. 1820. J. Vetch, A Practical Treatise on the Diseases of the Eye, 8vo. Lond. 1820. The sections of tlUs work on opaque cornea and ulceration of the cornea are highly interesting. CORNS. (Clavi, Spinre Pedum, Colli, Condylo- mata, i-c.) A corn, technically called cloxus, from its fancied resemblance to the head of a nail, is a brawn- Uke hardness of the skin, with a kind of root sometimes extending deeply into the subjacent cellular substance. When this is the case, the indurated part is fixed; but while the hardness is more superficial, it is quite moveable. Some corns rise up above the level of the skin in the manner of a flat wart. They are hard, dry, and insensible, just like the thickened cuticle which forms on the soles of the feet, or on the hands of la- bouring people. Corns are entirely owing to repeated and long-con- tinued pressure. Hence they are most frequentin such situations as are most exposed to pressure, and where the skin is near bones, as on the toes, soles of the feet, &c. However, corns have occasionally been seen over the crista ofthe ileum from the pressure of stays, and even on the ears from the pressure of heavy earrings. Corns of the feet are usually owing to tight shoes, and consequently they are more common in the higher classes, and in women, than other subjects. In females, indeed, the ridiculous fashion of wearing high-heeled shoes was very conducive to this affliction; for cer- tainly it merits the appellation. In shoes thus made the whole weight of the body falls principally on the toes, which become quite wedged, and dreadfully com- pressed in the end of the shoe. Though some persons who have corns suffer very little, others occasionally endure such torture from them, that they are quite incapable of standing or walking. Doubtless the great pain proceeds from the irritation of the hard corn on the tender cutis beneath, which is frequently very much inflamed in consequence of the pressure. It is observed that every thing which accelerates the motion of the blood, which heats the feet, which increases tlie pressure of the corn on the subjacent parts, or the determination of blood to the feet, or which promotes its accumulation in them, ex- asperates the pain. Hence, the bad effects of warm stockings, tight shoes, exercise, long standing, drinking, Sec. The pain in warm weather is always much more annoying than in winter. If a person merely seeks temporary relief, it may be obtained by pulling off his tight shoes, sitting down, plac- ing his feet in a horizontal posture, and becoming a little cool: the prominent portion of the com should be cut off, as far as it can be done without exciting pain or bleeding, and the feet should be bathed in warm water. The radical cure essentially requires the avoidance of all the above causes, and particularly of much walking or standing. Wide, soft shoes should be worn. Such means are not only requisite for a radical cure, but they alone very often effect it. How many women he- roine spontaneously free from corns in chUdbed and other confinements'. Though the radical cure is so easy, few obtain it, because their perseverance ceases as soon as they experience the wished-for relief. When business or other circumstances prevent the l»ationt from adopting this plan, and oblige him to walk or stand a good deal, stUl it is possible to remove all pressure from the corn. For this purpose, from eight to twelve pieces of linen, smeared with an emollient ointment, and having an aperture cut in the middle oxactly adapted to tlie size of the corn, are to be laid ov.r ea^-h otber, and so applied to the foot, that the corn is to lie in the opening in such a manner that it cannot be touched by the shoe or stocking. When the plaster has been applied some weeks, the corn commonly disap- pears without any other means. Should the corn be in the sole ofthe foot, it is only necessary to put in the shoe a felt-sole, wherein a hole has been cut, corresponding to the situation, size, and figure of the induration. A corn may also be certainly, permanently, and speedily eradicated by the following method, especially when the plaster and felt-sole with a hole in it are em- ployed at the same time. The corn is to be rubbed twice a day with an emollient ointment, such as that of marshmallows, or with the volatile liniment, which is stUl better; and in (he interim is to be covered with a softening plaster. Every morning and evening the foot is to be put for half an hour in warm water, and while there the com is to be well rubbed with soap. Afterward all the soft, white, pulpy outside ofthe corn is to be scraped off with a blunt knife; but the scraping is to be left off the moment the patient begins to com- plain of pain from it. The same treatment is be per- sisted in without interruption until the corn is totally extirpated, which is generally effected in eight or twelve days. If left off sooner, the corn grows again. A multitude of other remedies for curing corns are recommended. They all possess, more or less, an emol- lient and discutient property. The principal arc green wax, soap, mercurial and hemlock plasters, a piece of green oil-skin, &c. They are to be applied to the corn, and renewed as often as necessary. A very successful composition consists of two ounces of gum amrnonia- cum, the same quantity of yellow wax, and six drachms of verdigris. In a fortnight, if the corn yet remain, a fresh plaster is to be appUed. It is frequently difficult and hazardous to cut out a com. The whole must be completely taken away, or else it grows again ; and the more frequently it is par- tially cut away, the quicker is its growth rendered. When the skin is moveable, and consequently the corn not adherent to the subjacent parts, its excision may be performed with facility and safety, but not without pain. But, in the opposite case, either leaving a piece ofthe com behind, or wounding the parts beneath, can seldom be avoided. The latter circuffistance may ex- cite serious mischief. A person entirely cured of corns is sure to be affected with them again, unless the above-mentioned causes be carefully avoided. Some subjects are indeed particu- larly disposed to have the complaint. There are per- sons who for life wear tight shoes, and take no care of their feet, and yet are never incommoded with corns. On the contrary, others are constantly troubled with them, though they pay attention to themselves. Many are for a time vexed with corns, and then become quite free from them, though they continue to wear the same kind of shoes and stockings. Mr. Wardrop recommends cutting or tearing away as much of the corn as can be done with safety; then keeping the toe for some time in warm water; and af- ter the adjacent skin has been well dried, rub ling the exposed surface of^he corn with the argentum nitratum, or wetting it, by the means of a camel-hair pencti, with a solution of the oxymuriate of mercury in spirit of wine. Either of these appUcations, two or three times repeated, he says, wUl mostly effect a cure.—(See Med. Chir. Trans, vol. 5, p. 140.) However, the use of caus- tic for the cure of corns is not a new proposal.—(See Callisen's Syst. Chir. Hodierna, part 2, p. 200.) The above account is partly taken from Richter* Anfangsgriinde der Wundarzneykunst, b. 1. COUCHING. The depression of a cataract out ofthe axis of sight, or the displacement, breaking, and dis- turbance of the opaque lens in various ways with a kind of needle for these purposes, so as to bring about the dispersion and absorption of the cataract.—(See Ca- taract.) COUVRE CHEF. The name of a bandage.—(See Bandage.) CRANIUM. For an account of its fractures, see Head, Injuries of. CREMOR L1THARGYRI ACETATI. R. Cremoria lactis ;j. Liq. plumbi. acet. 3j. M. Employed by Kirkland in ophthalmies, and other inflammations. CREPITUS. The grating sensation or noise occa- sioned by the ends of a fracture, when they are moved and rubbed against each other; one ofthe most positive symptoms of the existence of such an accident. 294 DEC DIP CUPRI SULPHAS (Sulphate of Copper) is an es- charotic, and an ingredient in several astringent fluid applications, lotions for ulcers, collyria for the eyes, and injections for the urethra. CURETTE. (French.) An instrument shaped like a minute spoon or scoop, invented by Daviel, and used in the extraction of the cataract, for taking away any opaque matter, which may remain behind the pupil, im- mediately after the lens has been taken out. CURVATURE OF THE SPINE. See Vertebra, Disease of JJACRYOMA. (From Saxpoia, to weep.) An imper- m-w vious state of one or both the puncta lachrymalia, preventing the tears from passing intothe lachrymal sac. DAUCUS. See Cataplasma Dauci. DECOCTUM CHAMOJMELI. R. Florurn chamce- meli, 3 ss. Aqua? distillatae, tbj. Boil ten minutes, and strain the liquor. A common decoction for foment- ations.—(See Fomentum.) DECOCTUM DULCAMARA. R. Dulcamara? cau- lis concisa? unciam, aqua? oclarium cum semisse. De- coque ad octarium, et cola. The decoction of bittersweet, or woody nightshade, is recommended for some cutaneous diseases, proceeding from scrofula, lepra, and lues venerea. The dose is one or two table spoonfuls, three times a day. An aro- matic tincture should be added. DECOCTUM HELLEBORI ALBI. (Now the De- coctum Veratri.) R. Pulveris radicis hellebori albi, ?j. Aqua? distillata?, Ibj. Spiritus vinosi rectificati, 3 ij. Boil the water and powder till only one-half the fluid remains, and when cold add the spirit. This is used as a lotion for curing psora, porrigo, and some herpetic affections. DECOCTUM LOBELLE. (Blue Cardinal Flower of Virginia.) R. Radicis lobelia? syphilitica? sicca? ma- nip, j. Aqua? distillata?, Ibxij. This is to be boiled till only four quarts remain. The lobelia once gained re- pute as an antivenereal, though little reliance is now put in it. The patient is at first to take half a pint twice, and afterward four times a day. It operates, however, as a purgative, and the doses must be regulated accord- ing as the bowels appear to bear them. DECOCTUM MEZEREI. R. Corticis radicis meze- rei recentis, 3 ij. Radicis glycirrhiza? contuss, 3j. Aqua? distillatae, Ibiij. Boil the mezereon in the water till only two pints remain; and when the boiling is nearly finished, add the liquorice root. The decoction of mezereon has been much prescribed for venereal nodes and nocturnal pains in the bones, in doses of from four to eight ounces, three times a day. DECOCTUM PAPAVERIS. R. Papaveris somni- feri caps.'larum concisarum, ?iv. Aqute, ftiv. Boil for a quan?r of an hour, and strain. In cases attended with great pain and inflammation, this decoction is used as a fomenting fluid. DECOCTUM QUERCUS. R. Quercus corticis, ?j. Aquae, Ibij. Boil down to a pint, and strain the fluid. This decoction forms a very astringent injection, which is sometimes used for stopping gleets from the vagina. It also makes a lotion which is of considerable use in cases of prolapsus ani. It may be applied to some slight rheumatic white swellings, which it will some- times cure, particularly when a Uttle alum is put into it. DECOCTUM SARSAPARILL.**. R. Sarsaparilla? radicis concisa?, 3 iv. Aqua? ferventis, Ibiv. The sar- saparilla is to be macerated for four hours, near the fire, in a vessel lightly closed. The root is then to be taken out, bruised, and put into the fluid again. The mace- ration is to be continued two hours longer, after which the liquor is to be boiled till only two pints remain. Lastly it is to be strained. DECOCTUM SARSAPARILLiE COMPOSITUM. R. Decocti sarsaparilla? ferventis, tbiv. Sassafras radi- cis concisae, guaiaci ligiii rasi, glycirrhiza? radicis con- tus;e, singulorum 3J. Mezerci radicis corticis, 3 iij. These are to be boiled together for a quarter of an hour, and then strained. This and the preceding decoction of sarsaparilla are 1 much prescribed in cases of venereal nodes and pains; ] CUPPING. See Bleeding. CYSTITOME. (From/cOffrif.andrfVvu.tocut.) An instrument made on the same principle as the ptwyn- gotomus, and invented by M. de la Faye, for opening the capsule of the crystalline lens. CYSTOCELE. (From kvotK, the bladder, and KijXn, a tumour.) A hernia formed by a protrusion of the bladder.—(See Hernia.) CYSTOTOMIA. (From xuVrij, the bladder, and riuvto, to cut.) The operation of opening the bladder, for the extraction of a stone or calculus.—(See Lithotomy.) but while some surgeons hold them in high repute in such cases, others entertain an opposite opinion of them. They are also commonly given in several cutaneous dis- eases, and in scrofula. The simple decoction is frequently directed for the restoration of the constitution after a course of mercury, sometimes mixed with an equal quantity of milk. The common dose of both the decoctions is from four to eight ounces, three times a day. The compound one possesses similar qualities to those of the famous Lisbon diet drink, for which it is now a common substitute. DECOCTUM ULMI. R. Ulmi corticis recentis con- tus. 3 iv. Aquae, Ibiv. Boil to two pints, and then strain the liquor. The decoction of elm bark is often prescribed in cuta- neous diseases. Its operation is frequently promoted by giving with it the hydrargyri submurias. DECOCTUM VERATRI. See Decoctum Hellebori Albi. DEPRESSION OF THE SKULL. See Head, In- juries of. DEPRESSION OF THE CATARACT. Sec Ca- taract. DETERMINATION. When the blood flows into a part more rapidly and copiously than is natural, it is said, in the language of surgery, that there is a deter- mination of blood to it. DLERESIS. (From faaipiu, to divide.) A division of substance; a solution of continuity. This was for- merly a sort of generic term applied to every part of sur- gery, by which the continuity of parts was divided. DIGESTION. (From digero, to dissolve.) By the digestion of a wound, or ulcer, the old surgeons meant bringing it into a state in which it formed healthy pus. DIGESTIVES. Applications which promote this object. DIORTHOSIS. (From Siopddia, to direct.) One ofthe ancient divisions of surgery: it signifies the restoration of parts to their proper situations. DIPLOPIA. (From oiirXoCs, double, and S>4>, the eye, or Snropat, to see.) Visus duplicatvs is of two kinds. For instance, the patient either sees an object double, treble, &c. only when he is looking at it with both his eyes, and no sooner is one eye shut than the object is seen single and right; or else he sees every object double, whether he surveys it with one or both his eyes. The disorder is observed to affect persons in different degrees. Patients seldom see the two appear- ances which objects present with equal distinctness; but generaUy discern one much more plainly and per- fectly than the other. The first distinct shape which strikes the eye is commonly that of the real object, while the second is indistinct, false, and visionary Therefore patients labouring under this affection sel- dom make a mistake, but almost always know which is the true and real object. However, there are cases in which the patient sees, with equal clearness, the two appearances which thingsiassume, so that he is incapa- ble of distinguishing the real object from what is false and only imaginary. The disorder is sometimes transitory and of short du- ration, and may be brought on in a healthy eye by some accidental cause, generally an irritation affecting the organ. Sometimes the complaint is continual, some- times periodical. In particular instances the patient only sees objects double, when he has been straining his 1 sight for a considerable time, as, for example, when ne | has been reading a small print for a long while by can- D DIPLOPIA. 295 file-light. In this case, the disorder becomes lessened by shutting the eyes for a few moments. There are also instances in which the objects have a double ap- pearance only at a particular distance, and not either when they are nearer or farther off. Sometimes the patient sees objects double only upon one side ; as, for example, when he turns his eyes to the right-hand, while nothing of this sort is experienced in looking in any other direction. In certain cases, objects appear double, in whateverway the eyesare turned and directed. The causes of double vision may be divided into four classes. Namely, the object which the patient looks at maybe represented double upon the retina; which is the effect of the first class of causes. Or, the object may be depicted in one eye differently from what it is in the other, in regard to size, position, distance, clear- ness, Sec. This is the effect of the second class of causes. Or, the object may appear to one eye to be in a different place from Ihut which it seems to the other to occupy : the effect of the third class of causes. Or, lastly, the sensibility of the optic nerves is defective, so that the image of an object, though it may appear single to one eye as well as the other, yet in one identical situation will seem double to both of them. When the complaint originates from causes of the first and fourth class, the patient sees things double, whether he is using only one or both eyes; but when it proceedsfrom i the second and third class of causes, the patient sees I objects double only when he is looking at them with both eyes, and no sooner does he shut one than objects put on their natural single appearance. The following are the chief causes of the first class •f a single object being depicted upon the retina as if double. 1. An unevenness of the cornea, which is di- vided into two or more convex surfaces. There are cases, which show that such an uneven shape may actually be the cause of double vision.—(Haller, Ele- ment. Physiol, t. 5, p. 85.) According to Beer, this conformation of the cornea is mostly a result of several preceding ulcers of that membrane; in which circum- stance, the patient sees with the affected eye not merely double, but treble, and quadruple, of which facts Beer has1 met with some examples.—(Lehre von den Augenkr. b. 2, p. 31.) However, it must not be dissembled that in a far greater number of instances, such unevenness of the comea, though equally considerable, does not occa- sion this defect of sight. We have principally an oppor- tunity of observing cases of this sort after the operation of extracting the cataract. Hence, it would seem that the inequalities must be of very particular shape to produce double vision. The diagnosis of this cause is easy enough, but the removal of it is impracticable; for how is it possible to restore the original shape of the cornea 1 On this case, however, Beer delivers a more favourable prognosis than Richter; for he states, that when the patient is not decrepit, the double vision, from altered shape of the cornea, will gradually disap- pear of itself, when proper care is taken of the consti- tution, and in particular of the eye.—(B. 2, p. 32.) 2. An inequality of the anterior surface of the crystalline lens, whereby the same is divided into several distinct surfaces, it is suggested, may also be the occasion of diplopia. Such an inequality may possibly produce the disorder; but it is exceedingly doubtful, whether any case of this sort has ever been met with, and, as Richter properly remarks, the investigation is not worth undertaking, as the diagnosis and cure would be equally impracticable. The only possible method of cure would be the extraction or depression of the crystalline lens; yet with the uncertainty respecting the nature of the cause, what man would be justified in per- forming an operation, in which the patient is not wholly exempt from the danger of losing his sight altogether? a. double aperture in the iris, or, as the case is termed, i double pupil, and a deviation of the pupil from its natural position, have been enumerated as causes of diplopia —(liaumer, in Act. Soc.Hassiac. t. l,No. 27.) I lowever, Richter deems the reality of the first of these causes doubtful; for cases have been noticed, where double vision was not the effect of there being two openings in the iris.—(Janin, Mim. sur P(Eil.) But i were the disorder actually to originate in this way, the experiment might be made of converting the two aper- tures into one. The causes of the second class, by the effect of which the ohject is represented, in regard to its size, yosilion, distance, Ac, differently in one eye from what it is in the other, are for the most part rather possible, than such as have been actually-observed. The causes which make objects assume an appearance contrary to t'.ie real one, may sometimes be confined to one. eye, to which things are depicted.diversely from what they are to the other healthy eye, so that the patient sees, as it were, double. Thus, for example, there may be a stronger refraction of the rays of light in one eye than the other; the patient may be a my ops with one eye, and a presbyops with the other; and then the object will seem to one eye large, to the other small; to one eye distant, to the other plainly near. This state of the sight, indeed, is said to have occurred after operating upon a cataract in one eye.—(Heuermann.) However, that this is not a common consequence -of operating upon a cataract in one eye, while the other is perfect, is sufficiently clear from what has been said upon this subject in a foregoing part of this work.—(See Cataract.) In particular examples, objects which are perpendicular seem to the patient to have a sloping posture. When it is considered that only one eye is thus affected, and that to it things will appear sloping, and to the other straight, double vision must be the effect. A few re- marks connected with this subject will be introduced hereafter.—(See SiglU, Defects of.) When both eyes are so directed to an object, that it becomes situated in the axis of vision of each of these organs, such object is represented in both atthe same place, that is, it is depicted upon that part of the retina on which the axis of sight falls. Thus the object seems to both eyes to be in the same place; and though the two organs discern the thing, it only communicates a single appearance. But when one eye is turned to any object in a different direction from that of the other; that is to say, when one eye is turned to an ob- ject in such a way that the object is situated in the axis of vision of this eye, while the opposite eye is so turned that the same object is placed on one side of its axis of vision; in other words, when a person squints, the object is depicted in one eye upon a different part ofthe retina from what it is in the other; consequently, the object appears to the two respective organs to be dif- ferently situated, and the patient is affected with diplo- pia. This is the third species of this disorder, which arises from strabismus, as a third kind of occasional cause. Such patients naturally see objects double only when they behold them with both eyes. A lady, whom I frequently see, is much annoyed with diplopia, the effect of deep-seated disease in the orbit, whereby the eye is forced out of its natural position. A person who squints usually has one eye stronger than the other, and the weakness of one of those organs is the common cause of the strabismus. Such a person does not see objects double, because he only sees with one eye well, and with the other so faintly and imper- fectly, that scarcely any impression is made. Hence, every case of strabismus is not necessarily combined with diplopia; indeed, the common kind of squinting is not joined with it, A person affected with strabismus only sees double when the sight of each eye is equally strong, and when the squinting does not depend upon any weakness of one of the eyes, but upon some other occasional causes. The principal causes of the latter sort are of a spasmodic nature, viz. an irritation affects some muscle of the eye in such a manner, that the patient is incapacitated from moving both his eyes according to his will, and from directing them to any object, so that such object may be at once in the axis of vision of both. On this case, the observations of Sir E. Home are interesting, who has made many accurate reflections on the effect of an irregular action of the straight muscles of the eye in producing double vision. —(Phil. Trans. 1797.) Richter states that in the majority of cases, the irri- tation alluded to is seated in the gastric organs, though he thinks that any other species of irritation may ope- rate upon the eyes in a similar manner. This kind of diplopia is frequently attendant on other spasmodic diseases as a symptom. It often accompanies hypo- chondriasis. Sometimes it is the consequence of vio- lent pain. Richter informs us of a man who saw double, and squinted, during 'a severe headache. He stales that another was affected in the same way during a toothache. Sometimes the diplopia is owing to a para- lysis of one of the muscles of the eye (Morgagni de Sedibus et Causis Morborum, epist. 13, art. 20, a para lysis of the abductor muscle); sometimes to a tumour in 296 DIP DIS the orbit. The diagnosis of this kind of diplopia is free from difficulty; the patient having been affected with squinting ever since things appeared double to him. The views which Sir E. Home took of diplopia from irregular action, spasm, or weakness of any particular muscle of the eye, led him to propose a plan of treat- ment, the principle of which is to keep the muscle affected for a time perfectly at rest, which is eastiy done by covering the eye with a bandage, and not allowing the organ to be at all employed. The fourth class of causes are such irritations as act upon the optic nerves, changing their sensibUity in such a way that objects do not make that sort of impression upon them which they ought to do. Thus things some- times have the appearance of being coloured, when they are really not so; immoveable objects seem in motion, straight objects appear oblique, and in the cases which we are now treating of, single things seem to the eye double, treble, . 345.) A hypochondriacal patient got rid of the disorder by means of the warm bath. A diplopia, supposed to arise from disorder of the bUiary secretion was cured by means of pills madeof gum galbanum, guaiacum, rhubarb, and Venice soap, assisted with emetics and purgatives. When the irritation exciting the disorder is only of temporary duration, as, for instance, looking at shining objects; when the disorder continues after the removal of the irritation ; or, lastly, when the irritation cannot be well detected ; the surgeon is to endeavour, by means of nervous and soothing medicines, either to remove the impression which the irritation has left upon the nerves, or to render the nerves insensible to the continuing irritation. According to Richter, the following remedies have proved useful in cases of diplopia: hartshorn, dropped into the hand, and held before the eyes; the external use of the spiritus vini crocatus; warm bathing of the eye, particularly in a decoction of white poppy heads; bathing the eye in cold collyria; the internal administration of bark, va- lerian, small doses of ipecacuanha, flowers of zinc, and oleum cajeput. In one instance, in which it was im- possible to detect the canse, Richter states, that soluble tartar with ox's gall, and castoreum was found of ser- vice ; that, in another similar case, rhubarb, ox's gall, and asafcetida; and, in a third, liquor ammonia? ace- tata? with ox's gall proved useful. This author farther observes, that in all cases in which the particular cause of the disorder cannot be precisely determined, we may conjecture, that such cause has its seat in the abdominal viscera; and that much benefit may often be derived from mild resolvents, evacuants, and ano- dyne medicines.A^jRicter's Anfangsgr. der Wun- darzn. b. 3, kap. 15.) According to Beer, the diplopia which is not an effect of the continuance of another disease after in- flammation of the eye, but probably depends upon in- jury of the retina caused by such inflammation, usually diminishes without the assistance of art, if the eye be not abused.—(Lehre von den Augenkr. b. 2, p. 32.) For theforegoing account of diplopia, I am chiefly in- debted to Richter. See also A. Voter et J. C. Heinicker, Visus Vitia duo rarissima; alterum duplicati, alte- rum dimidiati, &c. Wittemb. 1723. (Haller, Diss, ad Morb. t. 1, p. 305.) /. /. Klauhold de Visu duplicato, 4to. Urgent. 1746. Buchner de Visione simplici et duplici, 4to. Argent. 1753. Euler, Recherches Phy- siques sur la diverse rifrangibiliti des rayons de lumiire; Mem. de l'Acad. des Sciences, ic. Berlin, p. 200, 1754. Klinke de Diplopia, ito. Goett. 1774. Sir E. Home's Obs. on the Straight Muscles of the Eye, and the structure of the Cornea, in Phil. Trans, for 1797; B. Gooch, Chir. Cases, i c. vol. 2,p. 42, ic. 8vo, Lond. 1792. Keghellini, Lettera sopra Pojfera delta cista in una Donna, i-c. Svo. Venet. 1749; an instance of Diplopiafrom double pupil. Diet, des Sciences Med. t.9,p 497. J. Wardrop, Essays on the Morbid Anatomy of the Human Eye, vol. 2, p. 216, i-c. Svo. Lond. 1818.) DIRECTOR. (From dirigo, to direct.) One of the most common instruments of surgery; it is long, nar- row, grooved, and made of silver, in order that it may be bent into any desirable shape. Its use is to direct the knife, and protect the parts underneath from the edge or point of the latter instrument. The surgeon introduces the director under the parts which he means to divide, and then either cuts down, along the groove of the instrument, with a common bistoury, or cuts upwards with a narrow, curved, pointed bistoury, the point of which is turned upwards, which he care- fttily introduces along the groove. This instrument and the crooked bistoury are commonly employed for opening sinuses, for cutting fistula? in ano, and fistula in other situations, and for dilating the stricture in cases of hernia. DISLOCATION. (From disloco, to put out of place.) A Luxation. When the articular surfaces of the bones are forced out of their proper situation, the acci- dent is termed a dislocation or luxation. i Sir Aftloy Cooper has justly remarked, thai of tha various aceidents which happen to the body, there art few which require more prompt assistance, or in which the reputation of the surgeon is more at stake, than cases of luxation ; for if much time be lost prior to the attempt at reduction, there is great additional difficulty in accomplishing it, and it is often entirely incapable or being, effected. If it remains unknown, and conse- quently unreduced, the patient becomes a Uving me- morial of the surgeon's ignorance or inattention. Hence this experienced surgeon forcibly inculcates the careful study of anatomy ; the want of an accurate knowledge of the structure of the joints being the chief cause of the many errors which happen in the diagnosis and treatment of dislocated bones. The following passage cannot be too deeply impressed upon the surgeon's mind: "A considerable share of anatomical knowledge is required to detect the nature of these accidents, as well as to suggest the best means of reduction; and it is much to be lamented, that our students neglect to inform themselves sufficiently of the structure of the joints. They often dissect the muscles of a limb with great neatness and minuteness, and then throw it av/ay, without any examination of the ligaments, the knowledge of which, in a surgical point of view, is of infinitely greater importance; and from hence arise the numerous errors of which they are guilty, when they embark in the practice of their profession; for the injuries of the hip, elbow, and shoulder are scarcely to be detected but by those who possess accurate ana- tomical information. Even our hospital surgeons, who have neglected anatomy, mistake these accidents; for I have known the pulleys applied to an hospital patient in a case of a fracture of the neck of the thigh-bone, which had been mistaken for a dislocation, and the pa- tient cruelly exposed, through the surgeon's ignorance, to a violent and protracted extension. It is therefore proper, that tbe form of the ends of the bones, their mode of articulation, the ligaments by which they are connected, and the direction in which the larger mus- cles act, should be well understood."—(Surgical Es- says, part 1, p. 2.) The most important differences of luxations are: 1. With respect to the articulation in which these acci- dents take place ; 2. The extent of the dislocation; 3. The direction in which the bone is displaced ; 4. The length of time the displacement has continued; 5. The circumstances which accompany it, and which make the injury simple or compound; 6. And lastly, with respect to the causes of the accident. 1. Every kind of joint is not equally liable to dislo- cations. Experience proves, indeed, that in the greater part of the vertebral column, luxations are absolutely impossible, the pieces of bone being articulated by ex- tensive numerous surfaces, varying in their form and direction, and so tied together by many powerful elas- tic means, that very little motion is allowed. Expe- rience proves, also, that the strength of the articula- tions of the pelvic bones can scarcely be affected by enormous efforts, unless these bones be simultaneously fractured. Boyer has therefore set down luxations of joints with continuous surfaces as impossible.—(Traiti des Maladies Chirurg. t. i, p. 17.) And Sir A. Cooper observes, that in the spine, the motion between any two bones is so small, that dislocations hardly ever occur, except between the first and second vertebra?, although the bones are often displaced by fracture.— (Surgical Essays, p. 14.) In the articulations with contiguous surfaces, the facility with which dislocations happen, depends upon the extent and variety of motion in such joints. Thus in the short bones of the carpus, and particularly of the tarsus, and at the carpal and tarsal extremities of the metacarpal and metatarsal bones, where flat broad surfaces are held together by ligaments, strong, nu- merous, and partly iuterarticular, and where only an obscure degree of motion can take place, dislocations are very unfrequent, and can only be produced by un- common violence. The loose joints, which admit of motion in every di- rection, are those in which dislocations most frequently occur; such is that of the humerus with the scapula. On tbe contrary, the ginglymoid joints, which allow motion only in two directions, are, comparatively speaking, seldom dislocated. The articular surfaces of the latter are of gretit extent, and consequently the heads of the bones must be pushed a great way in order to be completely dislocated; and the ligaments are numerous and strong. :ation. 207 2. With respect to the extent of the dislocation, luxa- tions are either complete or incomplete. The latter term is applied, when the articular surfaces stUl re- main partially in contact. Incomplete dislocations only occur in ginglymoid articulations, as those of the foot, knee, and elbow. In these, the luxation is almost al- ways incomplete ; and very great violence must have operated, when the hones are completely dislocated. In the elbow, the dislocation is partial, with respect both to the ulna and radius. In the orbicular articula- tions, the luxations are almost invariably complete. However, " the os humeri sometimes rests upon the edge of the glenoid cavity, and readily returns into ita socket."—(A. Cooper, Essays, part 1, p. 14.) The lower jaw is sometimes partially dislocated in a man- ner different from what is commonly meant by this expression, viz. one of its condyles is luxated, while the other remains in its natural situation. As Sir A. Cooper has explained, a partial dislocation sometimes occurs at the ankle-joint. "An ankle (says he; was dissected at Guy's, and given to the collection of St. Thomas's, which was partially dislocated : the end ofthe tibia rested still in part upon the astragalus, but a large portion of its surface was seated on the os naviculare, and the tibia, altered by this change of place, had formed two new articular surfaces, with their faces turned in opposite directions towards the two bones. The dislocation had not been re- duced." . ■-*-—-^ 3. In the orbicular joints, the head of the bone may be dislocated at any point of their circumference; and the luxations are named accordingly upwards, down- wards, forwards, and backwards. In the ginglymoid articulations, the bones may be dislocated either late- rally, or forwards, or backwards. 4. The length of time a dislocation has existed makes a material difference. In general, recent dislocations may be easily reduced; but when the head of a bone has been out of its place several days, the reduction becomes exceedingly difficult, and in older cases very often impossible. The soft parts and the bone itself have acquired a certain position; the muscles have adapted themselves in length to the altered situation ofthe bone to which they are attached, and sometimes cannot be lengthened sufficiently for it to be reduced. Indeed, I believe that Sir Astley Cooper's statement is quite correct, that the difficulty in the reduction, arising from the muscles, is proportioned to the length of time that has elapsed from the period of the accident.— (Treatise on Dislocations, p. 26.) Desault and Boyer beUeve, that frequently the open- ing in the capsular ligament soon becomes closed, and hinders the return of the head of the bone into its original situation. However, with regard to the doc- trine of the reduction being prevented by the capsular ligaments, it is considered by Sir Astley Cooper as destitute of foundation.—(Surgical Essays, part 1, p. 18; and Treatise, ire. p. 25) Lastly, the head of the bone may become adherent to the parts on which it has been forced. 5. The difference is immense, in regard to the dan- ger of the case, arising from the circumstance of a dis- location being attended or unattended with a wound, communicating internally with the joint, and externally with the air. When there is no wound of this kind, the danger is generally trivial, and the dislocation is termed a simple one; when there is such a wound, to- gether with the dislocation, the case is denominated compound, and is frequently accompanied with the most imminent peril. Indeed, the latter kind of acci- dent sometimes renders amputation necessary, and in too many instances has a fatal termination. 6. The causes of dislocations are external and in- ternal. A predisposition to such accidents may depend on circumstances natural or accidental. The great latitude of motion which the joint admits of; the little extent of the articular surfaces ; the looseness and fewness of the ligaments; the fewness of one side of the articular cavity, as at the anterior and inferior part of the acetabulum ; and the shallowness ofthe cavity, as of that of the scapula; are natural predisposing causes of luxations. A paralvtic affection ofthe muscles of a joint, and a looseness of its ligaments, are also predisposing causes. When the deltoid muscle has been paralytic, the mere weight of the arm has been known to cause such a lengthening ofthe capsular ligament of the shoulder- 293 DISLOCATION. joint, that the head of the os brachii descended two or three inches from the glenoid cavity. Two cases strikingly illustrative of the tendency to dislocation from a weakened or paralytic state of the muscles, are recorded by Sir A. Cooper. The first is that of a junior officer of an India ship, who, for some trifling offence, had been placed with his foot upon a small projection on the deck, whUe his arm was kept forcibly drawn up to the yard-arm for an hour. " When he returned to England, he had the power of readily throwing that arm from its socket, merely by raising it . towards his head; but a very stight extension reduced it. The muscles were wasted, also, as in the case of paralysis." The other example happened in a young gentleman, troubled with a paralytic affection of his right side from dentition. " The muscles of the shoul- der were wasted, and he had the power of throwing his os humeri over the posterior edge of the glenoid cavity of the scapula, from whence it became easily reduced." In these cases, no laceration of the liga- ments could have occurred, and the influence of the muscles in preventing dislocation and in impeding re- duction is exemplified.— (Surgical Essays, part 1, p. 10.) Mr. Brindley, of Wink Hill, commumcated to Sir A. Cooper an account of a dislocation of the os fern oris, which the patient, a man of 50, is able to produce and reduce whenever he chooses.—(Treatise on Disloca- tions, Preface.) The looseness of the ligaments sometimes makes the occurrence of dislocations so easy, that the slightest causes produce them. Some persons cannot yawn or laugh without running the risk of having their lower jaw luxated. On this account, collections of fluid within the knee, causing a relaxation of the ligament of the patella, are often followed by a dislocation of that bone. And whenever a bone has been once dislocated, it ever afterward has a tendency to be displaced again, by a slighter cause than what was first necessary to produce the accident. This tendency, indeed, increases with every new displacement. Diseases which destroy the cartilages, ligaments, and articular cavities of the bones, may give rise to a dislocation. The knee is sometimes, but not frequently, partially luxated, in consequence of a white sweUing; the thigh is often dislocated, in consequence of the acetabulum and Ugaments being destroyed by disease. Such dislocations are termed spontaneous. In the anatomical collection at St. Thomas's Hospi- tal, there is a preparation of a knee dislocated in con- sequence of ulceration, and in the state of anchylosis; the leg forming a right angle with the femur directly forwards.—(See Sir A. Cooper's Surg. Essays, part 1, p. 11.) An enarthrosis joint can only be dislocated by.exter- nal violence, a blow, a fall, or the action of the muscles, when the axis of the bone is in a direction more or less oblique with respect to the surface with which it is articulated. Any external force may occasion a dislocation of ginglymoid joints, which case is generally incomplete; but in the ball and spcket articulations the action of the museles constantly has a share in producing the accident So, when a person falls on his elbow, while his arm is raised outwards from his side, the force thus applied will undoubtedly contribute very much to push the head of the os brachii out of the glenoid cavity, at the lower and internal part. Still, the sudden action of the pectoralis major, latissimus dorsi, and teres major, which always takes place from the alarm, will also aid in pulling downwards and inwards the head of the bone. Under certain circumstances, the violent action of the muscles alone may produce a dislocation, without the conjoint operation of any outward force. But when the patient is aware in time of the violence which is about to operate, and his muscles are pre- pared for resistance, a dislocation cannot be produced without the greatest difficulty (Sir A. Cooper, op. cit. p. 15), unless the posture of the member at the moment be such as to render the action of the strongest muscles conducive to the displacement instead of preventive of it, as is frequently the case in luxations of the shoulder. Dislocations are constantly attended with more or less laceration or elongation of the ligaments; and in the shoulder and hip, the capsules are always torn, when the accident has been produced by violence. Some instances, in which the Ugaments are only lengthened and relaxed, I have already quoted. Sometimes a dis- location is attended with a fracture. The ancle is seldom luxated, without the fibula being broken; and in dislocation at the hip, the acetabulum is also occa- sionally fractured.—(Sir A. Cooper's Treatise on Dis locations, i-c. p. 15.) SYMPTOMS OF DISLOCATIONS. As Boyer justly observes, every dislocation produces pain and incapacity in the limb; but these are only . equivocal symptoms, and cannot distinguish the case from a fracture, nor even from a simple contusion. A severe but obtuse pain arises from the pressure of the head of the bone upon the muscles; sometimes the pain is rendered more acute by the pressure being made upon a large nerve.—(Sir A. Cooper's Treatise, p. 5.) In order that a dislocation may happen, there must be a particular attitude ofthe limb during the action of the external violence. Indeed, the displacement can hardly occur from the direct action ofthe cause on the articulation itself. The action ofthe luxating cause is the more efficient the farther it is from the joint, and the longer the lever is which it affects. Thus, in a fall on the side, when the arm, raised considerably from the trunk, has had to sustain all the weight of the body on a point at its inner side, the probability of a disloca- tion is evident, and even that the head of the bone has been forced through the lower portion of the capsular ligament. But the symptoms which Boyer terms positive, or actually present, are numerous and clear. 1. In dislocations of orbicular joints and complete luxations of ginglymoid joints, the articular surfaces are not at all in contact, and the point where the dislo- cated bone is lodged cannot be upon the same level with the centre of the cavity, from which it has been forced. Hence, a change in the length of the limb. In the ginglymoid joints, such alteration can only be a shortening proportioned to the extent ofthe displacement, for there is then an overlapping of the bones, similar to that of the fragments of a fracture longitudinally displaced. But in the orbicular joints, the bone may be displaced, and carried abpve or below the articular cavity; so that, in the first event, a shortening, in the second, an elongation, of the limb will be produced. But as the direction of the member is at the same time altered, it is not always practicable to place the limbs parallel together, nor to bring them near the trunk, for the purpose of judging whether they are lengthened or shortened. A comparison, however, made without this advantage, will generally enable the surgeon to form a correct opinion. The proper length of a dislocated limb cannot be restored, except by putting the bone back into the cavity from which it has slipped. In general, this cannot be accomplished without consider- able efforts, whUe a slight exertion is usually sufficient to obtain the same effect in cases where the shortening ofthe limb depends upon a fracture. It is also particu- larly worthy of notice, that when once the natural length of the limb has been restored in dislocations, it remains; while there are a great many fractures, in which the shortening of the member recurs after it has been made to disappear. The surgeon must also recol- lect, that an elongation of the limb can never happen in cases of fracture as it does in certain dislocations. 2. In almost all complete luxations, the direction of the axis of the limb is unavoidably altered. This cir- cumstance arises from the resistance of that portion of the articular ligaments which has not been ruptured, as well as from the action of the muscles. In complete lateral dislocations of ginglymoid joints, the direction ofthe axis ofthe limb is not altered, on account of the total rupture ofthe ligaments, and even of a part ofthe surrounding muscles. Neither is this observable in incomplete dislocations of such articulations, on account of the extent of the articular surfaces. But it is strongly marked in complete luxations of these joints, where the displacement has happened in the direction of the articular movements, although, in cases of this description, the ligaments must be totally ruptured. The muscles, which have suffered less, are in a state of extreme tension, and must necessarily alter the axis ofthe limb. The tension of certain muscles, and the preservation of some ofthe ligaments, especially in the orbicular joints, are also a cause of a rotatory movement of the dislocated Umb at the moment of the displace- DISLOCATION. S99 ment, and which it afterward retains. Thus, in luxa- tions of the thigh, the toes and knee are turned outwards or inwards, according as the head of the thigh-bone happens to be situated at the inside or outside of the Joint. These two kinds of alteration in the direction of the limb are permanent, when they depend upon a dis- location ; a circumstance quite different from what is observable in fractures, where the same changes occur, but can be made to cease at once, without any particu- lar effort. 3. The absolute immobility of a limb, or, at least, the inability of performing certain motions, is among the most characteristic symptoms of a dislocation. In some complete luxations of particular ginglymoid joints, the dislocated limb is absolutely, or very nearly, incapable of any motion. Thus, in the dislocation of the forearm backwards, the particular disposition of the bones, and the extreme tension of the extensor and flexor muscles, confine the limb in the half-bent state, and at the same time resist every spontaneous motion, and likewise almost every motion which is communi- cated. In the orbicular joints, the painful tension of the muscles which surround the luxated bone nearly impedes all spontaneous movements; but, in general, analogous motions to that by which the displacement was produced can be communicated to the limb, though not without exciting pain. Thus, in the dislocation of the humerus downwards, the elbow hardly admits of being put near the side, nor of being carried forwards and backwards; but it can be raised up with ease. In the dislocation of the acromial end of the clavicle, the patient can bring the arm towards the trunk, separate it a little from the side, or carry it forwards or back- wards ; but he cannot raise it in a direct way. Lastly, in complete lateral dislocations of such joints as have alternate motions, the patient has the power of per- forming no motion of the part; but the' complete de- struction of all the means of union allows the limb to obey every species of extraneous impulse; and this symptom, which is besides never single, makes the nature of the case sufficiently manifest. Sometimes, as Sir A. Cooper has remarked, a consi- derable degree of motion continues for a short time after a dislocation : thus, in a man, brought into Guy's Hos- pital, whose thigh-bone had just been dislocated into the foramen ovale, a great mobility of the femur still re- mained ; but, " in less than three hours, it became firmly fixed in its new situation, by the contraction of the muscles.—(Surgical Essays, part 1, p. 3.) 4. In dislocations attended with elongation of the limb, the general and uniform tension of all the muscles arranged along it, gives to these organs an appearance as if they lay nearer the circumference ofthe bone, and the limb were smaller than its fellow. The muscles, however, which belong to the side, from which the dislocated bone has become more distant, appear more tense than the others, and form externally a prominent line. This is very manifestly the case with the deltoid muscle, when the arm is luxated downwards. On the contrary, in dislocations where the limb is shortened, the muscles are relaxed; but, being irritated, they con- tract and accommodate themselves to the shortened state of the limb. Hence the extraordinary swelling of their fleshy part, and the manifestly increased diameter of the portion of the member to which they belong. We have a striking example of this in the dislocation of the thigh upwards and outwards, where the muscles at the inside of the limb form a distinct oblong tumour. The parts which surround the affected joint also ex- perience alterations in their form, whenever muscles connected with the dislocated bone occupy that situa- tion. Thus, in dislocations of the thigh, the buttock on the same sida- is flattened, if the bone is carried in- wards ; but it is more prominent, when the thigh-bone is carried outwards; and its lower edge is situated higher or lower than in the natural state, according as the luxation may have taken place upwards or down- wards. In the complete luxation of the forearm back- wards, thetriceps is tense, and forms a cylindrical pro- minence, owing to the displacement of the olecranon backwards, in which displacement it is obliged to parti- cipate. 5. The circumference of the joint itself presents al- terations of shape well deserving attention, and in or- der to judge rightly of this symptom, correct anatomi- cal knowledge is of high importance. Tbe form of the joints principally depends upon the shape of the heads of the bones. Hence, the natural relation of the bones to each other cannot be altered without a change being immediately produced in the external form of the joint. The changes'which the muscles passing over the luxated joint at the same time undergo in their situation and direction, contribute likewise to the difference of shape, by destroying the harmony of what may be called the outlines of the limb. When the head of a bone articulated by enarthrosis, has sUpped out of the cavity, instead of tbe plumpness which previously indicated the natural relation of parts, the head of the dislocated bone may be distin- guished at some surrounding point of the articulation, whUe at the articulation itself may be remarked a flat- ness, caused by one of the neighbouring muscles stretched over the articular cavity, and more deeply may be perceived the outline and depression produced bv this cavity itself. The bony eminences situated near the joint, and whose outlines were gradually effaced in the general form of the member, are ren- dered much more apparent by the displacement, and project in a stronger degree than in the natural state. On this part of the subject Sir A. Cooper is particu- larly correct, when he observes, that the head of the bone can generally be felt in its new situation, except- ing in some of the dislocations ofthe hip, and its rota- tion is often the best criterion of the accident. Tin natural prominences of bone near the joint either dis- appear or become less conspicuous, as the trochante) at the hip-joint. Sometimes the reverse occurs; for in dislocations of the shoulder, the acromion projects more them usual..—(Surg. Essays, part 1, p. 4.) The lines made by tha contour of the limb and the natural relation of the bones, are so manifestly broken in dislocations of ginglymoid joints, that when there is no inflammatory swelling the case is at once mani- fest. More certain knowledge, however, and more correct information respecting the kind of displace- ment, are to be obtained, by attentively examining the changes of position which the bony prominences form- ing the termination of the bones articulated together have undergone, and which are the more obvious in these joints, inasmuch as they give attachment to the principal muscles. The natural relations of these pro- cesses being known, the least error of situation ought to strike the well-informed practitioner. Thus, in the elbow-joint, a considerable difference in the respective height, and in the distances between the olecranon and internal and external condyles, can be easily distin- guished. But the thing is less easy when the sur- rounding'parts are So swelled and tense as to make the bony projections deeper from the surface and less ob- vious to examination. Even then, however, a good surgeon wtil at least find something to make him sus- pec* the dislocation, and the suspicion will be con- firmed when he again examines the part after the swelling has begun to subside. It is of the utmost consequence to make out what the case is as early as possible; for the unnatural state in which the soft parts are placed keeps up the swelling a long while; and if the surgeon wait till this has entirely subsided before he ascertains that the bones are luxated, he will have waited till it is too late to think of reducing them, and the patient must remain for ever afterward deprived of the free use of his limb.—(Boyer, Traite des Mala- dies Chir. t. 5, p. 45, ic.) It is not only the inflam- matory swelling which may tend to conceal the state of the ends of the bone; sometimes a quicker tumour arises from the effusion of blood in the cellular membrane, and causes an equal difficulty of feeling the exact position of the heads of the bones.—(See Treatise on Dislocation, by Sir A. Cooper,p. 5.) Dislocations are also sometimes attended with parti- cular symptoms, arising altogether from the pressure caused by the head of the luxated bone on certain parts. The sternal end ofthe clavicle has been known to compress the trachea and impede respiration : the head of the humerus may press upon the axUlary plexus of nerves, and produce a paralytic affection of the whole arm. In one instance cited by Sir A. Cooper, a dislocated clavicle pressed upon the oesophagus and endangered life.-( Surg. Essays, part 1, p. 4.) As Kirkland has observed, there are some luxations which are far worse injuries than fractures; of taia description are dislocations of the vertebrse, cases, which, indeed, can hardly happen without fracture, 300 DISLOC and are almost always fatal; dislocations of the long hones, with protrusion of their ends through the mus- cles and skin, and severe inflammation, extensive ab- scesses, attended with great risk of being followed by large and tedious exfoliations, and not unfrequently gangrene. According to Sir A. Cooper, young persons are rarely subjects of dislocations from violence; but he admits that they do sometimes experience them, and relates an instance which happened in a child seven years of age. In geaeral, their bones break, or their epiphyses give way, much more frequently than the articular surfaces are displaced.—(Surg. Essays, part. 1, p. 16; and Treatise, i-c. p. 23.) Suspected luxations of the hip in children commonly turn out to be disease of the joint, one instance of which is given by the preceding author,- and an example of which I was lately con- sulted about myself. Also, when a dislocation of the elbow is suspected in a child, because the bone appears readily to return into its place, but directly to sUp out of it again, the case, according to Sir A. Cooper, is an oblique fracture of the condyles of the humerus. Old persons are also much less liable to dislocations than individuals of middle age; a fact which is accounted for by the extremities of bones in old subjects being so softened that the violence sooner breaks than luxates tttem-.—(Sir Astley Cooper, Treatise, Sec. p. 23.) PROGNOSIS. In general, every unreduced dislocation must deprive the patient more or less completely of the use of the limb; for nature cannot re-establish the natural rela- tions which are lost. There is indeed an effort made to restore some of the motions and the use of the limb in a certain degree; but it is always very imper- fectly accomplished, and in the best cases, only a con- fined degree of motion is recovered. Nature cannot in any way alter the lengthened or shortened state of the limb; and she can only correct in a very imperfect manner its faulty direction. There are-even some cases Ui which no amendment whatsoever can be effected; as in complete dislocations of ginglymoid joints. There are, however, a few exceptions to this general rule. The arthrodia joints are seldom extensively dis- placed ; and as, in the natural state, their motions are very limited, the loss of these motions in consequence ofthe natural relations not having been restored, is of less importance. Thus, the bones of the carpus, those of the tarsus, and the acromial end of the clavicle, may be dislocated, and be reduced either imperfectly or not at all, without the functions of the limb to which they belong being materially impaired.—(Boyer, Traite des Maladies Chir. t. 4, p. 54.) Dislocations of enarthrosis joints are generally much Jess dangerous than those of ginglymoid ones; for the .action of the muscles has a great share in producing the former; the violence done to the external parts is less; and the laceration of the soft parts is not so considerable. Even in the same kind of joints, the seriousness ofthe case depends-on the largeness ofthe articular surfaces, and the number and strength of the muscles and ligaments. Dislocations of ginglymoid joints, however, are more easily reduced than those of enarthrosis ones, the mus- cles of which are frequently very powerful, and capa- ble of making great resistance to the efforts of the surgeon. This is frequently seen in luxations of the shoulder and thigh. It may be said, however, of the luxations of enar- throsis joints, that if they happen the most easUy, they are attended with less injury; and that although their reduction may require considerable efforts, yet it can be accomplished, and the accident leaves no Ul effects. On the contrary, in dislocations of ginglymoid joints, the same reason which renders them more un- frequent, makes them also more serious. The solidity of these joints prevents the uniting means from being destroyed except by great violence; and the extent of the articular surfaces does not permit a considerable displacement, especially a complete one, without ex- tensive injury of the ligaments and surrounding soft parts. It is for these reasons, no doubt, that compound luxations and protrusions of the heads of the bones are most coffimonly seen in the ginglymoid articula- tions. The more recent a luxation is, the more easy it is to reduce, and, therefore, cateris paribus, the less grave is the injury. In this point of view, dislocations of ginglymoid joints are the most serious, because they soon become irreducible. Simple dislocations are much leas dangerous than those which are complicated with contusion, the injury of a large nerve or blood-vessel, inflammatory sweU- ing, fracture, wound, and, especially, a protrusion of one of the articular surfaces.—(Boyer, Traiti: des Mala- dies, Chir. t. 4, p. 55, 56.) Dislocations from ulceration and suppuration in joints, termed spontaneous luxations, cannot admit of reduction : when they arise from the hip-disease, it is not merely in consequence of the ligaments being destroyed, the brim of the acetabulum itself is often annihilated. However, there are other spontaneous dislocations from preternatural looseness of the liga- ments, where reduction may be accomplished with the greatest facility ; though the displacement generally recurs from the slightest causes. TREATMENT OF DISLOCATIONS IN OKNIRAI.. Mr. Pott observes:—By what our forefathers havo said on the subject of luxations, and by the descriptions and figures which they have left us of the means they used, of what they call their organs and machinemata, it is plain, that force was their object, and that what- ever purposes were aimed at or executed by these in- struments or machines, were aimed at and executed principally by violence. Many or most of them are much more calculated to pull a man's joints asunder than to set them to rights. Hardly any of them are so contrived as to execute the purpose for which they should be used, in a manner most adapted to the na- ture or mechanism of the parts on which they are to operate. The force or power of some of the instru- ments is not always determinable, as to degree, by the operator, and consequently may do too little or too much, according to different circumstances in the case, or more or less caution or rashness in the surgeon. If, in the diagnosis of these accidents, an exact know- ledge of the ligaments is of the highest importance, a familiar acquaintance with the muscles is not less es- sential in the treatment. In dislocations, as in fractures, says Fott, our great attention ought to be paid to the muscles belonging to the part affected. These are the moving powers, and by these the joints, as well as other moveable parts, are put into action: whUe the parts to be moved are in right order and disposition, their actions will be re- gular and just, and generally determinable by the will of the agent (at least in what are called voluntary mo- tions) ; but when the said parts are disturbed from that order and disposition, "the action or power of the muscles does not therefore cease; far from it; they stUl continue to exert themselves occasionally, but instead of producing regular motions at the wUl of the agent, they pull and distort the parts they are attached to, and which, by being displaced, cannot perform the functions for which they were designed. " Hence principally arise the trouble and difficulty which attend the reduction of luxated joints. The mere bones composing the articulations, or the mere connecting ligaments, would in general afford very little opposition; and the replacing the dislocation would require very little trouble or force, was it not for the resistance of the muscles and tendons attached to and connected with them: for by examining the fresh joints of the human body, we shall find, that they not only are all moved by muscles and tendons, but also, that although what are called the ligaments of the joints do really connect and hold them together, in such manner as could not well be executed without them, yet in many instances they are, when stripped of all connexion, so very weak and lax, and so dilata- ble and distractile, that they do little more than connect the bones and retain the synovia; and that the strength as well as the motion of the joints, depends in great measure on the muscles and tendons connected with and passing over them; and this in those articulations which are designed for the greatest quantity, as well as for celerity of motion. Hence it must follow, that as the figure, mobitity, action, and strength of the principal joints depend so much more on the muscles and tendons in connexion with them than on their mere ligaments, that the former are the parts which re- quire our first and greatest regard, these being the DISLOCATION. 301 parts which will necessarily oppose us in our attempts for reduction, and whose resistance must be either eluded or overcome ; terms of very different import, and which every practitioner ought to be weU apprized of."—(See Pott's Chir. Works, vol. 1.) That the muscles are the_chief cause of resistance is strongly evinced by cases in which the dislocation is accompanied with injury of a vital organ; for then the bone may be reduced by a very slight force. Thus, in a man who had an injury of his jejunum, and a dislo- cation of his hip, the bone was most easily replaced.— (.Vj'r A. Cooper, Surgical Essays, part 1, p. 20.) In short, any thing which produces faintness or weak- ness facilitates the reduction, as intoxication, nadsea and sickness, paralysis, Sec The following, which are some of the principles laid down by Mr. Pott, merit attention. 1. Although a joint may have been luxated by means of considerable violence, it does by no means follow that the same degree of violence is necessary for its reduction. 2. When a joint has been luxated, at least one of the bones of which it is composed is detained in that un- natural situation by the action of some of the muscu- lar parts in connexion with it; which action, by the immobility of the joint, becomes as it were tonic, and is not under the direction of the will of the pa- tient. 3. That all the force used in reducing a luxated bone, be it more or less, be it by hands, towels, ligatures, or machines, ought always to be applied to the other ex- tremity of the said bone, and as much as possible to that only. Mr. Pott argues, that if the extending force were applied to a distant part of the limb, or to the bone below or adjoining, it would necessarily be lost in the articulation which is not luxated, owing to the yielding nature of the ligaments, and be of little or no service in that wlUch is dislocated. This remark, though made by Pott and generally received as true, is very incorrect; for it tends to state that if you pull at the ankle or wrist, the force does not operate on the hip or shoulder. 4. That in the reduction of such joints as are com- posed of a round head, received into a socket, such as those of the shoulder and hip, the whole body should be kept as steady as possible. 5. That in order to make use of an extending force with all possible advantage, and to excite thereby the least pain and inconvenience, it is necessary that all parts serving to the motion of the dislocated joint, or in any degree connected with it, be put into such a state as to give the smallest possible degree of resist- ance. 6. That in the reduction of such joints as consist of a round head, moving in an acetabulum or socket, no attempt ought to be made for replacing the said head, until it has by extension been brought forth from the place where it is, and nearly to a level with the said socket. This will show us, says Mr. Pott, a fault in the common ambi, and why that kind of ambi which Mr. Freke called his commander, is a much better in- strument than any of them, or indeed than all; be- cause it is a lever joined to an extensor; and that capable of being used -with the arm in such position as to require the least extension and to admit the most; besides which it is graduated, and therefore perfectly under the dominion of the operator. It will show us why the old method by the door or ladder-sometimes produced a fracture ofthe neck of the scapula; as Mr. Pott saw it do himself. Why, if a sufficient degree of extension be not made, the towel over the surgeon's shoulder, and under the patient's axilla, must prove an impediment rather than an assistance, by thrusting the head of the humerus under the neck of the scapula, instead of directing it into its socket. Why the bar, or rolliiiu-pin, under the axtila produces the, same ef- fect. Why the common method of bending the arm (that is, the os humeri) downwards, before sufficient extension has been made, prevents the very thing aimed at, by pushing the head of the bone under the scapula, which the continuation of the extension for a few seconds only would have carried into its proper place. To the observation that mere extension only draw* the head of the bone out from the axilla in whi ch it is Uvl'ed, but does not replace it in the acetabulum acauuUv" Mr Pott replies, that when the head of the os hunwri is drawn forth from the axilla, and brought to a level with the cup of the scapula, it must be a very great and very unnecessary addition of external force, that will or can keep it from going into it. All that the surgeon has to do is to bring it to such level; the muscles attached to the bone will do the rest for him, and that whether he will or not. 7. Another of Pott's principles is, that whatever kind or degree of force may be found necessary for the reduction of a luxated joint, that such force be em- ployed gradually; that the lesser degree be always first tried, and that it be increased gradatim.—(See Pott's Chir. Works, vol. 1.) The supposition of the reduction being sometimes prevented by the capsular ligaments, Sir A. Cooper considers erroneous: he assures us, that in disloca- tions from violence, those ligaments are always exten- sively lacerated; and that the idea of the neck of the bone being girt or confined by them, is altogether un- true.— (Surg. Essays, part 1, p. 18.) But, in addition to the resistance of the muscles, there are, in old dis- locations, three circumstances pointed out by him as causes of the difficulty of reduction. 1. The extre- mity ofthe bone contracts adhesion to the surrounding parts, so that in dissection, even when the muscles are removed, the bone cannot be reduced. In this state, he found the head of a radius, which had been long dislocated upon the external condyle, and which is preserved in the collection of St. Thomas's Hospital. In a similar state he has also seen the dislocated head ofthe humerus.— (On Dislocations, p. 28.) 2. The socket is sometimes filled up with adhesive matter. 3. A new bony socket is sometimes formed, in which the head ofthe bone is so completely confined that it could not be extricated without breaking its new lodgement. —(Surgical Essays, part 1, p. 21; and Treatise, i-c. p. 10.) Dislocations in general cannot be reduced without trouble; but after the reduction is accomplished, it is easily maintained. On the contrary, fractures are for the most part easy of reduction; but cannot be kept in this desirable state without difficulty. The moment extension is remitted, the muscles act, the ends of the broken bone slip out of their proper situation Wtih re- spect to each other, and the distortion of the limb recurs. As a modem writer has observed, the reduc- tion is only a small part of the treatment of fractures: the most essential point of it is the almost daily care which a fracture demands during the whole time re- quisite for its consolidation. The contrary is the case in luxations. Here, in fact, the reduction is every thing, if we put out of consideration the less frequent cases in which the dislocation is complicated, and at- tended with such grave circumstances as render it indispensably necessary to continue for a length of time the utmost surgical care. But even then the pro- tracted treatment ia less for the dislocation itself than for the extraordinary circumstances with which it is accompanied.—(See Roux, Parallile de la Chirurgie Angloise avec la Chirurgie Francoise, p. 207.) All the ancient writers recommend the extending force to be applied to the luxated bone; for instance, above the knee in dislocations of the thigh-bone, and above the elbow in those ofthe humerus. We have stated; that Pott advised this plan, and the same practice, which is approved by J. L. Petit, Duvemey, and Calli- sen, is almost generally adopted in this country. However, many of the best modern surgeons in France, for instance, Fabre, D'Apouy, Desault, Boyer, Richerand, and Leveille, advise the extending force not to be applied on the luxated bone, but on that with which it is articulated, and as far as possible from it. It is said that this plan has two most important advan- tages : first, the muscles which surround the dislocated bone are nqt compressed, nor stimulated to spasmodic contractions, which would resist the reduction; se- condly, the extending force is much more considerable than in the other mode; for, by usmg a long lever, we obtain a greater degree of power. In Pott's remarks, we find even him influenced by the prevailing prejudice against the above practice, that part of the extending force is lost on the joint in- tervening between the dislocation and the part at which the extension is made. This notion is qmte unfounded, as every man, who reflects for one moment, must soon perceive. When extension is made at the wrist, the tignments, muscles, &c. which connect the bones of the forearm with the os brachii, hivi the whole of tte 302 DISLOCATION. extending force operating on them, and they must ob- viously transmit the same degree of extension which they receive to the bone above, to which they are at- tached. Indeed, this matter seems so plain, that I think it would be an insult to the reader's understand- ing to say any more about it, than that such eminent surgeons as have contrary sentiments can never have taken the trouble to reflect for themselves on this par- ticular subject. Whether the force necessary to be ex- erted in some instances would have a bad effect on the intervening joint, may yet be a question; but as De- sault's practice was very extensive, and he did not find any objection of this kind, perhaps we have no right to conclude that such would exist. If, however, the common objection to Desault's plan of applying the extending force be unfounded, the ques- tion still remains to be settled, whether this practice is most advantageous on the grounds above specified? This is a point which, perhaps, cannot be at once pe- remptorily decided altogether in the negative or the af- firmative, since what may be best in one kind of dislo- cation may not be so in another. Thus, Sir A. Cooper states, that as far as he has had opportunity of observ- ing, it is generally best to apply the extension to the bone which is dislocated: but that dislocations of the shoulder are exceptions in which he mostly prefers to reduce the head of the bone, by placing his heel in the axilla, and drawing the arm at the wrist in a line with the side of the body, whereby the pectoralis major and latissimus dorsi are kept in a relaxed state.— (Surgical Essays, part 1, p. 25.) Extension may either be made by means of assist- ants, who are to take hold of napkins or sheets put round the part at which it is judged proper to make the extension; or else a multiplied pulley may be used. In cases of difficulty, Sir A. Cooper thinks the pulley should always be preferred. " When assistants are employed, their exertions are sudden, violent, and often ill-directed, and the force is more likely to produce la- ceration of parts, than to restore the bone to its situa- tion. Their efforts are also often uncombined, and their muscles are necessarily fatigued, as those of the patient, whose resistance they are employed to over- come." In dislocations of the hip-joint, and in those of the shoulder which have been long unreduced, pul- leys should always be employed.—(Surgical Essays, part 1, p. 24.) But whether pulleys be used or not, nothing more need be added to what Mr. Pott has stated, concerning the propriety of using moderate force in the first instance, and increasing the extending power very gradually. The extension should always be first made in the same direction in which the dislocated bone is thrown; but in proportion as the muscles yield, the bone is to be gradually brought back into its natural position. Thus the head of the bone becomes disengaged from the parts among which it has been placed, and is brought back to the articular cavity again by being made to follow the same course which it took in escap- ing from it. Extension will prove quite unavailing, unless the bone, with which the dislocated head is naturally ar- ticulated, be kept motionless by counter-extension, or a force at least equal to the other, but made in a con- trary direction. The mode of fixing the scapula and pelvis, in luxa- tions of the shoulder and thigh, will be hereafter de- scribed. In dislocations of ginglymoid joints, extension and counter-extension are only made for the purpose of di- minishing the friction of the surfaces of the joints, so that the reduction may be rendered more easy. When the attempts at reduction fail, the want of suc- cess is sometimes owing to the extension not being pow- erful enough, and the great muscular strength of the patient, which counteracts all efforts to replace the bone. In the latter case, the patient may be freely bled, and put into a warmTiath, so as to make him faint. The open- ing in the vein should be made large, because a sudden evacuation of blood is more likely to produce wsakness and swooning, than a gradual discharge of it; and the patient, for the same reason, may be bled as he stands up. In very difficult cases, the expedient of-intoxica- tion has been recommended, as, when the patient is in this state, his muscles are incapable of making great resistance to reduction. Under these circumstances, opium is also frequently administered with advantage. I "The means to be employed for the reduction of drs-" locations (says Sir Astley Cooper) are both constitu- tional and mechanical. It is generally wrong to em- ploy force only, as it becomes necessary to use it in such a degree as to occasion violence and injury; and it will be shown in the sequel, that the most powerful mechanical means fail, when unaided by constitutional remedies. The power of the muscles, in the first in- stance, is to be duly appreciated; as this forms the principal cause of resistance. The constitutional means to be employed for the purpose of reduction are those which produce a tendency to syncope, and this neces- sary st te may be best induced by one or other ef the following means, viz. by bleeding, warm bath, and nausea. Of these remedies, I consider bleeding the Ynost powerftti; and that the effect may be produced as quickly as possible, the blood should be drawn from a large orifice, and the patient kept in the erect posi- tion ; for by this mode of depletion, syncope is produced before so large a quantity of blood as might injure the patient is lost. However the activity of this practice must be regulated by the constitution of the person ; for as the accident happens to all the varieties of constitu- tion, it must not be laid down as a general rule; but when the patient is young, athletic, and muscular, the quantity removed should be considerable, and the me- thod of taking it away that which I have described. Secondly, in those cases where the warm bath may be thought preferable, or where it may be considered improper to carry bleeding any farther, the bath should be employed at the temperature of 100° or 110°; and as the object is the same as in the application of the last remedy, the person should be kept in the bath at the same heat till the fainting effect is produced, when he should be immediately placed in a chair, wrapped in a blanket, and the mechanical means employed. Of late years, I have practised a third mode of lower- ing the action of the muscles, by exhibiting nauseating doses of tatarized antimony; but as its action is uncer- tain, frequently producing vomiting, which is unneces- sary, I rather recommend its application, merely te keep up the state of syncope, already produced by the two preceding means, which its nauseating effects will most readily do, and so powerfully overcome the tone of the muscles, that dislocations may be reduced with much less effort, and at a much more distant pe- riod from the accident than can be effected in any other way."—(Sir A. Cooper on Dislocations, i-c. p. 29,30. Also, Surgical Essays, part 1, p. 22.) In cases of un- usual difficulty, the use of antimonium tartar., together with the warm bath and bleeding, seems rational and judicious; but except in cases of that description, I should prefer long-continued, unremitting, not too vio- lent, extension, which will at last overcome the mus- cles of the most athletic man. Sometimes the resist- ance made to reduction by muscles, acting in obedience to the will, may be eluded by the patient's attention being suddenly taken from the injured part, at which moment the action of those muscles is suspended, and a very little effort on the part of the surgeon will re- duce the bone. A case, illustrating this circumstance, is recorded by Sir A. Cooper, (Surgical Essays, part 1, p. 25; and Treatise, i-c. p. 34.) Dislocations of orbicular joints can seldom be re- duced after a month, though by means of great vio- lence Desault used to succeed at the end of three or four. Dislocations of ginglymoid articulations gene- rally become irreducible in twenty or twenty-four days, in consequence of anchylosis. The reduction of a dislocation is known by the limb recovering its natural length, shape, and direction, and being able to perform certain motions, not possible while the bone was out of its place. The patient ex- periences a great and sudden diminution of pain; and very often the head of the bone makes a noise at the moment when it turns into the cavity of the joint. Sir Astley Cooper believes, that much mischief is produced by attempts to reduce dislocations of long standing in very muscular persons. He has seen great contusion of the integuments, laceration, and bruises of the muscles, and stretching of the nerves, leading to an insensibility and paralysis of the hand, follow an abortive attempt to reduce a dislocation of the shoul- der. He is of opinion that three months for the shoul- der, and eight weeks for the hip, may be set down as the period from the accident when it would be impru- I dent to make the attempt, except in persons of very re- DlSLOC laxed fibre, or advanced age.—'See Treatise on Dislo- cations, ic. p. 35.) I have seen two cases, in which very great force was exerted with pulleys, to reduce the thigh-bone at the end of three or four weeks; but the attempts completely failed. However, the assist- ance to be derived from properly lowering the strength of the muscles previously, by means of nauseating doses of antimony, the warm bath, f the upper extremity, arising from the pressure made by the head ofthe bone, when dislocated inwards, upon the axillary plexus of nerves, and some- times resisting every means of relief. Indeed, when the nerves have been long compressed, the affection is very difficult of cure. Desault several times applied the moxa above the clavicle. The success which he at first experienced in some patients did not invariably follow in others. But when the head of the humerus has only made, as it were, a momentary pres- sure on the nerves, and the reduction has been effected soon after the appearance of the symptoms, the para lytic affection often goes off of itself, and its dispersion may always be powerfully promoted by the use of vola- tUe liniments. OF THE REDUCTION. We may refer to two general classes the infinitely various number of means proposed for the reduction of a dislocated humerus. The first are designed to push back, by some kind of mechanical force, the head ofthe bone into the cavity from which it is displaced, either with or without making previous extension. The others are merely intended to disengage the head ofthe bone from the place which it accidentally occupies, leaving it to be put into its natural situation by the ac- tion of the muscles. By the first means art effects every thing; by the second, it limits its .interference to the suitable dirtc- 312 DISLOCATION. tion of the powers of nature. In the first method, the force externally applied always operates on the bone in the diagonal of two powers, which resist each other at a more or less acute angle; in the last the power is only in one direction. All the means intended to operate in the first way, act nearly in the following manner. Something placed under the axilla serves as a fulcrum, on which the arm is moved as a lever, the resistance being produced by the dislocated head of the humerus, while the power is apptied either to the lower part of this bone, or the wrist. The condyles of the humerus being pushed downwards and inwards, the head ofthe bone is necessarily moved in the opposite direction, towards the glenoid cavity, mto which it slips with more or less factiity. Thus operated the machine so celebrated among the ancients and moderns; under the name of the ambi of Hippocrates; whether used exactly in the form described by him, or with the numerous corrections devised by Paul of jEgina, Ambrose Pare, Duverney, Freke, o a right angle with the os humeri, because this position relaxes the biceps, and lessens its resistance: in many cases, however, he makes tha extension at the wrist, a plan in which he finds more force requisite, but the bandage is less apt to sUp. Another simple mode of reduction, which Sir Astley Cooper considers proper for recent dislocations, delicate females, and very old, relaxed, emaciated persons, is that by means of the surgeon's knee, as a fulcrum, in the patient's axilla. The patient is placed on a low chair, on the side of which the surgeon rests his foot, whUe he takes hold ofthe os humeri just above tbe condyles, and applies his other hand to the acromion. The arm is then drawn down over the knee, and the head of the bone returns into its place.—(On Dislocations, p. 432.) In some cases the preceding methods are inadequate, and greater extension must' be made. The following was the practice of Desault. The' patient is laid upon a table covered with a mat- tress ; a thick linen compress is applied to the axilla, on the side affected, and upon this compress the middle of the first extending bandage is placed, the two heads of which ascend obliquely before and behind the chest, meet each other at the top of the sound shoulder, and are held there by an assistant, so as to fix the trunk and make the counter-extension. The action of" this band-, age does not affecf the margin of the pectoralis major and latissimus dorsi, in consequence of the pad project- ing over them. If this were not attended to, these mus- cles, being drawn upwards, would pull the humerus ia this direction, and thus destroy the effect of the extev sion, which is to be made in the following manner. Two assistants take hold of the forearm, above the wrist; or else the towel, doubled several times, is to be applied to this part. The two ends are to be twisted together, and held by one or two assistants, who are to begin pulling in the same direction in which the hum» rus is thrown. After this first proceeding, which is <"&■ signed to disengage the head of the bone from its '.cci- dental situation, another motion is to be employed, which differs according to the kind of luxation. If this should be downwards, the arm is to be gradually brought near the trunk, at the same time that it is gently pushed up- wards. Thus the head of the bone being separated from the trunk, and brought near the glenoid cavity, usually glides into this situtation with very little resistance. When the luxation is inwards, after the extension has been made in-the direction ofthe humerus, the end of this bone should be inclined upwards and forwards, in order that its head may be guided backwards; and vice versd, when the luxation is outwards. When the head of the bone has been disengaged by the first extension, the motion imparted to it by the rest of the extension, should in general be exactly con- trary to the course which the head of the bone has taken after quitting the glenoid cavity. When there is difficulty experienced in replacing the head ofthe bone, I we should, after making the extension, move the bone i about in various manners according to the differem DISLOCATION. 313 direction of the dislocation, and the principle just no- ticed. This plan often accomplishes what extension alone cannot; and the head of the bone, brought by Buch movements towards its cavity, returns into it during their execution. When the dislocation is consecutive, it is the first ex- tension made in the direction of the displaced bone, which brings back its head to the situation where it was primitively lodged, and the case is then to be managed just as if it were a primitive dislocation. Thus we see that, except in a few cases, where the beneficial operation of the muscles had been prevented by the oldness of the dislocation or by adhesions, and where it was necessary to employ means to force, as it were, the head ofthe bone into its cavity, to which the muscles could not bring it, Desault only employed exten- sion variously diversified, till he had put the muscles in a state favourable for accomplishing reduction. When the muscles are very powerful, or the displace- ment has continued several days, Sir Astley Cooper,' instead of the treatment by the heel in the axilla, re- commends the patient to be put upon a chair, and the scapula to be fixed by means of a bandage which allows the arm to pass tlirough it, and is buckled on tbe top of the acromion, so that it cannot slip downwards. A wetted roller is next applied round the arm just above the elbow, and over the roller a strong worsted tape, fixed with what the sailors term the clove-hitch knot. The arm should now be raised to a right angle with the body, and, if much difficulty be experienced, even above the horizontal line, in order to relax more completely the deltoid and supraspinatus muscles. Two persons are then to pull the worsted tape, and two the scapula bandage, in opposite directions, with a steady, equal, and combined force. After the exten- sion has been kept up a few minutes, the surgeon is to place his knee in the axilla, with his foot resting upon the patient's chair; he now raises his knee, while he pushes the acromion downwards and inwtfrds, and the head of the bone usually slips into the glenoid cavity. Sometimes Sir Astley Cooper has seen a gentle rotatory motion of the limb, made during the extension, bring about the reduction. In old cases, and others attended with great difficulty from the powerful contraction of the muscles, Sir Ast- ley prefers making the extension with pulleys, because with them, when the resistance is likely to be long, jerks and unequal force are more likely to be avoided than in the preceding method of reduction; and the assistants less apt to be fatigued. The patient sits between two staples,'which are screwed into the sides of the room ; the bandages are then applied precisely in the same way as when the extension is made with- out pulleys; and the force is applied in the same direc- tion. The surgeon is to pull the cord of the pulley gently and steadily until pain is complained of, when he is to maintain the extension already made, but not increase it. During this stop, he should converse with the patient, and direct his mind to other subjects. In two or three minutes, more force should be applied, and very gently increased, until pain be again com- plained of, when another stop should be made. The surgeon should proceed in this way for a quarter of an hour, at intervals slightly rotating the limb. When the extension seems great enough, an assistant should hold the cord of the pulley, and keep up the degree of extension, while the surgeon puts his knee into the axilla, and resting his foot upon the chair, gently raises and pushes back the head of the bone tovvards the glenoid cavity, into which it generally returns without the snap usually heard when the reduction is effected by other means. Sir Astley Cooper precedes the use of the pulleys with venesection, the warm bath, and a grain of tartarized antimony every ten minutes, until falntness is produced, as already noticed in our general remarks.—(On Dislocations, p. 429.) When the head ofthe humerus is dislocated forwards. or undir the middle of the clavicle, Sir Astley Cooper recommend* the biceps to be relaxed, and the extension to be made obliquely downwards and a little back- wards. In most instances of this kind, he savs, the plan of reduction by means of the heel in the' axilla will succeed, care being taken to apply the foot rather more forwards than in a dislocation into the axilla, so that It may press on the head of the bone. However, when the dislocation has continued several days, he considers gradual extension with pulleys necessary. As soon as the heattof the bone has been drawn below the level of the coracoid process, it is to be pressed backwards with the surgeou's heel or knee, and the elbow at the same moment pulled forwards.—(Op. cit. p. 439.) The dislocation on the dorsum of the scapula ap- pears, from some cases in Sir Astley Cooper's work, to be reducible by nearly the same, mode of extension as 'iat employed for the reduction of the dislocation in the axilla. Mr. Coley, of Bridgenorth, who has met with two cases of luxation backwards, advises the re- duction to be effected by elevating the arm and rotating it outwards, so as to roll the head of the humerus to- \vard3 the axitla, when it is to be kept in this position, while the arm is brought down into a horizontal direc- tion : on the extending force being now applied, the bone is easily reduced.—(Op. cit. p. 444.) In the partial dislocation forwards, or that where the head of the bone lies at the scapular side of the coracoid process, the mode of reduction, according to Sir Astley Cooper, is the same as that employed in the complete dislocation forwards; but it is necessary to draw the shoulders backwards, and as soon as the reduction is accomplished, the bone is to be kept from slipping for- wards again by maintaining the shoulders in that posi- tion with a bandage.—(Op. cit. p. 449.) The elbow and forearm should also be supported as much forwards as possible in a sling. In the museum of St. Thomas'? Hospital is a prepa- ration, exhibiting a dislocation of the humerus into the axilla, complicated with a separation of the greater tu- bercle by fracture. In Sir Astley Cooper's valuable work on this subject is also recorded a case of com- pound dislocation of the shoulder, which was under the care of Messrs. Saumarez and Dixon, of Newing- ton, and was cured by anchylosis.—(P. 450.) Such an accident must be treated on the same principles as other severe compound dislocations. For the purpose of preventing the head of the bone from slipping out of its place again, the arm should be kept for some days quiet, the elbow bandaged close to the side, and supported in a sling. Sir Astley Cooper recommends a cushion to be mit in the axilla, and a stellate bandage and sling to be applied.—(On Disloca- tions, p. 432.) After the reduction of a dislocation which has happened downwards, the facility of a fresh displacement is said to depend very much upon the extent to which the tendon of the subscapularis muscle has been lacerated.—(A. Cooper's Surgical Essays, part 1, p. 7.) OF SOME CIRCUMSTANCES RENDERING THE REDUCTION DIFFICULT. 1. Narrowness of the Opening of the Capsule. While Desault considers this circumstance as one of the chief impediments to the return of the head of the humerus into the glenoid cavity, Pott and Sir Ast. ley Cooper are of opinion that the capsular ligament can never create any such difficulty. According to De- sault, the obvious indication is to enlarge such an open- ing by lacerating its edges. This is fulfilled by moving the bone about freely in every direction, particularly in that in which the dislocation has taken place. Now by pushing the head of the bone against the capsule already torn, the latter becomes lacerated still more, in consequence of being pressed between two hard bodies. The reduction, which is frequently impracti- cable before this proceeding, often spontaneously fol- lows immediately after it has been adopted. In the Journal de Chirurgie are two cases, by Anthaume and Faucheron, establishing this doctrine. Mr. C. White, of Manchester, also believed that the reduction was sometimes prevented by the head of the bone not being able to get through the laceration in the capsule again. He succeeded in reducing some cases which he supposed to be of this nature, in tbe following manner: having screwed an iron ring into a beam at the top of the patient's room, he fixed one end of the pulleys to it, and fastened the other to the dislocated arm by ligatu-es attached to the wrist, placing the arm in an erect position. In this way, he drew up the pa- tient tUl his whole body was suspended; but that too much force might not be sustained by the wrist, Mr. White at the same time directed two other persons to support the arm above the elbow. He now used to try with his hands to conduct the arm into its place, if the reduction had not already happened, as was some- • 314 DISLOCATION. times the case. Occasionally, a snap might be heard as soon as the patient was drawn up: but the reduc- tion could not be completed till he was let down again, and a trial made with the heel in the armpit. When no iron ring was at hand, Mr. White used to have the patient raised from the ground by three or four men who stood upon a table.—(Cases in Surgery, p. 95.) 2. Oldness of the Dislocation. When the head of the bone has lodged a long while in its accidental situation, it contracts adhesions to it. The surrounding cellular substance becomes con- densed, and forms, as it were, a new capsule, which resists reduction, and which, when such reduction cannot be accomplished, supplies in a certain degree the office of the original joint by allowing a consider- able degree of motion. In such cases, the common advice used to be that no attempt at reduction should be made, as it would be useless in regard to the dislocation, and might be inju- rious to the patient from the excessive stretching of parts. This was for some time the doctrine of Desault; but in his latter years experience led him to be bolder. Complete success obtained in dislocations which had existed from fifteen to twenty days, encouraged him to at- tempt reduction at the end of thirty and thirty-five days ; and in the two years preceding his death he succeeded three or four times in reducing dislocations which had existed two months and a half, and even three months, both when the head of the bone was situated at the lower and at the internal part of the scapula. In these cases it is necessary, before making the extension, to move the bone about extensively in all directions for the purpose of first breaking its adhesions, lacerating the condensed cellular substance which forms an accidental capsule, and of producing, as it were, a second dislocation, in order to remove the first Extension is then to be made in the ordinary way, but with an additional number of assistants. The first attempts frequently fail, and the dislocated head of the bone continues unmoved notwithstanding the most violent efforts. In this case, after leaving off the extension, the arm is to be again moved about very extensively. The humerus is to be carried upwards, downwards, forwards, and backwards; and every re- sistance overcome. Let the arm describe a large seg- ment of, a circle in the place where it is situated. Let it be once more rotated on its axis ; then let the exten- sion be repeated, and directed in every way. Thus the head of the bone will first be disengaged by the free motion, and afterward reduced. In these cases, when the dislocation, in consequence of being very old, presents great obstacles to reduction, even though the attempts made for this purpose should fati, they are not entirely useless. By forcing the head of the bone to approach the glenoid cavity, and even placing it before the .cavity, and making it form new adhesions after the destruction of the old ones, the mo- tions of the arm are rendered freer. Indeed, they are always the less obstructed, the nearer the head of the bone is to its natural situation. Notwithstanding the encouragement given by Desault to making attempts to reduce old dislocations of the humerus, experience proves that when the bone has been out of its place more than a month, success is rarely obtained. And as for the danger which may arise from long-protracted, immoderate force, a case which I have elsewhere cited proves that caution is here a virtue which cannot be too highly commended,—(See First Lines of Surgery, vol. 2, p. 465.) Another instance, in which a woman died from the violence used in the extension, is reported by Sir Astley Cooper.—(On Dislocations, p. 422.) [The late Dr. Colin Mackenzie, of Baltimore, several years since reduced a dislocation of the humerus, of nearly six months' duration, in the Maryland Hospital, with entire success; and Dr. James Cocke, also of Baltimore, reduced a luxated humerus after it had been displaced 120 days.—Reese.] 3. Contractions of the Muscles. A third impediment to the reduction of every kind of dislocation is the power of the muscles, which is aug- mented beyond the natural degree, in consequence of their being on the stretch. Sometimes this power is so considerable, that it renders the head of the bone im- moveable, though the -most violent efforts are made patient; bleeding, the warm bath, nauseating doses of tartarized antimony, as advised by Loder, Sir Astley Cooper, «fcc.; opium, &c. Should the patient happen to be intoxicated at the time of his being first seen by the surgeon, the opportunity would be very favourable to reduction, as the muscles would then be capable of less resistance. Extension unremittingly, but not vio- lently, continued for a length of time, will ultimately fatigue the resisting muscles, and overcome them with more safety and efficacy, than could be accomplished by any sudden exertion of force. In all cases of difficulty, pulleys should be preferred. The swelling about the joint, brought on by the acci- dent, usually disappears without trouble. Another consequence, which seldom occurs in prac- tice, but which Desault saw twice, is a considerable emphysema, sudenly originating at the time of reduc- tion. In the middle of such violent extension, as the long standing of the dislocation requires, a tumour sud- denly makes its appearance under the great pectoral muscle. Rapidly increasing, it spreads towards the armpit, the whole extent of which it soon occupies. It reaches backwards, and in a few minutes sometimes becomes as large as a child's head. A practitioner un- acquainted with this accident, might take it for an aneurjsm, occasioned by the sudden rupture of the axillary artery, by the violent extension. But if atten- tion be paid to the elasticity of the tumour, its fluc- tuation, the situation where it first appears, commonly under the great pectoral muscle, and not in the axilla; the continuance of the pulse ; and the unchanged colour of the skin ; the case may easily be discriminated from a rupture of the artery.—((Euvres Chir. de Desault, par Bichat, t. 1.) For dispersing the above kind of swelling, the lotio plumbi acetatis, and gentle compression with a bandage, are recommended. I shall conclude the subject of luxations of the shoulder with the following singular observation, re- corded by Baron Larrey. _" Among the curious anatomical preparations (says he) which I saw in the cabinet of the university of Vienna, there was a dissected thorax, shown to me by Professor Prokaska, in which the whole orbicular mass of the head of the right humerus, engaged between the second and third true ribs, projected into the cavity of the chest. This singular displacement was the result of an accidental luxation, occasioned by a fall on the elbow, while the arm was extended and lifted from the side. The head of the humerus, after tearing the cap- sular ligament, had been violently driven into the hollow of the axilla, under the pectoral muscles, so as to sepa- rate the two corresponding ribs, and pass between them. The diameter of the head of the bone sur- mounted this obstacle, and penetrated entirely into the cavity of the thorax, pushing before it the adjacent portion of the pleura. Every possible effort was made in vain to reduce this extraordinary dislocation. The urgent symptoms which arose were dissipated by bleeding, warm bathing, and antiphlogistic remedies. The arm, however, remained at a distance from the side, to which condition the patient became gradually habituated, and after several years of suffering and oppression, he at length experienced no inconvenience. The patient was about sixteen or seventeen, when he met -with the accident; and he lived to the age of thirty- one, when he died of some disease, which had no con- cern with the dislocation. His physicians were anxious to ascertain the nature of this curious case, of which they had been able to form only an imperfect judgment. They were much surprised to find, upon opening the body, the head of the humerus lodged in the chest, sur- rounded by the pleura, and its neck closely embraced by the two ribs above specified. They were still more astonished to find, instead of a hard spherical body co- vered with cartilage, only a very soft membranous ball, which yielded to the slightest pressure of the finger. The cartilage and osseous texture of the whole portion of the humerus, contained within the cavity of the chest, had entirely disappeared. Les absorbans s'en itaientemparis (says Mr. Larrey), et commeautant de gardiensfidiles, ils avaient cherche a ditruire par portions, n'ayant pu I'cxpulser en masse, un ennemt qui s'etait furtivement introduit dans un domicile ou sa prisence devait Itre importune et nuisible. Of the humerus, there only remained some membranous rudi- Here the means to be adopted are such as weaken the | ments of its head, and a great part of these seemed to -& DISLOCATION. 315 belong to the pleura costalis."—(Mimoiresde Chirurgie Militaire, t. 2, p. 405—407.) DISLOCATIONS Or THE FOREARM FROM THE HUMERUS. Notwithstanding the extent of the articular surfaces of the radius and ulna, the strength of the muscles and ligaments surrounding the joint, and the mutual recep- tion of the bony eminences, rendering the articulation a perfect angular ginglymus, a dislocation of both the radius and ulna from the humerus, is an accident for which a surgeon is sometimes consulted. The radius and ulna are most frequently luxated backwards; some- times laterally, but very rarely forwards : the latter luxation cannot occur without a fracture of the ole- cranon. Indeed, it is so uncommon, that neither Petit nor Desault ever met with it. The luxation backwards is facilitated by the small size of the coronoid process, which, when the humerus is forcibly pushed down- wards and forwards, may slip behind it, and ascend as high as the cavity which receives the olecranon in the extended state of the forearm. Sir Astley Cooper's experience has made him ac- quainted with five different luxations of the elbow: 1. That of the radius and ulna backwards. 2. That of both these bones laterally. 3. That of the ulna alone. 4. That of the radius alone forwards. 5. That of the radius backwards.—(On. Dislocations, p. 467.) In the luxation backwards, the radius and ulna may ascend more or less behind the humerus; but the coro- noid process of the ulna is always carried above the articular pulley, and is found lodged in the cavity des- tined to receive the olecranon. The head of the radius is placed behind and above the external condyle of the humerus. The annular ligament, which confines the superior extremity ofthe radius to the ulna, may be la- cerated : in which case, even When the bones are re- duced, it is difficult to keep them in their proper places, as the radius tends constantly to quit the ulna. This accident always takes place from a fall on the hand; for when we are falling, we are led by a me- chanical instinct to bring our hands forwards to protect the body. If, in this case, the superior extremity, instead of resting vertically on the ground, be placed obliquely with the hand nearly in a state of supination, the repulsion which it receives from the ground will cause the two bones of the forearm to ascend behind the humerus, while the weight of the body pressnig on the humerus, directed obliquely downwards, forces its extremity to pass down before the coronoid process of the ulna. The forearm is in a state of half flexion, and every attempt to extend it produces acute pain. The situa- tion of the olecranon, with respect to the condyles of the humerus, is changed. The olecranon, which, in the natural state, is placed on a level -with the external condyle, which is itself situated lower than the internal, is even higher than the latter. Posteriorly a consider- able projection is formed by the ulna and radius. On each side of the olecranon, a hollow appears. A con- siderable hard swelling is felt on the fore part of the joint, arising from the projection of the lower end of the humerus. The hand and forearm are supine, and the power of bending the joint is in a great measure lost.—(Sir Astley Cooper on Dislocations,p. 468.) The swelling, which supervenes in twenty-four hours after the accident, renders the diagnosis more difficult; but, notwithstanding the assertion of Boyer, I believe the olecranon and internal condyle are never so ob- scured that the distance between them cannot be felt to be increased. It is true that the rubbing of the coro- noid process and olecranon against the humerus may cause a grating noise, similar to that of a fracture; and some attention is certainly requisite to establish a diag- nosis between a fracture of the head of the radius and a dislocation of the forearm backwards. " This dislo- cation (says Sir Astley Cooper) is at first sometimes undiscovered, in consequence of the great tumefaction, which immediately succeeds the injury ; but this cir- cumstance does not prevent the reduction, even at the period of several weeks after the accident; for I have known it thus reduced by bending the limb over the knee, even without great violence being employed." —(On Dislocatmns.Ac.p. 470.) A luxation back wards must be attended with serious Injury of the surrounding soft parts. The lateral liga- ments are constantly ruptured, and sometimes the an- nular ligament of the radius. In a case dissected by Sir Astley Cooper the annular ligament was entire. The biceps muscle was only slightly put upon the stretch; but the brachialis was excessively so. Pro- bably the lower insertions of the biceps and brachialis internus would likewise be more frequently lacerated by the violent protrusion of the head of the humerus forwards, were it not that their attachments are at some distance from the joint. This mischief, however, occa- sionally takes place, and then the forearm is observed to be readily placed in any position, and not to retain one attitude, as is generally the case in dislocations. The lower end of the humerus, indeed, has been known not only to lacerate these muscles, but to burst the integuments and present itseiPexternally; an instance of which is recorded by Petit, and two such cases I saw myself, during my apprenticeship at St. Bartholomew's. Boyer justly remarks, that it is difficult to conceive how, under these circumstances, the brachial artery and median nerve can escape. In fact, this vessel has sometimes been ruptured, and mortification of the limb been the consequence ; but this injury of the artery, and the laceration of the muscles and skin, are rare occurrences.-(Traiti des Mai. Chir. t. 4, p. 215.) Nor if the artery were wounded, would gangrene be inva- riably the result; for if my memory is correct, an instance in which the Umb was "saved, notwithstanding such a complication, is mentioned by Mr. Abernethy in his lectures, thoughuio doubt the risk would be great. The following method of reducing the case is advised by Boyer:—The patient being seated, an assistant is to take hold of the middle of the humerus, and make counter-extension, while another assistant makes ex- tension at the wrist. The surgeon, seated on the out- side, grasps the elbow with his two hands, by applying the fore-fingers of each to the anterior part of the hu- merus, and the thumbs to the posterior, with which he presses on the olecranon, in a direction downwards and forwards. This method will generally be successful If the strength of the patient, or the long continuance of the luxation, render it necessary to employ a greater force, extension is to be made with a towel applied on the wrist, and a cushion is to be placed in the axilla, and the arm and trunk fixed as is done in cases of luxa- tion of the humerus. In Sir Astley Cooper's method, the patient sits in a chair. The surgeon places his knee on the inner side of the elbow-joint, in the bend of the arm, and taking hold of the patient's wrist, bends the arm. At the same time he presses on the radius and ulna with his knee, so as to separate them from the os humeri. Thus the coronoid process is pushed out of the posterior fossa of the humerus; and while tbe pressure is kept up with the knee, the arm is to be forcibly but slowly bent, and the reduction is soon effected. According to the same authority, the bones may also be reduced by bending the arm over a bedpost, or by bending it while it is engaged in the opening of the back of the elbow-chair in which the patient sits.—(On Dislocations, p. 469.) A bandage may afterward be applied in the form of a figure of 8, evaporating lotions used, and the arm kept in a sling. The swelling which follows is to be combated by antiphlogistic means. At tbe end of seven or eight days, when the inflam- mation has subsided, the articulation is to be gently moved, and the motion is to be increased every day, in order to prevent an anchylosis, to which there is a great tendency. In this luxation, the annular ligament which con- fines the head of the radius to the extremity of the ulna is sometimes torn, and the radius passes in front of the ulna. In such cases, pronation and supination are difficult and painful; though the principal luxa- tion has been reduced, the head may be easily replaced by pressing it from before backwards, and it is to be kept in its place by a compress, applied to the superior and external part of the forearm. The bandage and compress are to be taken off every two or three days, and the joint gently bent and extended, in order to prevent anchylosis. In a modern pubheation, an instance of a dislocation of the heads of the radius and ulna backwards is rela- ted, where the lower end of tbe humerus protruded through the integuments, and, as it could not be re- duced, it was sawed off. The patient, a boy, recovered the full use of his arm.—(Evans, Pract. Obs. on Cata- ract, Compound Dislocations, i-c. p. 101 316 DISLOCATION. A luxation forwards should be treated as a fracture of the olecranon, with which it would be inevitably accompanied. Here, on account of the great injury done to the soft parts, it would also be right to bleed the patient copiously, and put him on the antiphlo- gistic regimen. With respect to lateral luxations, either inwards or outwards, they are always incomplete and easUy dis- covered. In the case outwards, the coronoid process is situated on the back part of the external condyle. The projection of the ulna backwards is even greater than in the dislocation of both bones directly back- wards, and the radius forms a protuberance behind and on the outer side of the os humeri. By moving the hand, the rotation ofthe head of the humerus can be distinctly felt In the lateral dislocation inwards, the ulna may be thrown upon the internal condyle, so as to produce an apparent hollow above it, and the ro- tation of the head of the radius can be distinctly felt. Sometimes when the ulna is thrown upon the internal condyle, it still projects backwards, as in the external lateral dislocation, in which circumstance the head of the radius is in the posterior fossa of the humerus, and the outer condyle forms a considerable projection. —(A. Cooper, op. cit. p. 471.) Boyer advises the re- duction of lateral dislocations to be effected by ex- tending the humerus and forearm, and at the same •■time pushing the extremity ofthe humerus and the heads of the ulna and radius in opposite directions. According to Sir Astley Cooper, in each of the late- ral dislocations, the reduction may be performed by bending the arm over the knee; but in a recent case, as one which he relates proves, he considers that the business may be most readily accomplished by forcibly extending the arm ; for when this is done, the biceps and brachialis draw the heads of the radius and ulna into their right places again.—(P. 472.) These luxations cannot be produced without consi- derable violence; but when the bones are reduced, they are easUy kept in their place. It will be sufficient to pass a roller round the part, to put the forearm in a middle state, neither much bent nor extended, and to support it in a sling. But much inflammation is to be expected from the injury done to the soft parts. In order to prevent, or at least mitigate it, the patient is to be bled two or three times and put on a low diet, and the articulation is to be covered with the lotio plumbi acet. or an emollient poultice. It is scarcely necessary to repeat that the arm is to be moved as soon as the state of the soft parts will admit of it.— - (Boyer, sur les Maladies des Os, t. 2.) A dislocation of the forearm backwards is said to occur ten times as frequently as lateral luxations; and those forwards are so rare, that no comparison what- ever can be drawn.—(tt.uvres Chir. de Desatdt, 1.1.). All recent dislocations of the elbow are easily re- duced and as easily maintained so ; for a displacement is prevented by the reciprocal manner in which the ar- ticular surfaces receive each other, and by their mutual eminences and cavities. This consideration, however, should not lead us to omit the application of a bandage in the form of a figure of 8, and supporting the arm in a sling. DISLOCATION OF THE RADIUS FROM THE ULNA. The majority of writers on dislocations of the fore- arm have not separately considered those ofthe radius. The subject was first well treated of by Duverney. However, dislocations of its lower end remained unno- ticed, until Desault favoured the profession with a par- ticular account of them. The radius, the moveable agent of pronation and supination, rolls round the ulna, which forms, its im- moveable support, by means of two articular surfaces; one above, slightly convex, broad internally, narrow outwardly, and corresponding to the little sigmoid ca- vity of the ulna, in which it is lodged; the other below, concave, semicircular, and adapted to receive the con- vex edge of the ulna. Hence, there are two joints, differing in their motions, articular surfaces, and liga- ments. . Above, the radius in pronation and supination only moves on its own axis: below, it rolls rotind the axis of the Ulna. Here, being more distant from the centre, its motions must be both more extensive and powerful than they are above. The head of the radius, turning on its own axis in the annular or coronary ligament. cannot distend it in any direction. On the contrary, below, the radius, in performing pronation, stretches the posterior part of the capsule, and presses it against the immoveable head of the ulna, which is apt to be pushed through, if the motion be forced. A similar event, in a contrary direction, takes place in supina- tion. The front part of the capsule being rendered tense, may now be lacerated. Add to this disposition the difference of strength be- tween the ligaments of the two joints. Delicate and yielding below ; thick and firm above; their difference is very great. The upper head of the radius, sup- ported on the smaller immoveable articular surface of the ulna, is protected from dislocation in most of its motions. On the contrary, its lower end, carrying along with it in its motions the bones of the carpus, which it supports, cannot itself derive any solid sta- bility from them. From what has been said, the following conclusions may be drawn : 1. That with more causes of luxation, the lower articulation of the radius has less means of resistance: and that under the triple consideration of motions, ligaments tying the articular surfaces toge- ther, and the relations of these surfaces to each other, this joint must be very subject to dislocation. 2. That, for opposite reasons, the upper joint must, according to Desault, be rarely exposed to such an accident. He here excludes from consideration cases in which the annular ligament of the radius is lacerated in a luxa- tion of both heads of the radius and ulna backwards; and particularly confines his reasoning to a dislocation of the upper head of the radius from the lesser sig- moid cavity of the ulna, as a single and uncomplicated injury, suddenly produced by an external cause, and, therefore, neither to be confounded with the cases above specified, nor with other examples in which the displacement happens slowly, especially in children, in consequence of a diseased or relaxed state of the ligaments. However, some instances of dislocation ofthe upper head of the radius, suddenly produced by external causes, are recorded by Duverney ; the particulars of another case were transmitted to the French Academy of Surgery; and I have been informed of four exam- ples which were met with in this country. Two of these cases occurred in the practice of Mr. Dunn, of Scarborough; one in that of Mr. Lawrence; and the other was attended by Mr. Earle. Sir Astley Cooper has himself seen six examples of the disloca- tion of the head of the radius forwards. Baron Boyer says, that many instances are now known in which the upper head of the radius was dislocated backwards; indeed, in opposition to what Desault has stated, he as- serts, that dislocations of the lower joint between the radius and ulna are more rare than those of the upper joint between the same bones. The latter accident he has twice seen himself—(Mai. Chir. t. 4, p. 248.) The displacement backwards is described by this author, as occurring more readily and frequently in children than in adults or old subjects. The reason of this "circumstance is ascribed to the less firmness both of the ligaments and of the tendinous fibres of the exterior muscles, which fibres, in a more advanced age, contribute greatly to strengthen the external la- teral Ugament. In a child, also, the little sigmoid ca- vity of the ulna is smaller, and the annular ligament, extending farther round the head of the radius, is longer, and more apt to give way. Hence, in a subject of this description, efforts, which may not at first produce a dislocation, if frequently repeated, cause a gradual elongation of the ligaments, a change in the natural po- sition of the bones, and at length, a degree of displace- ment as great as in a case of luxation suddenly and immediately effected.—(Traite des Mai. Chir. t. 4, p. 239.) Another fact mentioned by Boyer is, that the dislo- cation of the upper head of the radius backwards is always complete, its articular surfaces being perfectly separated both from the lower end of the humerus, and from the little sigmoid cavity of the ulna. The usual cause of the accident is a pronation of the fore- arm, carried with great violence beyond the natural limits. In a dislocation of the head of the radius backwards, the forearm is bent, and the hand fixed in tbe state of pronation. Supination can neither be performed by the action of the muscles, nor by external force; and DISLOCATION. 317 every attempt to execute this movement produces a considerable increase of pain. The hand and fingers are moderately bent, and the upper head of tne radius may be observed forming a considerable projection be- hind the lesser head of the humerus. In the case which was mentioned to me by my friend Mr. Law- rence, the head of the radius lay upon the outside of the external condyle. Sir Astley Cooper has never seen a dislocation of the upper head of the radius backwards in the living subject; but a man was brought for dissection into the theatre of St Thomas's Hospital, who had such a dis- location which had never been reduced. The head of the radius was thrown behind tlie external condyle, and rather to the outer side of the lower extremity of the humerus. The fore part of the coronary ligament was torn through, as well as the oblique one, and the capsular was partially lacerated. In the kind of case described by Sir Astley Cooper, where it seems the limb was extended, this experienced surgeon conceives, that the bone would be easily re- duced by bending the arm. The reduction is to be accomplished by extending the forearm, and endeavouring to bring it into tlie su- I pine posture at tbe same time that the surgeon tries to press with his thumb the head of the radius forwards towards the lesser tubercle of the humerus, and into the little sigmoid cavity of the ulna again. Success is indicated by the patient being now able to perform the supine motion of the hand, and to bend and extend the elbow with freedom For the purpose of preventing a return of the dis- placement, and giving nature an opportunity of repair- ing the torn ligaments, measures must be taken to hinder the pronation of the hand. Boyer recommends with this view a roller, compresses, and a sling; but it appears to me, that a splint, extending nearly to the extremity of the fingers, and laid along the inside of the forearm with a pad of sufficient thickness to keep the hand duly supine, would be right, in addition to the sling, roller, Dislocations inwards or outwards are never com- plete. The projection of the carpal bones at the inner or outer side of the joint, and the distortion of the hand, make such cases sufficiently evident. Recent dislocations of the wrist, particularly such as are incomplete, are easy of reduction: but when the displacement has been suffered to continue some time more difficulty is experienced, and in a few days all attempts are generally unavailing. This observation applies to all dislocations of ginglymoid joints; and I cannot, therefore, too strohgly condemn the waste of time in trials to disperse the swellings ofthe soft parts ere the bones are replaced ; an absurd plan, which, I am sorry to say, is sanctioned by Boyer.—(Mai. Chir. t. 4. p. 260.) For the purpose of reducing the dislocated bones, gentle extension must be made, while the two surfaces of the joint are made to slide on each other in a direc- tion contrary to what they took when the accident oc- curred. In dislocations of the wrist, numerous tendons are always seriously sprained, and many ligaments lace- rated ; consequently, a good deal 6f swelling generally follows, and the patient is a long time in regaining the perfect use of the joint. Hence the propriety of bleed- ing, low diet, and opening, cooling medicines; while the hand and wrist should be continually covered with linen wet with the lotio plumbi acetatis, or spirit of wine and water, and the forearm and hand kept in splints, which ought to extend nearly to the end of the fingers, so as to prevent a return of the displacement. The limb must also remain quiet in a sling. When the ruptured ligaments have united, liniments will tend to dispel the remaining stiffness and weak- ness of the joint. DISLOCATION OF THE CARPUS, METACARPUS, FINGERS, AND THUMB. A simple dislocation of the carpal bones from each other seems almost impossible. The os magnum, however, has been known to be partially luxated from the deep cavity formed for it in the bs scaplioides and os lunare. This displacement is produced by too great a flexion of the bones of the first phalanx on those of the second, and thews magnum forms a tumour on the back ofthe hand.—{Chopart; Boyer; Richerand.) Chopart once met with a partial luxation of the os I magnum in a butcher. Baron Boyer has seen several examples ofthe accident,which, he aays, is more com- mon in women than men; a circumstance which he imputes to the ligaments being looser in females, and to the bones of the carpus in them having naturally a greater degree of motion. The tumour increases when the hand is bent, and diminishes when It is extended. The case does not produce any serious inconvenience. If the wrist be extended, and pressure be made on the head of the os magnum, the reduction is easily accom- plished ; though a renewal of the displacement cannot be prevented, unless the extension and compression be kept up by means of a suitable apparatus, during the whole time requisite for the healing of the torn liga- ments. As the inconveniences ofthe accident are slight, few patients will submit to any tedious, irksome treat- ment ; and sometimes the surgeon is never consulted, tUl it is too late to think of replacing the bone. In general, therefore, he is obliged to be content with treating the case as a sprain or contusion. Sir Astley Cooper has seen two cases of displace- ment of the os magnum in females: the accidents pro- duced a weakened state of the limb, and arose from relaxation of the ligaments. One example is also given of a dislocation of the os scaphoides, which was thrown backwards upon the (jarpus, with the lower portion of the broken radius.—(On Dislocations, p. 514, 515.) Compound dislocations of the carpal bones are not un- common, and generally arise from gun-shot violence, or other great mechanical injury. In these cases, it is sometimes necessary to take away the displaced bones altogether; and too frequently the accident is such as to require amputation. The connexion of the metacarpal bones with one an- other, and with those ofthe carpus, is so close, and the degree of motion so slight, that a dislocation can hardly take place. Thus, Sir Astley Cooper, in his vast expe- rience, has never seen them dislocated, except by the bursting of guns, or by the passage of heavy carriages over the hand; cases frequently demanding amputa- tion.—(On Dislocations, p. 519.) The first metacarpal bbne, which is articulated with the os trapezium, and admits of the movements of flexion, extension, abduc- tion, and adduction, is capable of being luxated ; but the accident is uncommon, for reasons explained in my other work. Although from the nature of the joint, between the first metacarpal bone and the trapezium, one might infer that a dislocation is possible in the four directions, backwards, forwards, inwards, and outwards, yet if we are to believe Boyer, the first case is the only one which has been observed. The accident is produced by tbe application of external force to the back of the metacarpal bone,which is suddenly and violently thrown into a state of flexion, the case usually arising from a fall on the outer edge of the hand. In this circum- stance, the upper head of the bone is forcibly driven backwards, the capsular ligament is lacerated, the ex- tensor tendons of the thumb are pushed up, and the head of the bone slips behind the trapezium. For an account of the symptoms and treatment of this accident, I must refer to the fifth edition of the First Lines of the Practice of Surgery. The first phalanges of the fingers may be dislocated backwards off the heads of the metacarpal bones. A luxation forwards would be very difficult, if not impos- sible, because the articular surfaces of the metacarpal bones extend a good way forwards, and the palm of the hand makes resistance to such an accident. The first phalanx of the thumb, in particular, is often dis- located backwards behind the head of the first meta- carpal bone, in which case it remains extended, whUe the second phalanx is bent. These dislocations should be speedily reduced; for after eight or ten days they become irreducible. In a luxation of the first bone of the thumb which was too old to be easily reduced, and where the part was thrown behind the head of the metacarpal bone, De- sault proposed cutting down to the dislocation, and pushing the head of the bone into its place with a spa- tula. Even in cases which are quite recent, this kind of dislocation frequently cannot be reduced without the utmost difficulty, and the different proposals which have been made respecting this particular accident, by Mr. Evans, the late Mr. Hey, Mr. C. Bell, and Boyer, deserve the notice of the surgical practitioner, who wtil find them explained in my other work. On this sub- DISLOCATION. 319 Jeot, however, Sir Astley Cooper remarks, that he has seen too much mischief arise from injury to the ten- dons and ligaments, ever to recommend their division, In order to facilitate their reduction, when extension will not succeed.—(Ore Dislocation, p. 523.) Disloca- tions of the thumb and little finger inwards, and that of the thumb outwards (which are possible cases), and luxations of the first phalanges of the other fingers backwards, and of their second phalanges forwards, are all reduced by making extension on the lower end of tlie affected thumb or finger, and at the same time pressing the head of the bone towards its natural situ- ation. After the reduction, the tliuri* or finger should be rolled with tape, and surrounded and supported with pasteboard, till the lacerated ligaments have united ; care being taken to keep the hand and forearm in a sling. The luxation of the first phalanx of the thumb behind the metacarpal bone, requires peculiar treatment, as I have elsewhere explained. DISLOCATIONS OF THE BONES OF THE PELVIS. Experience proves, that the bones of the pelvis, not- withstanding the vast strength of their ligaments, may be dislocated by violence: thus the os sacrum may be driven forwards towards the interior of the pelvis; the ossa ileum may be displaced forwards and up- wards ; and the bones of the pubes may be totally se- parated at the sytnpyhsis, and an evident degree of moveableness occur between them. For the produc- tion of these accidenls the operation of enormous force is requisite; and, in fact, their usual causes are falls from a great height; the fall of a very heavy body against the sacrum, at a period when the body is fixed; and the pressure of the pelvis between a wall or post and the wheel of a carriage or wagon. Hence, the dislocation is generally the least part of the mischief occasioned by such kinds of violence, and the case is commmonly attended with concussion of the spinal marrow, injury of the sacral nerves, extravasation of blood in the cellular substance of the pelvis or cavity of the peritoneum, injury of the kidneys, and fracture of one or more of the bones of the pelvis. As Sir A. Cooper has remarked, some of these cases complicated with fracture, are liable to be mistaken for dislocations ofthe thigh:—" When," says this gentleman, " a frac- ture of the os innominatum happens through the aceta- bulum, the head of the femur is drawn upwards, and the trochanter somewhat forwards, so that the leg is shortened, and the knee and foot are turned inwards. Such a case, therefore, may be readily mistaken. If the os innominatum is disjointed from the sacrum, and the pubes and ischium are broken, the limb is slightly shorter than the other; but the knee and foot are not turned inwards. These accidents may generally be detected by a crepitus perceived in the motion of the thigh, when the surgeon applies his hand to the crista of the ileum, and there is greater motion than in a dis- location of the thigh."— (Surgical Essays,part 1, p. 49.) In addition to the complications which may attend a dislocation of the bones of the- pelvis, and arise imme- diately from the external violence, the case is always followed by inflammation, which may be very serious, not only on account of the extent of the articular sur- faces affected, but because such inflammation may ex- tend to the peritoneum and viscera of the abdomen and pelvis, as I have myself seen in two or three instances. Louis relates a case in which the os ileum of the riglu side was found separated from the sacrum so as to project nearly three inches behind it. This accident was caused by a heavy sack of wheat foiling on a la- bourer.—(Mim. de l'Acad. de Chir. t. 4,4to.) In a case recorded by Sir A. Cooper, the posterior part of the acetabulum was broken off, and the head of the thigh-bone had slipped from its socket; the frac- ture extended across the os innominatum to the pubes, the bones of which were separated at the symphysis nearly an inch asunder. Tho ilia were separated on each side, and the left os pubis, ischium, and ileum broken.—(Surgical Essays,part l,p. 50.) In the same work may also be penised another case of fracture of the body of the os pubis and ramus of the ischium, combined with a luxation of the right os innominatum fVom the sacrum and laceration of the ligaments of the symphysis of the pubes. When these cases do not prove fhtal from the direct effect of the great violence sommitted on many parts, or from peritonitis, the same unpleasant event some- times follows rather later from suppuration of the ar- ticular surfaces taking place, and abscesses forming in the cellular membrane of the pelvis.—(Boyer, Traiti des Mai. Chir. t. 4, p. 147.) A case in which a dislocation of the left os innomi- natum upwards had a successful termination, was at- tended by Enaux, Hoin, and Chaussier, and is pub- lished in a modern work.—(M m. de PAcad. des Sci- ences de Dijon.) As the reduction could not be accom- plished at first, antiphlogistic treatment was followed for some days, when new attempts to replace the bone were made, but could not be continued, as they caused a recurrence of pain and other bad symptoms. A third trial, made at a later period, was not more effectual; and all thoughts of reduction were then abandoned. After the patient had been kept quiet some time, though not so long as was wished, he quitted his bed and began to walk about on crutches. 1 do not under- stand, however, as is asserted, how the weight of the body could now bring about the reduction which had been previously attempted in vain. Be this as it may, the result wa.s the patient's recovery. The fact clearly proves, as Boyer observes, that in cases of this descrip- tion the most important object is not to aim at the re- duction, but rather to oppose, by every means in our power, inflammation and its consequences. Frequently the use of the catheter is necessary, and sometimes an incontinence of urine, or the involuntary discharge of the feces, demands the strictest attention to clean- liness. In these cases.if the patient live any time, there is also another source of danger, consisting in a ten- dency to sloughing in the soft parts, on which the pa- tient lies, and which, when they have been bruised, require still greater vigilance. The os coccygis is not so easily dislocated as frac- tured. Boyer has seen it displaced in a man who was greatly emaciated by disease. This subject had consi- derable ulcerations about the coccyx, and the bona itself was bare. There was an interspace of nearly two inches between the sacrum and base of the os coc- cygis. In proportion as the man regained his strength, the bone recovered its right position, and at length united to the os sacrum, notwithstanding the action of the levatores ani, which are inserted into it. This case, however, was not an accidental luxation; and it clearly arose from the destruction of the ligaments by disease. Authors mention two kinds of dislocation to which the os coccygis is liable; one inwards, the other out- wards. The first is always occasioned by external vio- lence ; the second by the pressure of the child's head in difficult labours. Pain, difficulty of voiding the feces and urine, tenesmus, and inflammation, some- times ending in abscesses which interest the rectum, are symptoms said to attend and follow dislocations of the os coccygis. The best authors now regard all schemes for the re- duction useless, as the bone will spontaneously return into its place as soon as the cause of displacement ceases: and the introduction of the finger within the rectum, and handling of the painful and injured parts, are more likely to increase the subsequent inflamma- tion, and produce abscesses, than have any beneficial effect. In short, the wisest plan is to be content with enjoining quietude, and adopting antiphlogistic mea- sures, i DISLOCATION OF THE RIBS. J. L. Petit was silent on this subject, as he thought such cases never occurred. Since his death, a French surgeon, Buttet, has related an instance which he sup- posed to be a dislocation of the posterior extremity of the rib from the vertebra?; but Boyer clearly proves, that there were no true reasons for this opinion, and that the case was only a fracture of the neck or end of the bone near the spine.—(Traiti de Mai. Chir. t. 4, p. I23-) Ambrose Part, Barbette, Juncker, Platner, and Heis- ter not only admit the occurrence of luxations of the ribs, but describe different species of them. Lieutaud also extended the term luxations to cases in which the head of the rib is separated by disease, the pressure of aneurisms, &c. In a modem work may be read the particulars of a case where all the ribs are said to have been dislocated from their cartilages. The accident arose from the chest being violently compressed between the bcum of 320 DISLOCATION. a mill and the wall. In such a case there is no means of reduction except the effect produced by forcible in- spirations; nor are there any modes of relief but bleeding, and the application of a roUer round the chest. —(See C. BelPs Surg. Obs. p. 171.) DISLOCATIONS OF THE THIGH-BONE. The head of the thigh-bone may be dislocated up- wards on the dorsum of the ileum; upwards and for- wards on the body of the os pubis; downwards and forwards on the foramen ovale; and backwards on the ischiatic notch. The dislocation upwards, and that downwards and forwards, are the most frequent. The dislocation of the thigh-bone upwards on the dorsum of the ileum is attended with the following symptoms. The limb is from one inch and a half to two inches and a half shorter than its fellow, the thigh a little bent and Carried inwards. The knee inclines more forwards and inwards than the opposite one; the leg and thigh are turned inwards, and the foot points in this direction ; the toe resting, as Sir A. Cooper re- marks, against the tarsus of the other foot.— (Surgical Essays, part 4, p. 27.) There is an approximation of the trochanter major to the anterior superior spinous process of the ileum, and at the same time it is ele- vated and carried a little forwards. It is also less pro- minent than that on the opposite side, and the natural roundness of the hip has disappeared. The natural length of the limb cannot be restored without reducing the luxation: the foot cannot be turned outwards, and any attempt to do so causes pain; but the inclination of the foot inwards may be increased.—(Boyer.) When an attempt is made to draw the leg away from the other, it cannot be accomplished: but the thigh may be slightly bent across its fellow. A dislocation on the dorsum ofthe ileum is generally at once readily discriminated from a fracture of the neck ofthe thigh-bone within the capsular ligament, by the rotation of the limb inwards; a position which is unusual in a fracture of any part of the os femoris. " In a fracture of the neck of the thigh-bone (says Sir A. Cooper), the knee and foot are generally turned out- wards ; the trochanter is drawn backwards: the limb can be readily bent towards the abdomen, although with some pain; but, above all, the Umb which is short- ened from one to two inches by the contraction of the muscles, can be made of the length of the other by a slight extension, and when the extension is abandoned the leg is again shortened. If, when extended, the limb is rotated, a crepitus can often be felt, which ceases when rotation is performed under a shortened state of the limb. The fractured neck of the thigh-bone, within the capsular ligament, rarely occurs but in advanced age, and it is the effect of the most trifling accidents, owing to the absorption which this part of the bone undergoes at advanced periods of life. Fractures ex- ternal to the capsular ligament occur at any age, but generally in the middle periods of life; and these are easily distinguished by the crepitus which attends them, if the limb is rotated and the trochanter is com- pressed with the hand. The position is the same as in fractures within the ligament. The proportion of frac- tures of the neck of the thigh-bone which I have seen, is at least four cases to one of dislocation."—(A. Cooper, Surg. Essays, part l,p. 28.) The rotation of the limb inwards, in cases of fracture of the neck of the thigh-bone, is uncommon, though sometimes met with. Sir A. Cooper saw one example of it, under the care of Mr. Langstaff.—(On Disloca- tions, Preface.) To reduce this dislocation, the patient should be placed on his opposite side upon a table firmly fixed, or a large four-posted bedstead. A sheet folded longitudinally is first to be placed under the pe- rineum ; and one end being carried behind the patient, the other before him, they are to be fastened to one of the legs or posts of the bed. Thus the pelvis will be fixed, so as to aUow the necessary extension of the thigh-bone to be made. Great care must be taken during the extension to keep the scrotum and testicles, or the pudenda in women, from being hurt by the sheet passed under the perina?um. The patient must be far- ther fixed by the assistants. The best practitioners of the present day in France advise the extending force to be applied to the inferior part of the leg, in order that it may be as far as possible from the parts which resist the return of the head of the bone into its natural situation. In this country, surgeons generally prefer making the extension by means of a sheet, or the strap of a pulley, fastened round the limb, just above the condyles of the os femoris. The direction in which Sir A. Cooper makes the extension is in the line made by the limb, when it is brought across the other thigh a little above the knee. As soon as the head of the bone has been brought on a level with the acetabulum by the assistants who are making the extension, the surgeon is to force it into this cavity by pressing on the great trochanter, or by rotating the knee and foot gently outwards, as practised by Sir A. (:ooper. The extension should always be made in a gradual and unremitting manner; at first gently, but afterward more strongly; never violently. The difficulty of re- duction arises from the great power and resistance of the muscles, especially the glutei and triceps, which will at length be fatigued, so as to yield to the extend- ing force, if care be taken that it be maintained the necessary time, without the least intermission. Some- times, when there is difficulty in bringing the head of the bone over the lip of the acetabulum, Sir A. Cooper raises it by placing his arm under it near tbe joint. The disappearance of all the symptoms, and the noise made by the head of the bone when it slips into < the acetabulum, denote that the reduction is effected. This noise, however, is not always made when pulleys are used. The bone is afterward to be kept from slipping out again, by tying the patient's thighs toge- ther with a bandage placed a little above the knees. The patient should be kept in bed at least three weeks, live low, and rub the joint with a camphorated lini- ment. Due time must be given for the lacerated liga- ments to unite, and the sprained parts to recover. Premature exercise may bring on irremediable disease in the joint. Mr. Hey gives the following description of the way in which he reduced a case of this kind. " The extension of the limb must be made in a right line with the trunk of the body; and, during the exten- sion, the head of the bone must be directed outwards as well as downwards. A rotatory motion of the oa femoris on its own axis, towards the spine (the patient lying prone), seems likely to elevate the great trochan- ter, bring it nearer to its natural position, and direct the head of the bone towards the acetabulum. These circumstances led to the following method: a folded blanket was wrapped round one of the bed-posts, so that the patient, lying in a prone position, and astride of the bed-post, might have the affected limb on the outside of the bed. The bed was rendered immoveable by placing it against a small iron pillar, which had been fixed for the purpose of supporting the curtain- rods. The leg was bent to a right angle with the thigh, and was supported in that position by Mr. Lucas, who, when the extension should be brought to a proper degree, was to give the thigh its rotatory motion, by pushing the leg inwards; that is, towards the other interior extremity. Mr. Jones sat before the patient's knee, and was to assist in giving the rotatory motion, by pushing the knee outwards at the same moment. I sat by the side of the patient, to press the head of the bone downwards and outwards during the extension. Two long towels were wrapped round the thigh, just above the condyles; one towel passing on the inside of the knee, the other on the outside. Three persons made the extension ; but when we attempted to give the thigh its rotatory motion, we found it confined by the towel, which passed on the inside of the knee and leg. We therefore placed both the towels on the out- side ; and in this position, the extending force concurred in giving the rotatory motion. The first effort that was made, after the towels were thus placed, had the de- sired effect; and the head of the bone moved down- wards and outwards into the acetabulum.''—(Hey'* Practical Observations, p. 313.) For the purpose of facilitating the reduction, many surgeons endeavour to produce a temporary faintness by a copious venesection, immediately before the exten- sion is begun j a practice which, when the patient's state of health does not forbid it, is advisable, as less- ening very materially the resistance of the muscles. Sir A. Cooper gives it his general approbation, as well as the warm bath, and nauseating doses of tartarized antimony. After taking away from twelve to twenty ounces of blood, this gentleman places the patient in a DISLOCATION. 321 bath heated to 100 degrees, and gradually raised to 110 degrees, until fuintness is induced. While in the bath, the patient is also to take a grain of tartarized antimony every ten minutes, until nausea is excited; when he is to be removed from the bath, put in blan- kets, and placed between two strong posts, in each of which a staple is fixed ; or he may be placed on the floor, into which two rings may be screwed. The manner in which Sir A. Cooper performs the reduction with pulleys, and by making the extension with the thigh slightly bent, having been detailed in the last edition of the First Lines of Surgery, I shall not here repeat it. Of Mr. Hey's plan, especially the direction of the limb in it, he entertains an unfavourable opinion, as little calculated to answer where the reduction has been at all delayed.— (On Dislocations, p. 45.) In this sentiment I fully concur. In all cases of difficulty, the above-mentioned debilitating means, the intoxicating ef- fect of a liberal dose of opium, and the use of pulleys, for the reduction, appear to me to deserve recommendation. An instance of dislocation of the thigh-uone on the dorsum of the ileum, with fracture of the same bone, is recorded by Sir Astley Cooper: the dislocation was not at first detected, and afterward no attempt to re- duce the bone was considered prudent. " Tlie probabi- lity is, that dislocations, thus complicated With fracture, will generally not admit of reduction, as an extension cannot be made until three or four months have elapsed from the accident, and then only with strong splints upon the thigh, to prevent the risk of disuniting the fracture."—(On Dislocations, i-c. p. 62.) Luxations of the thigh-bone, downwards and for- wards, upon the obturator foramen, are the next in fre- quency to those upon the dorsmn of the Ueum. The accident is facilitated by the great extent to which the abduction of the thigh can be carried ; by the notch at the inferior and internal part of the acetabulum; by the weakness of the orbicular ligament, which on this side is torn through; and by the ligarr.entum teres not oppos- ing, or being necessarily ruptured by it; that is to say, it is only broken when the head of the femur has been carried with great violence a certain distance from the acetabulum. On this point, however, I mention with great respect the statement of Sir Astley Cooper: " The dislocation in the foramen ovale happens while the thighs are widely separated, during which the ligamen- tum teres is upon the stretch; and when the head of the bone is thrown from the acetabulum, the ligament is torn through before it entirely quits the cavity."—(On Dislocations, ic. p. 65.) That the ligamentum teres is frequently raptured admits of no doubt. It seems also that the pectinalis and adductor brevis muscles are sometimes lacerated.—(See Case, vol. cit. p. 66.) The head of the bone is thrown between the obturator liga- ment and obturator extemus muscle. The symptoms are as follows: the injured Umb is two inches longer than its fellow, the head of the femur being lower than the acetabulum; the trochanter ma- jor, which is less prominent than natural, is removed to a greater distance from the anterior superior spinous process of the ileum, and the thigh is flattened in con- sequence of the elongation of the muscles. A hard, round tumour, formed by the head of the femur, is felt ut the inner and superior part of the thigh, towards the perinaium. The leg is slightly bent; and, according to Sir A. Cooper's experience, the foot, though widely sepa- rated from the other, is generally turned neither out- wards nor inwards; but he has seen a little variation in this respect in different instances. Hence, he pre- fers as the diagnostic symptoms, the bent position of the body, caused by the psoas and Uiacus muscles being on the stretch; the separated knees; and the increased length of the limb.—(Essays, part 1, p. 37.) The lat- ter symptom alone is a sufficient indication of the case not being a fracture. Dislocations on the obturator foramen are very easy of reduction. The pelvis having been fixed, the exten- sion is to be made downwards and outwards, so as just to dislodge the head of the bone. The muscles then generally draw it into the acetabulum, on the ex- tending force being gradually relaxed, if the upper part of the bone be pidled outwards with a bandage, and the ankle be at the same instant inclined inwards. Thus the limb is used as a lever, with very considerable power. Mr. Hey says, that " in this species of dislocation (downwards and forwards,, as the head of the bone is Vol. I-X situated lower than the acetabulum, it is evident, that an extension made in a right line with the trunk of the body must remove the head of the bone farther from its proper place, and thereby prevent, instead of assisting, reduction. The extension ought to be made with the thigh at a right angle, or inclined somewhat less than a right angle to the trunk of the body. When the exten- sion lias removed the head of the bone from the exter- nal obturator muscle, which covers the great foramen of the os innominatum, the upper part of the os femoris must then be pushed or drawn outwards; which motion will be greatly assisted by moving the lower part of the os femoris, at the same moment, in a contrary direction; and, by a rotatory motion of the bone upon its own axis, turning the head of the bone towards the aceta- bulum."—(.Hey, p. 316.) The ensuing case illustrates Mr. Hey's practice. " Tlie lower bed-post, on the right side of the bed on which the patient lay, was placed in contact with a small immoveable iron pillar (about an inch square in thickness), such as in our wards are used for support- ing the curtain-rods of the beds. A folded blanket be- ing wrapped round the bed-post and pillar, the patient was placed astride of them, with his left thigh close to the post, and his right thigh on the outside of ihe bed. A large piece of flannel was p9t between the blanket and the scrotum, that the latter might not be hurt dur- ing the extension. The patient sat upright with his abdomen in contact with the folded blanket which covered the bed-jiost. He supported Irmself by putting his amis round the post, and an assistant sat behind him to prevent him from receding backwards. He was also supported on each side. Two long towels were put round the lower part of the thigh, after the part had been well defended from excoriation by the application of a flannel roller. The knot which the towels form was made upon the ante- rior part of the thigh, that the motion intended to be given to the leg might not be impeded by the towels. The thigh being placed in a horizontal position, or rather a little elevated, with the leg hanging down at right angles to the thigh, I sat down upon a chair di- rectly fronting the patient, and directed a gentle exten- sion to be made by the assistants standing at my left side. This was done with the view of drawing the head of the bone a little nearer to the middle of the thigh, and the extension had this effect. I then placed the two assistants who held the towels at my right side, by which means the extension would be made in a direction a Uttle inclined to the sound limb. ""Mr. Lo- gan stood on the right side of the patient, 'With lus hands placed on the upper and inner side of tfie thigh, for the purpose of drawing the head of the bone to- wards the acetabulum, when the extension should have removed it sufficiently from the place in which it now lay. I desired the assistants to make the extension slowly and gradually, and to give a signal when it arrived at its greatest degree. At that moment Mr. Logan drew the upper part of the bone outwards, while I pushed the knee inwards, and also gave the os femoris a con- siderable rotatory motion, by pushing the right leg to- wards the left. By these combined motions, the head of the os femoris was directed upwards and outwards, or, in other words, directly towards the acetabulum, into which it entered at our first attempt made in this manner.—(Hey, p. 318.) The thigh-bone is sometimes luxated upwards and forwards on the pubes. The whole limb is turned out- wards, and cannot be rotated inwards: it is shortened by one inch; the trochanter major is nearer the anterior superior spinous process of the ileum than natural; the head of the bone forms a tumour in the groin above the level of Poupart's ligament, on the outer side of the femoral artery and vein, where it can be perceived to move when the thigh-bone itself is moved. By the stretching of the anterior crural nerve, which lies over the neck of the bone (see A. Cooper on Dislocations, p. 95), great pain, numbness, and even paralysis, are liable to be produced. The knee is gene- rally carried backwards. In the account of the position of tbe limb, however, authors vary; and, in opposition to what Boyer has stated, Sir A. Cooper remarks, that there is a slight flexion forwards and outwards.—(Surgical Essays, part 1, p. 45.) The bead of tbe bone felt in the groin, and the i.n- 322 DISLOCATION. possibility of rotating the limb inwards, distinguish this case from a fracture of the neck of the bone. In reducing this dislocation, Sir A. Cooper recom- mends the extension to be made til a Une behind the axis of the body, so as to draw the thigh-bone back- wards j and, when such extension has been continued some time, a napkin is to be put under the upper part of the bone, and its head lifted over the pubes and edge of the acetabulum. The last dislocation of the thigh remaining to be spoken of, is that backwards. In this case, according to the valuable description of it given by Sir A. Cooper, the head of the thigh- bone is placed on the pyriformis muscle, between the edge of the bone which forms the upper part of the isehiatic notch and the sacrosciatic Ugament, being be- hind the acetabulum, and a little above the level of the middle of that cavity. The limb is generally not more than half an inch shorter than its fellow; and the knee and foot are turned inwards, but not nearly in so great a degree as in the dislocation on the dorsum of the ileum. The thigh inclines a little forwards, the knee is slightly bent, and the limb is so fixed that flexion and rotation are in a great measure prevented. Sir A. Cooper considers this dislocation as the most difficult, both to detect and reduce: difficult to detect, because the length of the limb and the position of the knee and foot are but little changed; difficult to re- duce, because the head of the bone is placed deeply behind the acetabulum, and requires to be drawn over the edge of the socket, as well as towards it. In thin subjects, a hard tumour is felt at the posterior and in- ferior part of the buttock, and the great trochanter is removed farther from the spine of the ileum. The pelvis being fixed, the extension is to be made downwards and forwards across the middle of the other thigh, so as to dislodge the head of the bone, while the surgeon, with a napkin placed just below the trochanter minor, pulls the upper part of the femur towards the acetabulum. In this case, pulleys are pre- ferable for making the extension. [CONOEN1TAL DISLOCATION OF THE HIP-JOINT. M. Dupuytren, of Paris, has divided dislocations into three kinds, viz. primitive, consecutive, and con- genital. In the course of eighteen years he has met with twenty cases of the congenital kind, seventeen of which were females. The following extract is made from his work, to which I must refer the reader for much valuable in- formation. " The signs which characterize it are, shortening of the limb; presence of the head of the femur on the dorsum ileum; prominence (saillie) of the trochanter major; retraction of almost all the muscles of the upper part of the thigh towards the crest of the ileum, where they form around the head of the femur a kind of cone, the base towards the os innominatum, the apex towards the trochanter; the almost entire denudation in consequence of the tuber ischii; the rotation of the limb inwards; the obliquity ofthe thigh, proportioned, of course, to the age and developement of the pelvis; the meagreness of the limb, out of all proportion to the trunk and upper extremities, which are really well de- veloped; and the imperfect motions, particularly of ab- duction and rotation. The upper part of the trunk of the persons thus affected is thrown backwards, while the lumbar portion ofthe column projects as much for- wards ; the pelvis is placed almost horizontally on the femurs, and the ball of the foot alone touches the ground. In walking, we observe them incline the body strongly towards the limb which is to support the weight, at which moment the head of the femur of that side is seen distinctly to rise on the dorsum Uei, in con- sequence of the superincumbent weight and sinking of the pelvis, and then they drag painfully forwards the opposite limb, the' head of the femur of which is per- ceived not to rise, but to sink, in consequence of its own weight drawing it down. This series of pheno- mena, then, is repeated each step the patient takes, and although locomotion to him is not so painful as it ap- pears, still he is incapable of making any thing like a long journey. In the recumbent posture, most of the symptoms of the dislocation in a great measure disappear, in conse- quence, no doubt, of the relaxation of the muscles, and removal of tha weight of the trunk. In this posi- tion of the body, the surgeon can, by a slight effort, elongate the limb, and shorten it again ; that ia, he can pull the head of the femur downwards, or press il again upwards to the extent of two, or even three inches, according to circumstances. Let us look to the history of this complaint. Even at birth, the prominence of the haunches, the obliquity of the femurs, mpanum, and certainly he is right in ge- nerally insisting upon the prudence of avoiding such an accident. It will appear, however, in the sequel of this article, that under certain circumstances puncturing the tympanum has been successfully practised, as a mode of remedying deafness. The operation, however, de- mands caution ; for, if done so as to injure the con- nexion of the malleus with the membrana tympani, the hearing must ever afterward be very imperfect. 3. Unusual Smallness of the Meatus Auditorius Externus. Imperforation is not the only congenital imperfection of the meatus auditorius; this passage is occasionally too narrow for the admission of a due quantity of the sonorous undulations, and the sense is of course weak- ened. Leschevin mentions that M. de la Melrie found this canal so narrow in a young person that it could hardly admit a probe. What has been observed con- cerning the imperforation is also applicable to this case. If it depends upon malformation ofthe bone it is mani- festly incurable; but if it is owing to a thickening of the soft parts within the meatus, hopes may be indulged of doing good by gradually dilating the passage with tents, which should be increased in size from time to time, and lastly making the patient wear, for a consi- derable time, a tube adapted to the part in shape.—(Les- chevin in Prix de l'Acad. de Chiiurgie, t. Q,p. 132.) Mr. Earie has published a case in which the diame- ter ofthe meatus auditorius was considerably lessened by a thickening of the surrounding parts, and espe- cially of the cuticle, attended with a discharge from the passage, and great impairment of hearing. A cure was effected by injecting into the passage a very strong so- lution of the nitrate of silver, which in a few days was followed by a detachment of the thickened por- tions of cuticle. This evacuation was assisted by throwing warm water into the passage.—(See Med. Chir. Trans, vol. 10, p. 411, i-c.) Boyer was consulted for a deafness, which arose from a malformation which con- sisted of a flattening of the meatus, its opposite sides being for some extent in contact. The patient was advised to wear in the ear a gold tube of suitable shape by which means he was enabled to hear perfectly well. 4. Faulty Shape of the Meatus Auditorius Externus. Anatomy informs us that this passage is naturally oblique, and somewhat winding ; and natural philoso- phy teaches us the necessity of such obliquity, w hich multiplies the reflections of the sonorous waves, and thereby strengthens the sense. This theory, says Les- chevin is confirmed by experience; for there are per- sons in whom the meatus auditorius is almost straight, and they are found to be hard of hearing. If there is any means of correcting this defect, it must be that of substituting for the natural curvature of the passage a curved and conical tube, which must be placed at the outside of the, organ, just like a hearing trumpet. The acoustic instrument invented by Deckers, winch is much more convenient, might also prove useful.—(Ou. cit. p. 133.) 5. Extraneous Substances, Insects, i-c. in the Meatus Auditorius Externus. Foreign bodies met with in this situation are inert substances which have been introduced by some exter- nal force; insects, which have insinuated themselves into the passage; or the cerumen itself, hardened in such a degree as to obstruct the transmission of the sonoous undulations. Worms which make their ap- pearance in the meatus auditorius are always produced subsequently to ulcerations in the passage, or in the interior of the tympanum, and very often such insects are quite unsuspected causes of particular symptoms. In the cases of surgery published in 1778 by Acrel, there is an instance confirming the statement just of- fered It is the case of a woman who, having been long afflicted with a hardness of hearing, was suddenly seized with violent convulsions without any apparent cause, and soon afterward complained of an acute pain in the ear. This affection was followed by a re- currence of convulsions, which were still more vehe- ment. A small tent of fine linen moistened with a mix- ture of oil and laudanum, was introduced into the men- EAR. 333 tus auditorius, and on removing it the next day several small round worms were observed upon it, and from that period all the symptoms disappeared. To this case we shall add another from Morgagni. A young woman consulted Valsalva, and told him that when she was a girl a worm had been discharged from her left ear; that another one about six months ago had also been discharged very much like a small silkworm in shape. This event took place after very acute pain in the same ear, the forehead, and temples. She added, that since this she had been tormented with the same pains at dif- ferent intervals, and so severely that she often swooned away for two hours together. On recovering from this state, a small worm was discharged, of the same shape as, but much smaller than the preceding one, and she was now afflicted with deafness and insensibiltiy on the same side. After hearing this relation Valsalva no longer entertained any doubt of the membrane ofthe tympanum being uicerated. He proposed the employ- ment of an injection in order to destroy such worms as yet remained. For this purpose distilled water of St. John's wort, in which mercury had been agitated, was used. In order to prevent a recurrence of the incon- venience, Morgagni recommends the affected ear to be closed up when the patient goes to sleep, in autumn and summer. If this be not done, flies, attracted by the suppuration, enter the meatus auditorius, and while the patient is unconscious deposite their eggs in the ear. Acrel, in speaking of worms generated in the meatus auditorius, observes, that there is no better re- medy for them than the decoction of ledum palus- tra injected into the ear several times a day. How- ever, as this plant cannot always be procured, an in- fusion of tobacco in oU of almonds may be used, a few drops of which are to be introduced into the ear and retained there by means of a little bit of cotton. This application, which is not injurious to the lining of the passage, is fatal to insects, and especially to worms. When caterpillars, ants, earwigs, and other insects, have insinuated themselves into the meatus auditorius, they may be removed with apiece of lint smeared with honey; and when they cannot be extract- ed by this simple means, they may sometimes be taken out with a small pairof forceps. In general, however, the most safe and expeditious practice for the removal of small insects, peas, beads, and other extraneous bodies from the meatus auditorius, is to throw tepid water into the passage with a proper syringe, by which means they are forced out with the fluid. When the bead or globular substance is small (according to Mr. Buchanan), the best mode of extraction will be by means of a syringe and injection of tepid water. For this purpose the point of the syringe .ought to be pressed gently against the edge of the meatus, so that it may occupy as little of the diameter of the tube as possible, and when the injection arrives at the mem- brana tympani, the regurgitation will force the bead or other substance outwards. If this be rather large, it may perhaps remain at the entrance of the meatus, whence it ought to be extracted by means of a pair of forceps.--(See Buchanan's Illustrations of Acoustic Surgery, p. 40.) A few days ago (May, 1829) I was called to a child about two years and a half old, into one of whose ears a pebble, and into the other a French bean, had been pushed by another child, and remained there for ten months, causing complete deafness and extreme suffer- ing. By throwing tepid water forcibly into the ear, I soon dislodged these foreign bodies, which lay close against the tympanum, entirely hidden by the swollen state ofthe lining of the ear, indurated wax and dried discharge. With a bent probe their extraction was Ihen readily effected. Several surgeons, previously consulted, had failed in their endeavours to remove the substances by other methods. The presence of foreign bodies in the ear often occa- sions the most extraordinary symptoms, as we may sec in the fourth observation of Fabricius HUdanus, Cent. 13 After four surgeons, who had been succes- sively consulted, had in vain exerted all their industry to extract a bit of glass from the left ear of a young girl, the patient found herself abandoned to the most excruciating pain, which soon extended to all the side r>f the head, and which, after a considerable time, was followed by a paralysis of the left side, a dry cough, suppression of the menses, epileptic convulsions, and at length an atrophy of the left arm HUdanus cured her by extracting the piece of glass which had re- mained eight years in her ear, and had been the cause of all this disorder. Although the extraction must have been very difficult, it does not appear that HUda- nus found it necessary to practise an incision behind the ear, as some authors have advised, and among them Duverney, who has quoted the foregoing case. We must agree with Leschevin that such an incision does not seem likely to facilitate the object very ma- terially ; for it must be on the outside of the extrane- ous substance, which is in the bony part of the canal. The incision enables us in some measure to avoid the obliquity of the passage, as Duverney has observed; but it is not such obliquity of the cartilaginous portion of the canal that can be a great impediment; for as it js flexible it may easily be made straight by drawing the external ear upwards. Hence Fabricius ab Aqua- pendent e rejected this operation first proposed by Pau- lus jEgineta; and it is justly disapproved of by Lesche- vin —(Prix de l'Acad. de Chir. t. 9, p. 147, idit. 12mo.) Sabatier relates a case in which a paper ball, which had been pushed into the meatus auditorius, made its way by ulceration into the cavity of ihe tympanum, where an abscess formed, which communicated with the interior of the cranium.—'Did. des Sciences Mid. t.7,p.S.) 6. Meatus Auditorius obstructed with thickened or hardened Cerumen. The cerumen secreted in the meatus auditorius by the sebae- ECTROPIUM. 341 lid, as alroady explained, so as to produce a loss of sub- stance on the inside of the everted eyelid. In invete- rate cases of ectropium, in which the fining of the eyelids has become hard and callous, Scarpa applies to the everted eyelid, for a few days before tlie operation, a soft bread-and-milk poultice, in order to render the part flexible, and more easily separated than it could be in its former rigid state. The division of the cicatrices which have given rise lo the shortening and eversion of the eyelid, as Scarpa observes, does not procure any permanent elongation of this part, and consequently it is of no avail in the cure ofthe present disease. We see the same circum- stance occur after deep and extensive burns ofthe skin of the palm of the hand and fingers: whatever pains may have been taken, during the treatment, to keep the hand and fingers extended, no sooner is the cicatriza- tion thus completed, than the fingers become irremedi- ably bent. The same thing happens after extensive burns of the skin of the face and neck. Fabricius ab Aquapendente, who weU knew the inutility of making a semilunar cut in the skin of the eyelids, for the purpose of remedying their shortness and eversion, proposes, as the best expedient, to stretch them with adhesive plas- ters, applied to them and the eyebrow, and tied .closely together. Whatever advantage may result from this practice, ihe same degree of benefit may be derived from using, for a few days, a bread-and-milk poultice, after- ward oily embrocations, and lastly, the uniting band- age, so put on as to stretch the shortened eyelid in an opposite direction to that produced by the cicatrix; a practice which Scarpa thinks should always be care- fully tried before the operation is determined upon. The surgeon, with a small convex-edged bistoury, is to make an incision of sufficient depth into the internal membrane of the eyelid, along the tarsus, carefully avoiding tbe situation of the puncta lachrymalia. Then with a pair of forceps he should raise the flap ofthe di- vided fungous membrane, and continue to detach it with the bistoury from the subjacent parts all over the inner surface of the eyelid, as far as where the membrane quits this part, to be reflected over the front of the eye, under the name of conjunctiva. The separation being thus far accomplished, the membrane is to be raised still more with the forceps, and cut off with one or two Strokes of the scissors, at the lowest part of the eyelid. The compresses and bandage, to keep the eyelid replaced, are to be applied as above directed. On changing the dressings, a day or two after the operation, the eyeUd wUl be found, in a great measure, replaced, and the dis- figurement which the disease caused greatly amended. The operation is rarely followed by bad symptoms, such as vomiting, violent pain, and inflammation. However, should they occur, the vomiting may be re- lieved by means of an opiate clyster; and as for the pain and inflammation, attended with a great tumefac- tion ofthe eyelid operated upon, these complaints may be cured by applying a poultice, or bags filled with emollient herbs, at the same time applying internal an- tiphlogisties, untU the inflammation and swelling have subsided, and suppuration has commenced on the in- side of the eyelid ou which the operation has been done. After this the treatment is to consist in washing the part twice a day with barley-water and confect. rosae, and lastly, in touching the wound a few times with the argentum nitratum, in order to keep the granulations within certain limits, and to form a permanent cicatrix, proper for maintaining the eyelid replaced.—(Scarpa sulle Mallattie degli Occhi.) In cases in which the eversion is considerable, Sir W. Adams has never found the simple incision of the fungus, as practised by Scarpa, sufficient to effect a ra- dical cure, and he therefore tried a new mode of opera- ting. In his first attempts, he employed a very small curved bistoury ,the point of which he carried ^long the inside of the eyelid, at its outer angle, downwards and outwards, as far as the point of reflection of the con- junctiva would admit. He then pushed it through the whole substance of the everted eyetid and its integu- ments, and cut upwards through ihe tarsus, making an incision nearly half au inch in length. With a curved pair of scissors, he next snipped off apiece of the edge of the tarsus, about one-third of an inch iii width, and lie afterward removed \\ ith the same instrument the whole of the diseased conjunctiva. When the bleeding bad ceased. Sir W. Adams passed a needle and ligature tliruu^ti itu whole substance of the two divide por- tions, and brought them as accurately into contact as possible. Finding, however, that too much integument had been left at the lower part rf the incision, he cm- ployed in future operations, instead of the scalpel, a pair of straight scissors, with which he cut out an an- gular piece of the lid, resembling the letter V. Latterly Sir W. Adams has found it advantageous to leave about a quarter of an inch of the lid adjoining its external angle, and after shortening the part as much as neces- sary he brings the edges of the incision together with a suture.—(See Practical Observations on the Ectropium, i-c. p. 4 and 5, Lond. 1812.) On the subject of the foregoing proposal, M. Roux observes, " What Sir W. Adams says, with a view of enhancing the value of his own method, about the fre- quent recurrence of ectropium, when the conjunctiva is simply cut out, is a gratuitous assertion, contradicted by experience. I have already in a very great number of cases undertaken the cure of ectropium in the com- mon way: the operation always succeeded as much as the degree or other circumstances of the disease allowed; and I have not yet observed an instance of a relapse."—(Voyage fait a Londres en 1814, ou Parallile de la Chirurgie Angloise avec la Chirurgie Francoise, p. 291.) If this new operation, however, will cure the ectropium, caused by the contraction of cicatrices, as its inventor describes, or produce great improvement, as the experience of Mr. Travers confirms (Synopsis of the Diseases of the Eye, p. 235), it is clear that though it may not be necessary in ordinary cases, its usefulness will not be entirely lost. Mr. Guthrie acknowledges that it may be highly useful in the ectropium from the contraction of a cicatrix.—(On the Operative Surgery of the Eye, p. 71.) The contracted scar must of course be divided, in addition to the other proceedings. In the form of ectropium described by Mr. Guthrie as arising from a hardened and contracted state of the integuments of the eye, but without any cicatrix, he observes that the indications are, 1st, to relieve the contraction of the skin externally; 2dly, to restore and retain the eyelid in its proper situation, until the unna- tural curvature of the cartilage has been overcome, and the chronic inflammation removed. For fulfilling the first indication he recommends washing the external parts with warm water, so as to leave the skin as clean as possible. It is then to be carefully dried, and re- peatedly anointed with the ung. zioci, for three or four days. Being thus protected from the irritation, it be- comes softer, and in a favourable state to yield to mild extension. For accomplishing the second indication, Mr. Guthrie applies the sulphuric acid : the eyelid having been cleansed so as to prevent its slipping, the conjunctiva is to be gently wiped dry and everted as much as possible, so that the part where it begins to be reflected over the eyeball may be seen. An assistant is to raise the upper eyelid a little, and the patient to look upwards. The blunt end of a common silver probe is then to be dipped in the sulphuric acid and rubbed over the conjunctiva, so that every part of it may be touched with the acid. The round point of the probe is to be carried as far as where the membrane begins to be re- flected over the eyeball, but no farther. The punctum lachrymale, caruncle, and semilunar fold are to be avoided ; but the external angle, as well as every other part, except what is reflected over the eye, is to be care- fully rubbed. The acid will turn the touched portion of the conjunctiva white; and in order to prevent ihe acid from affecting the eyeball, a stream of water is now to be directed over the eyelid with an elastic gum syringe. If the conjunctiva should not be turned suffi- ciently white, its application may be repeated. The use of the acid is to be repeated every fourth day; •' and when applied in the manner directed it does not cause a slough, but a general contraction of the part, which is, however, only perceptible after two or three applications, by its ef- fect in inverting the lid, which gradually begins to take place. After six or eight applications, the cure will be more than half accomplished, and in most cases of this species of eversion, the thickening of the con- junctiva will have subsided." The ung. zinci is to be constantly applied to the skin, and the ung. hydrarg. nitr. in the proportion of one part to four or six of the ung. cetacei, to the edge of the eyelid. Alter the eye- lid has returned two-thirds of the way towards its na- tural position, the intervals between the applications of the acid must be longer, lest the contraction within 1 iht •yeUJ be carried too far, and an inversion *n itp.-o- 342 EMB EMP duced.* After the eversion is cured, the lippitudo may yet partly remain, and demand the use of the ung. hy- drarg. nitr. or other gentle stimulants.—(See Scarpa's Osservazioni sulle Malattie degh Occhi; ed. 5, cap. 6. Richter's Anfangsgr. der Wundarzneykunst, b. 2, p. 473, Sc. Wenzel's Manuel de I'Oculiste. Pellier, Re- cueil d'Obs. sur les Maladies des Yeux. Sir W. Adams Pract. Observ. on Ectropium, or Eversion of the Eye- lids, with a Description of a new Operation for the Cure of that Disease; on the modes of forming an artificial Pupil; and on Cataract, 8vo. Lond. 1812. M. Bordenave, Mimoire dans lequel on propose un nouveau ProciiU pour traiter le Renversement des Paupiires, in Mem. de l'Acad. Royale de Chirurgie, t. 13, p. 156, el seq. edit. 12mo. It was in this memoir, that the proposal of removing a portion of the inside of the eyelid for the cure of ectropium was first made. Here may also be found the best historical account of the different methods of treatment, which have prevailed from the earliest periods of surgery. Consult also Parallile de la Chirurgie Angloise avec la Chirurgie Francoise, par P. J. Roux, p. 289—292, Paris, 1815. G. J. Beer, Lehre von den Augenkrankheiten, b. 2, p. 133, ire 8vo. Wien, 1817. Ben'. Travers, Synopsis of the Diseases of tlie Eye, p. 234. 356, i-c. Svo. Lond. 1820. Demours, Traiti des Mai. des Yeux, p. 98. G. J. Guthrie, Lectures on the Operative Surgery of the Eye, Svo. Lond. 1823.) ECZEMA, or Ecze'sma (from tK~\ij>, to boil out), is characterized by an eruption of small vesicles on va- rious parts of the skin, usually close or crowded together, with little or no inflammation round their bases, and unattended by fever. It is not contagious. —(Bateman's Synopsis, p. 250, ed. 3.) There are se- veral varieties of this disease, the most remarkable of which is the eczema rubrum from the irritation of mer- cury. This form is attended with quickened pulse and a white tongue; but the stomach and sensorium are not materially disturbed.—(See Mercury.) EFFUSION, in surgery, means the escape of any fluid out of tlie vessel or viscus naturally containing it, and its lodgement in another cavity in the cellular substance, or in the substance of parts. Thus, when the chest is wounded, blood is sometimes effused from the vessels into the cavity of the pleura; in cases of false aneurisms, the blood passes out of the artery into the interstices of the cellular substance ; in cases of fistula? in perinseo, the urine flows from the bladder and urethra into the cellular membrane of the perina?um and scrotum; and when great violence is applied to the skull, blood is often effused even in the very substance of the brain. Effusion also sometimes signifies the natural secre- tion of fluids from the vessels; thus surgeons fre- quently speak of the coagulable lymph being effused on different surfaces.—(See Extravasation.) ELECTRICITY. Among the aids of surgery, elec- tricity once held a conspicuous and important situation. It has, however, met with a fate not unusual with reme- dies too much cried up and too indiscriminately em- ployed ; that of having fallen into an undeserved degree of negleet. Whatever its effects may be on the system, it cer- tainly possesses this advantage over other topical reme- dies, that it may be made to act on parts very remote from the surfaee. Electricity, as a topical remedy for surgical diseases, is chiefly used in amaurosis, deafness, some chronic tumours and abscesses, weakness from sprains, or con- tusions, paralysis, 3.) Were a part of a diseased rib to admit of being sawed away, Mr. Hey's convex siw would be a more proper instrument for the purpose than a trepan. An abscess ofthe preceding kind may be so situated, and attended with such a pulsation, as greatly to re- semble an aneurism of the origin of the aorta. An in- teresting case of this description is detailed by Pelletan (Clinique Chir. t. 3, p. 254); and another was seen by Baron Boyer (Traite des Mai. Chir. t. 7, p. 333). When the surface of the lungs and that of the pleura costalis have become adherent to each other, in the situation of the abscess, so as to constitute what is termed encysted empyema, the pus, disposed by a law of nature to make its way to the surface of the body, generally occasions ulceration of the intercostal mus- cles, and collects on the outside of them. An abscess of this kind comes on with a deep-seated pain in the part affected; an cedematous swelling, which retains the impression of the finger; and a fluctuation, which is at first not very distinct, but from day to day be- comes more and more palpable; and al length leads the surgeon to make an opening. If this be not done when the fluctuation becomes perceptible, the abscess may possibly insinuate itself into the cavity of the pleura, in consequence of the ad- hesion being in part destroyed by ulceration. Sabatier affirms that the case may take this course, even when the abscess has been punctured, and while a free ex- ternal opening exists; and this experienced surgeon has adduced a fact in confirmation of such an occur- rence.—(See Midecine Opiratoire, torn. 2, p. 249.) In a few instances, the surface ofthe lung ulcerates, and the matter is voided from the trachea. But in the majority of examples, the pus makes its way outwards through the pleura costalis. If inflammation occurs in the anterior mediastinum, and ends in suppuration, the abscess ma,v possibly burst into neither of the cavities of the chest, but make its way outwards, after render- ing the sternum carious, as happened in the example recorded by Van Swieten.—(Comment on Boerhaave's 895«A Aphorism.) But though collections of matter in the anterior me- diastinum are influenced by the general law, whereby abscesses in general tend to the surface of the body, and though it be true that they rarely burst inwardly into the cavity of the pleura, the contrary may happen, as is proved by the 9th case in La Martinie'res's me- moir on the operation of trepanning the sternum. Here the event wna the more extraordinary, as there was already an external opening in the abscess. External injuries, such as the perforation of the ster- num with a sword (Vanderwel, Obs. 29, Cent. 1), a contusion, a fracture, or a caries of this bone may give rise to an abscess in the anterior mediastinum, (.alen has recorded a memorable example, where the abscess was the consequence of a wound ofthe fore part ofthe chest. After the injury, which was in the region of the sternum, seemed quite well, an abscess formed in the same situation, and being opened healed up. The part, however, soon inflamed and suppurated again. Tbe abscess could not now be cured. A consultation was held, at which Galen attended. As the sternum was obviously carious, and the pulsation of the heart was visible, every one was afraid of undertaking the treatment of the case, since it was conceived that it EMPYEMA. 347 would be necessary to open the thorax itself. Galen, however, engaged to manage the treatment, without making any sach opening,and he expressed his opinion that he should be able to effect a cure. Not finding the bones so extensively diseased as was apprehended, he even indulged considerable hopes of success. After the removal of a portion of the bone, the heart was quite exposed (as is alleged), by reason of the pericardium having been destroyed by the previous disease. After Ihe operation, the patient experienced a speedy recovery. J.J.. Petit met with an abscess in the anterior me- diastinum, in consequence of a gun-shot wound in the situation of the sternum. The injury had been merely dressed with some digestive application; no di- latation, nor any particular examination of the wound had been made. The patient, after being to all ap- pearance quite well, and joining h's regiment again, was soon taken ill with irregular shiverings, and other febrile symptoms. Petit probed the wound, and found the bone affected. As there was a difficulty of breath- ing, he suspected an abneess either in the diploe or be- behind the sternum; and, consequently, he proposed laying the bone bare and applying the trepan. The operation gave vent to some sanious matter; and as soon as the inner part of the sternum was perforated, a quantity of pus was discharged. The patient was relieved, and afterward recovered.—(Petit, Traiti des Mai. Chir. LI, p. 80.) Another instance, ill which an abscess behind the sternum was cured by making a perforation in that bone opposite the lower part of the cavity in which the matter collected, is recorded by De la MartinUre.— (Mim. de PAcad. de Chir. t. 12, idit. 12mo.) When, in consequence of inflammation, an abscess forms deeply in the substance of tho lungs, the pus more easily makes its way into the air-cells, and tends towards the bronchia?, than towards the surface of the ungs. In this case the patient spits up purulent mat- ter. When the opening by which the abscess has burst internally is large, and the pus escapes from it in con- siderable quantity at a time, the patient is in some dan- ger of being suffocated. However, if the opening be not immoderately large, and the pus which is effused be not too copious, a recovery may ensue. Abscesses in the substance of the diaphragm, and collections of matter in the liver may also be discharged by the pus being coughed up from the trachea, when the parts af- fected become connected with the lungs by adhesions, and the abscesses of the liver are situated on its con- vex surface. When the collection of matter in the liver occupies any other situation, the abscess fre- Suently makes its way into the colon, and the pus is ischarged with the stools. Several cases of this kind are related by authors; Sabatier has recorded two in his M dicine Operatoire, Le Dran makes mention of others, and l'embcrton, in his book on the Diseases of the Abdominal Viscera, p. 36, relates additional in- stances of a similar nature. I shall now proceed to the consideration of empyema strictly so called. Sometimes it is a consequence of a penetrating wound of the chest; occasionally it pro- ceeds from the bursting of one or more vomica?; in a few examples it arises from the particular way in which abscesses of the liver burst (Journ. de Mid. t. 3, p. 47; Mirgagni, epist. 30, art. 4;) but in the greater number of instances it originates from pleuritic inflammation, especially that ofthe chronic kind.—(Boyer, Traiti des Mai. Chir. t. 7, p. 352.) Empyema very rarely takes place in both sides of the chest, but is almost always limited to one cavity of I'.'e pleura. According to Baron Boyer, when empyema arises from thoracic inflammation, pleuritis, or pneumonia, the symptoms characterizing it are always preceded by those of the disease, of which the effusion of pus upon the diaphragm is the effect. Inquiry must, therefore, b,' made whether the patient has pleurisy or peripneu- mony, the symptoms of which have lasted longer than a fortnight; and whether, after a transient amendment, there have been frequent shiverings, followed by a low, rontiuued fever, with nightly exacerbations. Now| these first circumstances justify the belief, that the in- rUmniatory disorder has terminated in suppuration, and tbit the symptoms afterward experienced depend upon effusion of matter in ihe chest. Some of these arise from the mechanical action of the pus upon the Inng-t, heart, and parietes of the chest, and belong also to other effusions in the thorax; the rest may be said to be the effects of ulceration and suppuration of the parts on the animal economy, and, therefore, parti- cularly belong to empyema. First, of the common symptoms, respiration is diffi- cult, sbort, and frequent; the patient suffere great op- pression, and experiences a sense of suffocation, and of weight upon the diaphragm. He cannot move about, even for a short time, without being quite out of breath, and threatened with syncope. He has an almost in- cessant and very fatiguing cough, which is sometimes drv, sometimes attended with expectoration.—(Boyer, Traite des Mai Chir. t. 7, p. 356.) No surgical writer with whom I am acquainted has treated with more discrimination than Mr. Samuel Sharp, of the symptoms produced by collections of matter in the chest. He remarks, that it has been al- most universally taught, that when a fluid is extrava- sated in the thorax, the patient can only lie on the dis- eased side, the weight of the incumbent fluid on the mediastinum becoming troublesome; if he places him- self on the sound side. For the same reason, when there is fluid in both cavities of the thorax, the patient finds it most easy to lie on his back, or to lean for wards, in order that the fluid may neither press upon the mediastinum nor the diaphragm. But it is noticed by Mr. Sharp, that however true this doctrine may prove in most instances, there are a few in which, not- withstanding the extravasation, the patient does not complain of more inconvenience in one posture than another, nor even of any great difficulty of breathing. - -(See Le Dean's Obs. 217, and Marchetti, 65.) On this account, observes Mr. Sharp, it is sometimes less easy to determine when the operation is requisite, than if we had so exact a criterion as we arc generally supposed to have. But, says he, though this may be wanting, there are some other circumstances which will generally guide us with a reasonable certainty. He states, that the most infallible symptom of a large quantity of fluid in one of the cavities of the thorax, is a preternatural expansion of that side of the chest where it lies; for, in proportion as the fluid accumu lates, it will necessarily elevate the ribs on that side, and prevent them from contracting so much in expira- tion as the ribs on the other side. This change is said to be most evident when the surgeon views the back of the chest.—(Boyer, vol. cit. p. 357.) Mr. Sharp also re- fers to Le Dran's Obs. 211, vol. 1, in order to prove that the pressure of the fluid on the lungs may sometimes be so great, as to make them collapse, and almost totally obstruct their function. When, therefore, says Mr. Sharp, the thorax becomes thus expanded after a pre- vious pulmonary disorder, and the case is attended with the symptoms of a suppuration, it is probably owing to a collection of matter. The patient, he observes, will also labour under a continual low fever, and a particular anxiety from the load of flu-id. Besides this dilatation ofthe cavity by an accumula tion of the fluid, the patient will be sensible of an un- dulation, which is sometimes so evident, that a by standcr can plainly hear it in certain motions of the body. Mr. Sharp adds, that this was the case with a patient of his own, on whom he performed the opera- tion ; but the fluid in this instance, he says, was very thin, being a serous matter rather than pus. Some- times, when the practitioner applies his ear close to the patient's chest, while this is agitated a noise can be heard like that produced by shaking a small cask not quite ftill of water.—(See Dr. Archer's Caset in Trans. of the Fellows, i-c. of the King's and Queerl's College of Physicians in Ireland, vol. 2, p. 2.) In this instance the fluid resembled whey. According to the same author it will also frequently happen, that though the skin and intercostal muscles are not inflamed, they will become cedematous in certain parts ofthe thorax: or, if they are not cedematous, they will be a little thickened ; or, as Boyer states, the inter- costal spaces are widened, and, when the empyema is considerable, instead of being depressed, as they are in thin persons, they project beyond the level of the ribs. —(Mai. Chir. t. 7, p. 357.) These symptoms, joined with the enlargement of the thorax, and the preceding affection of the pleu ra or lungs, «eem unquestionably to indicate the propriety of the operation. But, observes Mr. Sharp, among other motives to recommend it upon such an emergency, this is one, that if the operator should mistake the case, an incision of the intercostal muscles would neither be very painful nor dangerous.—(See 348 EMPYEMA. Critical Inquiry into the Present State of Surgery, sect, on Empyema.) " The difficulty of lying on the side opposite to the collection of pus," says Le Dran, " is always accounted a sign of an empyema. This sign, indeed, is in the af- firmative ; but the want of it does not prove the nega- tive ; because, when there is adhesion of the lungs to the mediastinum, the patient may lie equally on both sides."—(Le Dran's Obs. p. 108, edit. 2.) The expla- nation of this circumstance offered by Le Dran is, that when the cyst, in which the matter is contained, is between the mediastinum and the lungs, the medias- tinum gradually yields to the volume of the pus in proportion as it is formed, and the cyst in which it is contained becomes dilated; " whence habitude becomes a second nature." Whereas, in an empyemal person, in whom the lung is not adherent to the mediastinum, and who lies on the side opposite to that on which the collection of pus is situated, the mediastinum is on a sudden loaded with an unusual weight of fluid.—(P. 111.) Richerand contends, that the difficulty of breathing which patients with extravasated fluid in the chest ex- perience in lying upon the side opposite to that on which the disease is situated, never originates, as has been commonly taught and believed, from the fluid pressing upon the mediastinum and opposite lung. " I have (says he) produced artificial cases of hydro- thorax, by injecting water into the thorax of several dead subjects, through a wound made in the side. This experiment can only be made on subjects in which the lungs are not adherent to the parietes of the chest. In this way from three to four pints of water were in- troduced. I then cautiously opened the opposite side of the chest; the ribs and lungs being removed, the mediastinum could be distinctly seen, reaching from the vertebra? to the sternum, and supporting, without yield- ing, the weight of the liquid, in whatever position the body was placed. It is evident, then, that patients with thoracic extra- vasations lie on the diseased side, in order not to ob- struct the dilatation ofthe sound side of the respiratory organs, one part of which is already in a state of inac- tion. It is for the same reason, and in order not to in- crease the pain by the tension of the inflamed pleura, that pleuritic patients lie'on the diseased side. The same thing is observable in peripneumony; in a word, in all affections of the parietes of the chest.—(Riche- rand, Nosogr. Chir. t. 4, p. 168, 169, edit. 2.) It appears to me, that there may be some truth in the foregoing statement; but ihe experiments are far from being conclusive with respect to the assertion, that in cases of empyema, hydrothorax, Lthre von den Augenkr. b. 2, p. 187, 188.) This form 350 ENC ENE of encanthis only admits of palliative treatment; un- less, indeed, an effort be made to extirpate it entirely, together with the whole of what is contained in the orbit, and even then the event is dubious. Beer joins Scarpa in the statement that the opera- tion rarely proves successful, and adds, that it is al- ways followed by an incurable weeping, and a con- siderable eversion of the lower eyelid.—(Vol. cit. p. 189.) Fortunately, the truly cancerous encanthis is uncommon; Mr. Guthrie has not seen it (Operative Surgery of the Eye, p. 117); and Mr. Travers, who was a surgeon to the London Eye Infirmary several years, never met with an instance of it.—(Synopsis of Diseases of the Eye, p. 103.) The benign encanthis, how large soever it may be, is always curable by extirpation. Those instances which are small, incipient,-and granulated, like a mulberry, or of a fringed structure, which originate either from the caruncula lachrymalis, or the semilunar fold ofthe conjunctiva, or from both these parts together, and even in part from the internal commissure of the eye- lids, may be raised by means of a pair of forceps, and cut off from the whole of their origin closely to their base, with the curved scissors with convex edges. In the performance of this operation, it is unnecessary to introduce a needle and thread through this little ex- crescence, as some are wont to do, for the purpose of raising it, and destroying more accurately all its ori- gins and adhesions. The same object is fulfilled by means of forceps, without inconveniencing the patient with a puncture of this kind, and drawing a thread through the part in order to make a noose. However, tin cutting out an encanthis of this small size, care should be taken not to remove, together with that por- tion of the excrescence which originates from the ca- runcula lachrymalis, any more of this latter body than what is absolutely necessary for the precise eradica- tion of the disease, in order that no irremediable weep- ing may be occasioned. When the little excresence has been detached from all its roots, says Scarpa, the eye must be washed se- veral times with cold water, in order to cleanse it from the blood, and then it is to be covered with a piece of fine linen, and a retentive bandage. On the 5th, 6th, or 7th day, the inflammation arising from the operation entirely ceases, and the suppuration from the wound is accompanied with the mucous appearance already described. The little wounds are then to be touched with a piece of alum, scraped to a point like a crayon, and the vitriolic collyrium, containing the mucilage of quince seeds, is to be injected into the affected eye several times a day. If these means should not bring about the wished-for cicatrization, but, on the contrary, the small wounds situated on the caruncula and inter- nal commissure of the eyelids should become station- ary and covered with proud flesh, the argentum nitra- tum ought to be applied to them. The conjunctiva, however, should be avoided as much as possible, espe- cially if at all wounded. When the fungous granula- tions have been destroyed, the cure may be perfected by the collyrium already mentioned, or rather by intro- ducing thrice a day, between the eyeball and the inter- nal angle ofthe eyelids, the powder of tutty and the Armenian bole. Bidioo recommends powdered chalk, either alone or in conjunction with burnt aium.—(Ex- ercit. Anat. Chir. decad. 2.) Excision is equally applicable to the inveterate en- canthis, which is of considerable size, and broken down at iis body, or which forms a prominence as large as a nut or chestnut, with two fleshy-append- ages extending along the inner surface of one or both eyelids. The application of a ligature to such an ex- crescence ought never to be regarded as a method of cure; for the large inveterate encanthis never has a sufficiently narrow neck to admit of being tied. On the contrary', when the tumour is voluminous, its roots invariably extend to the caruncula lachrymalis, the semilunar fold, and the conjunctiva covering the eye- ball, oftentimes nearly as far as the comea. In this state also, the encanthis has one or two fleshy append- ages, which reach along the membranous lining of one or both eyelids. Hence, though the ligature were to produce a separation of the body of the encanthis, one or both the appendages would still remain to be ex- tirpated. This second operation could only be accom- plished with the knife. In this disease, there is no foundation for the fear of hemorrhage, to which tha advocates for the ligature attach so much import ance; for cases are recorded of considerable inve- terate encanthes being removed, without the least untoward occurrence from loss of blood. To these, Scarpa observes, he could add a great number of his own, so that no doubt can now be entertained on this point. Pellier relates a case, in which an encanthis wns followed by a dangerous hemorrhage, though it had been cut out by an expert oculist. He enters, however, into no detail concerning the nature of the complaint, nor the way in which the operation was performed; circumstances from which one might deduce the reason of this unusual accident. Indeed, the same aathor adds, " I have often performed this operation for such ex- crescences, and have never met with a similar occur- rence."— (Recueil d'Observ. sur les Maladies de Pd.il part 2, obs. 118.) When the encanthis is large and inveterate, with two extensive fleshy elongations, one on the inside of the upper eyelid, and Ihe other on that of the lower one, we are to proceed in the following manner. The patient being seated, an assistant is to turn out the inside of the upper eyelid, so as to make one of the appendages of the encanthis project outwards. By means of a small bistoury, a deep incision is next to be made into the elongation, in the direction of the margin of the eyelid; and then having taken hold of and drawn it forwards with a pair of forceps, we are to separate it throughout its whole length, from the inside of tha upper eyelid, proceeding from the external towards the internal angle of the eye, as far as the body or middle of the encanthis. We are then to do the same to the lippomatous appendage on the inside of the lower eye- lid. Afterward the body ofthe encanthis is to be ele- vated, if possible, with a pair of forceps; but when this instrument will not answer the purpose, a double hook must be employed. This middle portion is now to be detached, partly with the bistoury, and partly with the curved scissors, from the subjacent conjunctiva, on the globe of the eye, from the semilunar fold, and from the caruncula lachrymalis; dividing the substance of this last part more or less deeply, according to the depth and hardness of the large inveterate encanthis. Here it is proper to state distinctly, that when we have to deal with an old large tumour of this nature, deeply rooted in the caruncula lachrymalis, it is not regularly in our power to preserve a sufficient quantity of the substance of this part, to prevent the tears from drop- ping over the cheek after the wound is healed. The eye is to be repeatedly washed with cold water. The rest of the treatment consequent to the extirpa tion of a large encanthis, is almost the same as what was explained in speaking of the small incipient case. Bathing the eye very frequently in the lotion of mal- lows, and employing anodyne, detergent collyria, are the best local means, until the mucous appearance, preceding suppuration, has taken place on the surface of the wound. Then we may have recourse to mild astringent ointments and collyria. Tlie mildest topical npplications are generally the best, both in the first stage of suppuration, as well as afterward, parti- cularly when, together with the encanthis, we have removed a considerable piece ofthe conjunctiva which covered the eyeball towards the nose, and was inti- mately connected with the body ofthe excrescence. Consult Scarpa sulle Malattie degli Occhi, ed. It, cap. 12; Richter, Anfangsgr. der Wundarzn. band 2, p. 473, ic. edit. 1802. G. J. Beer, Lehre von den Au- genkr. b. 2, p. 187, Svo. Wien, 1817. B Travers, A Synopsis ofthe Diseases of the Eye. p. 103, ic. G. T. Guthrie, Lectures on the Operative Surgery ofthe Eye, 8vo. Lond. 1823, p. 117, i-c. ENCEPHALOCELE. (From h/Ki tion, venesection will be proper; and it may be neces- sary to bleed largely, to repeat the evacuation, or to fol- low venesection by local abstraction of blood. Under such circumstances, the other parts of the antiphlogistic plan must also be employed; that is, the aUmentary ca- nal should be cleared by an active purgative, which may be followed by salines and antimonials, with the occa- sional use of milder aperients, and low diet should be enjoined. As Mr. Lawrence adds, nothing can be more different from such a case, than that of an elderly per- son, with a small and feeble pulse, in the advanced stage of the disease. The interval between these ex- tremes is filled by numerous gradations, requiring cor- responding modifications of treatment. The antiphlo- gistic plan itself embraces a wider range in point of degree; from blood-letting, local and general, with purging, vomiting, the free use of mercury and antimo- ny, and low diet, to the exhibition of a mild aperient, with some saline medicine. Mr. Lawrence believes, that the treatment of erysipelas, like that of any other inflammation, should be modified according to the age, constitution, previous health, and habits ofthe patient, and the period of the complaint. " In asserting gene- rally that the antiphlogistic treatment is proper, I speak (says he) of the beginning of the disease, when the original and proper character of the affection is appa- rent ; and I am decidedly of opinion that, in some shape or degree, such treatment will always be beneficial in that stage. In many instances, active antiphlogistic measures are of the greatest service in lessening the severity both of the local and general symptoms. In others, the administration of calomel with aperients, and of diaphoretics with low diet, will he sufficient. When the affection occurs in old and debilitated subjects, the powers of life are soon seriously Unpaired, and our efforts must be directed rather towards supporting them, than combating the local affection. I have often seen such subjects labouring under erysipelas of the face in its ad- vanced stage, with rapid and feeble pulse, dry and brown tongue, recovered, under circumstances apparently des- perate, by the free use of bark and wine." The same writer deems local bleeding sufficient in the milder cases of erysipelas, and often necessary in the more se- vere ones, as an auxiliary measure. Cupping, when practicable, he sets down as more efficacious than leeches, though objectionable on account of the pain- ful state of the skin. Leeches, he remarks, when ap- plied to the sound skin of some individuals, produce an effect analogous to erysipelas, but they exert no such influence over the inflamed skin, to which they maybe applied freely and safely. In order to produce any de- cided benefit, he thinks that they should be applied in large numbers. The authorities which may be cited in favour of the treatment of erysipelas on antiphlogistic principles, are Sydenham (Obs. circa Morborum Acut. Hist. i-c. sect. 6, c. 6); Cullen (Works by Thomson, vol. 2, p. 188); Richter (Anfangsgr. der Wundarzn. vol. 1, $188); Vogel (Handb. vol. 3, p. 348); J. P. Frank (De Cur. Huminum Morbis, lib. 3, p. 54); Dr. Duncan, junior (Edin. Med. Journ. vol. 19). Several of these writers consider bleeding more particularly proper when ery- sipelas is seated on the head and face. As Mr. Lawrence has noticed, high authorities may be brought forward against the use ofthe lancet in ery- sipelas, and most of them are comparatively of modem date. Some of them not only object to evacuations of aU kinds, but recommend tonics and stimuli, such as bark, ammonia, and wine. Dr. Fordyce declares that he always found bleeding and evacuations hurtful, and Peruvian bark the best remedy. "It should be exhi- bited (he says) in substance if the patient's,stomach will bear it, and in this disease it will almost always bear it; and in as great a quantity as the pattern's sto- mach wUl bear, which is commonly to the quantity of a drachm every hour!"—(Trans, of a Society for the im- provement of Chir. Knowledge, vol. 1, p. 293.) Some animadversions on the practice of giving bark in this manner will be found in our preceding columns.— (See Cinchona.) Dr. Wells is also an advocate for the treatment recoini. tended by Fordyce. With regard to Cullen, he only sanctioned it when the case was at- tended with typhoid symptoms. After the inflammation has be.-n checked by anti- phlogistic inenr.s, the surgeon should not be in too great a hurry to prescribe tonics, stiniui;»its, and a full diet. li Medical practitioners in general (.says Mr. Lawrence) 3.J6 ERYSIPELAS. are anxious to begin the strengthening plan; they seem to have the fear of debility constantly before their eyes and lose no time in directing the employment of bark, and recommending animal food with beer or wine. In this way relapses are frequently produced; the inflam- mation and fever are renewed; farther local mischief is caused, and recovery is retarded."—-(Med. Chir. Trans, vol. 14, p. 59.) When it is doubtftil whether stimuli should be employed or not, he deems subcar- bonate of ammonia the best medicine. Bark comes next in order to it, and the sulphate of quinine is the most eligible preparation. Wine is sometimes neces- sary; but Mr. Lawrence thinks it should be given very sparingly.—(See Med. Chir. Trans, vol. 14.) The proposal to treat erysipelas by compression -with bandages, as adopted by Bretonneau and Velpcau, seems to require here no farther notice than that it has proved in this country very unsuccessful, and even fatally hurtful.—(See Duncan, in Med. Chir. Trans. vol. 1, p. 543 ; Laivrence, in Med. Chir. Trans, vol. 14, p. 65.) The application of blisters to erysipelatous parts, as sometimes practised by Dupuytren, can only be entitled to the briefest mention, even when viewed as represented by the French surgeons themselves.— (See Roche and Sanson, Nouveaux Elm. de Pathol. Mid. Chir. t. 1, p. 352.) In the bilious erysipelas, or that originating with strongly marked gastric disorder, whatever degree of heat or fever might exist, Desault gave in the first in- stance a grain of tartarized antimony dissolved in a considerable quantity of fluid; and the symptoms gene- rally diminished as soon as the effects of the medicine had ceased. He had seen them entirely subside, al- though the medicine produced no other sensible altera- tion in the animal economy than an increase of the insensible perspiration and urine ; sometimes the symp- toms resisted these evacuations, and he was obliged to have recourse once or twice, or even more frequently, to the use of the emetic drink. When the erysipelas was cured, and the bitterness in the mouth and fever had subsided, two or three purges of cassia and manna, with a grain of emetic tartar, were exhibited: during the cure, the patient was ordered to drink freely of a diluting ptisan acidulated with oxymel: and as soon as the symptoms were mitigated, the diet of the patient was allowed to be more nourishing and generous; for when it was too spare, the case was remarked never to proceed so favourably, particularly in hospitals, where the air, generally speaking, is unhealthy. In the bilious erysipelas, Desault observed that the cases of the patients who had been bled previously to their admission into the hospital, were invariably the most serious and obstinate, particularly when the bleeding had been frequently repeated. In cases of bilious erysipelas, many modern prac- titioners would be bolder with antimonials than De- sault, first by imitating Richter, and giving an emetic at the commencement of the attack, and then by exhibit- ing more freely either antimonial powder or tartarized antimony, with a dose or two of calomel. In phlegmonous erysipelas, Desault was an advocate for bleeding in the beginning of the disorder, and this practice he followed up by the administration of tartar- ized antimony and evacuants. Mr. Lawrence recommends, in the early stage, vene- section and the application of leeches in large numbers to the inflamed part, together with the antiphlogistic treatment generally, in order to prevent the full develope- ment of the affection. The bleeding of the leech-bites he directs to be encouraged by fomentations, and cold lotions afterward to be applied. When, however, the inflammation is more advanced (he says), the latter should be exchanged for fomentations and poultices. My own experience in these cases leads me to refer very great efficacy to cold applications, which I find particularly useful in retarding the effusion in the cel- lular membrane, averting gangrene of this tissue, aud stopping altogether the progress of the disorder. In the cage of a patient in Fleet-market, whom I attended with Mr. Lawrence and Mr. Bullin, and whose limb was so swelled as to be nearly twice its natural thick- ness from one end to the other, cold lotions, evacuations, leeches, and other antiphlogistic remedies had a decided effect in giving ease, and preventing all occasion for the practice of extensive incisions. The abscesses were very limited; and two small incisions, made at different periods for tho discharge of the matter, an- swered every purpose. After the bowels have bcm emptied, Mr. Lawrence prescribes freely calomel n>d antimony, with saline medicines. The local abstrac- tion of blood he considers more serviceable in p ii«g- monous erysipelas than venesection. The latter, there- fore, he advises to be reserved for instances in win'-h the patient is young and plethoric, the pulse full and sirong, or the head much affected. When such practice is unavailing, Mr. Lawrence finds the plan of making incisions through the inflamed skin and the subjacent adipous and cellular textures, the most powerful means of arresting the complaint. If this be not done (he says), the inflammation will now pursue its course, both in the cellular membrane and skin, in spite of bleeding, whether general or local, suppuration and sloughing rapidly supervene; and these destructive processes 60on extend over a larga portion of a limb. It was with the view of preventing such consequences, that Mr. Lawrence, in imitation of Mr. C. Hutchison, tried the practice of making free and even very extensive incisions in the inflamed parts, as will be presently noticed. In cases of idiopathic erysipelas, whether phlegmo- nous or bilious, external applications have been deemed useless or hurtful by a large proportion of practitioners, among whom is Desault. In the early stage of the dis- ease, Dr. Bateman found powdery substances, Uke flour, starch, chalk, Sec, increase the heat and irritation, and afterward when the fluid of the vesications oozes out, such substances produce additional irritation by form- ing with the concreting fluid hard crusts upon the ten- der surface. This practice is also condemned by Mr. Pearson. The qply plan, perhaps, which is unobjec- tionable as a means of allaying the irritation produced by the discharge from the vesication, is that advised by Dr. Willan, and which consists in fomenting or washing the parts from time to time with milk, bran and water, or a decoction of elder-flowers and poppy- heads. In the early stage of the inflammation, Dr. Bateman saw great relief derived from moderate tepid washing, or the application ofthe diluted liquor ammon. acet.—(Synopsis of Cutaneous Diseases, p. 133, ed. 3.) Though Desault forbids local remedies in cases of idiopathic erysipejas, he does not extend the prohibition to examples either of bilious or phlegmonous erysipelas from a contusion, wound, or ulcer: regimen and inter- nal medicines, according to Desault, here being insuffi- cient unless topical applications are employed to abate the local irritation, and excite suppuration. With this view he commends cataplasms, but he deems one cau tion essential, viz. that the application of the poultice should not extend much below the contused surface or the edges of the wound. If any application be per mitted on the rest of the erysipelatous surface, he thinks that it should be the liquor plumbi acetatis dilu- tus made weak.—(Parisian Chir. Journ. vol. 2.) Mr. Pearson prefers cataplasms composed of the pow- ders of aniseed, fennel, chamomile-flowers, Sec, mixed with a fourth part, or an equal quantity of bread, and a proper quantity of milk. Linseed powder, he says, may sometimes prove a convenient addition. As for what is termed accidental erysipelas, or that caused by casual local irritation applied directly to the skin, as from acrid substances, heat, friction, the sting of insects, Sec, the removal of the cause, the employ- ment of cold, or even ice-cold lotions, and other anti- phlogistic means, are the only measures essentially ne- cessary. In cases of phlegmonous erysipelas, if the inflamma- tion continue in an unabated form beyond the seventh or eight day, suppuration is to be apprehended. Here Boyer recommends the employment of emollient appli- cations, and as soon as a fluctuation is distinguishable (or even what he terms " un empdtement purulent") he advises the surgeon to make such incisions as may be necessary for the discharge of the matter. He also states that the incisions should be made at several de- pending points.—(See Boyer, Traiti des Mai. Chir. t. 2, p. 22.) It appears from the observations of Mr. A. C. Hutchison, formerly surgeon to the Naval Hospital at Deal, that seafaring men are very liable to phlegmonous erysipelas of the extremities, particularly of the legs The cause is ascribed to the irritation ofthe salt water and the friction of their loose coarse trousers. In this description of patients the disease frequently proceeds rapidly to the gangrenous state, and the consequence is the loss of many lives and limbs. Even when the ERYSIPELAS. 357 danger of mortification is avoided, abscesses often occur, which spread between the muscles and under ihe integuments to a surprising extent: 'from the ankle to the trochanter and over the gluttei muscles. In the first few cases which came under the care ot Mr. Hutchison, this gentleman's plan of treatment, in addition to the usual medical means, consisted of local bleeding by means of cupping glasses, followed by lo- menlations. Subsequently, however, he has adopted the method of making several free incisions with a scalpel on the inflamed surface in a longitudinal direc- tion through the integuments, and down to the mus- cles as early in the disease as possible, and before any secretions Itaoe taken place. These incisions may be about an inch and a half in length, two or three inches apart, and vary in number from six to eighteen, accord- ing to the extent of surface which the disease is found to occupy. Mr. Hutchison states, that these incisions will yield between fifteen and twenty ounces of blood, and give relief to the tense skin, at the same time that they form channels for the escape of fluid, and the pre- vention of bags of matter. After the operation, fomen- tations or saturnine lotions are employed. By the preceding kind of treatment, Mr. Hutchison thinks the fatal termination of the disease may be rendered less frequent, and gangrenous mischief wholly prevented. He supports this assertion by ob- serving, that he never lost a case in the Deal Hospital for the last five years, during which the practice was followed.—(See Med. Chir. Trans, vol. 5, p. 278, i-c.) Mr. Lawrence thinks the most powerful means of arresting the complaint is by making one or more long incisions through the inflamed skin and the subjacent adipous and cellular textures, which are the seat of the disease. These incisions, he asserts, are followed very quickly and almost instantaneously by relief and cessa- tion ofthe pain and tension; and this alleviation ofthe local suffering, he assures us, is accompanied by a cor- responding interruption of the inflammation, whether it be in the stage of effusion, or in the more advanced period of suppuration and sloughing. Mr. Lawrence farther maintains that this treatment is employed to the greatest advantage at the beginning, since it pre- vents the farther extension of inflammation and the occurrence of suppuration and sloughing. At a more advanced stage the incisions limit the extent of suppu- ration and gangrene; and at a still later time they afford the readiest outlet for matter and sloughs, and facilitate the commencement and progress of granula- tion and cicatrization.—(Med. Chir. Trans, vol. 14, p. 67, i-c.) The great points on which a diversity of opi- nion exists respecting the treatment by incisions are the period when they are really necessary, and their number and extent. Believing from extensive observa- tion that phlegmonous erysipelas, when properly treated, doe* not lead so invariably to extensive gangrenous mis- chief and suppuration under the skin as Mr. Lawrence's account, would make us suppose,but, on the contrary, that it frequently admits of resolution, and often occasions only abscesses which may be effectually opened as soon as formed, I cannot acknowledge the wisdom or utility of miking incisions for the prevention of evils, the oc- currence of winch at all is quite a matter of uncertainty. Thus, though Mr. Lawrence has inferred from several of the cases in which he practised early and free inci- sions, that these had the effect of preventing extensive sloughing and suppuration, the conclusion is certainly' without satisfactory proof; and a cure might have taken place very well without them. To the practice, therefore, in the early stage of the disease I should ob- ject as unnecessary. At a more advanced period, how- ever, when matter is formed, I am decidedly an advo- cate for making a free opening for its discharge, but not for inflicting ten or sixteen different wounds for this or any other purpose, nor for using the scalpel with such perfect reliance on the innocence and sweetness of its edge as to make with it a gash requiring a foot or yard ruler for its measurement. Whoever looks over ine reports of this treatment, as detailed in the Lancet and other works, oannot fail to be struck with the fol- lowing facts. Several patients, treated in this way, have not been saved, and some have certainly gone out of the world in a very sudden manner. Whether this arose from the shock of an enormous wound on the constitution in its very disturbed state, or from profuse hemorrhage, or other causes, it is needless to inquire. lu o.ic or nvo instances, the cuianoous norvus as well as large veins and arteries, were not spared, and a par- tial paralysis ensued. Against the proposed treatment by numerous or long incisions I must therefore conti- nue to protest: in the early stage the practice of inci- sions in any way is not truly indicated for the reason above explained; and at a more advanced period if subcutaneous suppuration or gangrene commence, a prompt and free opening is undoubtedly required accord- ing to all the established principles of surgery, but not a wound of preposterous extent. Dr. Dobson, of Green- wich Hospital, makes in all kinds of erysipelas nume- rous small punctures in the part, and repeats them to the number and extent required mostly twice a day ; and often in bad cases three or four times in the twenty-four hours. The quantity of fluid (for it is not blood alone, but blood and effused serum) which these punctures dis- charge, although sometimes considerable, he says, need never create any alarm. With this practice he joins the exhibition of the camphor mixture, liquor ammon. acet. and tincture of rhubarb. He also employs a lotion, composed of liq. ammon. acet. camphorated spirit, and water—(See Med. Chir. Trans, vol. 14, p. 206.) Of this method I shall merely observe that it has not fallen to my lot ever to see it tried; but that, if I were the pa- tient, I should rather submit to it than to the bold sweeping incision or numerous deep cuts which have been recommended by gentlemen whose opinions on other points in surgery 1 sincerely respect. [In this country, during the winter months, and es- pecially in variable seasons, phlegmonous erysipelas as it is here called, is a frequent consequence of local injury, as burns, wounds, Sec, and by speedily running into suppuration, this disease has often proved fatal, although the original mischief was circumscribed and inconsiderable. I have frequently known this kind of erysipelas to originate from a slight wound on the hand, and in a few days involve the whole arm in the suppurative process. And although the wound or bum scarcely penetrated the cutis, yet the matter would difftise itself beneath the fascia of the limb, and require the most prompt and efficient remedies to prevent death by the pain and irritation occasioned by distention. Mr. Lawrence's plan of treatment has been attended with signal success under my own observation, the threatening symptoms subsiding immediately after long and free incisions were made through the skin and subjacent adipose and cellular textures. • Professor Delafield of this city has had opportunities of testing this practice to considerable extent, and he informs me that he has uniformly obtained the most satisfactory results.—Reese.] What is termed oedematous erysipelas is generally considered to be an unfit case for bleeding and free evacuations, and almost always to require a tonic plan of treatment. In short, the right practice, in every ex- ample of erysipelas, is to let the remedies be regulated in a great measure by the state of the constitution, the pulse, the strong or reduced condition of the system, the sort of fever accompanying the disorder, the age, temperament of the patient, and the particular stage of the complaint. At first, though antiphlogistic treat- ment may be the only safe plan, circumstances»after- ward change so considerably that this must be aban- doned, and a method quite the reverse of it rigorously adopted. With regard to the treatment of gangrenous erysi- pelas, nothing more need be said than what is con- tained in the article on Mortification. Consult Desault's Parisian Chirurgical Journal, vol. 2. Also, (Euvres Chir. de Desault par Bichat, t. 2, p. 581, i-c. Encyclopidie Mcthodique, partie Chir. art. Erysipile. Cullen's First Lines of the Practice of Physic, vol. 1. Peart's Pract. Obs. on Erysipelas, ic. 1802. Pearson's Principles of Surgery, 1808. Some parts of Hunter's Treatise on the Blood, Inflammation, i-c. Richerand, Nosogr. Chir. t. 1, p. 118, i-c. ed. 2. Lassus, Pathologie Chir. t. 1, p. 8, i-c. ed. 1809. 7Vai£<; des Maladies Chir. par M. le Baron Boyer, t. 2, p. 6, et seq. Willan on Cutaneous Diseases. A. C. Hutchison, in Med. Chir. Trans, vol. 5, p. 278, i-c. and Practical Obs. in Surgery, ed. 2. T. Bateman, A Practical Synopsis of Cutaneous Diseases, p. 125, i$-c. ed. 3. Diet, des Sciences Mid. vol. 13, p. 253, i-c. Rayer, Traiti des Mai. de la Peau, t. 1. Butter's Re mark* on Irritative Fever. Devonport, 1825. Dr ' Duncan, in Edin. Med. Chir. Trans, vol. 1. Arnott 358 ERY EXF in Med. Phys. Journ. vol. 57. James on Inflamma- tion. Wells, in Trans, of a Society for the Improve- ment of Med. and Surgical Knowledge, vol. 1. W. H. Burrell, in Edin. Med. Journ. vol. 24. Lawrence, in Med. Chir. Trans, vol. 14. ERYTHEMA. (From ipvOpbc, red.) A redness of any part. A mere rash or efflorescence, not accompa- nied by any swelling, vesication, or fever; circumstances which, according to Dr. Bateman, distinguish it from erysipelas.—(Synopsis of Cutaneous Diseases, p. 119. ed. 3.) Its six varieties are described in the latter work. For the erythema mercuriale, see Mercury. The term is often wrongly applied to eruptions attended with redness, and distinct papular and vesicular eleva- tion, as we see in the instance of mercurial erythema, which Dr. Bateman says should be named eczema. [From the extraordinary use and consequent abuse of mercurial remedies, which, I regret to state, too much characterizes the practice of many of the medical pre- scribers of this country, I am induced to add a remark or two on this very interesting disease. The erythi- mus arising from mercury, which has received several different names by different authors, as the hydrargyria of Alley, the eczema mercuriale of Pearson, the erythe- ma mercuriale of Spens, the mercurial lepra of Mori- arty, Sec, is sometimes compounded with other disor- ders of an eruptive character, supposed to arise from a syphilitic origin. But in adverting to the various causes which exert their influence in producing affec- tions of the skin resembling that under notice, we must not omit to remember the modifying operation of a cachectic condition of the body, and that, independently of mercury, occasionallj- other agents are capable of producing like morbid appearances. These disordered changes are often difficult to discriminate, and can per- haps only be known by the history of the case, and by a course of experimental treatment. Mr. Carmichael has well pointed out that diseases likely to be con- founded with syphilis, which arise spontaneously from a disordered state of the constitution, frequently as- sume the form of the tubercular eruption, and he adds, " before ulceration occurs I have seldom been able to distinguish this spontaneous disease from that arising from a venereal infection." Hence, while in ihe mercu- rial erythema mercury will often aggravate the evil; in that species of affection which occurs spontaneously we may derive the greatest benefit from mercurials. Moreover, in that which has taken place in the syphi- litic habit, mercury may do much harm from the pre- vious injudicious use of this remedy. Hence, too, Bate- man has given us an excellent history of a tubercular eruption of a syphilitic appearance, but curable with- out mercury.—(See Medico-Chirurg. Trans, vol. 5.) The history of the mercurial eczema is perhaps best given us by Pearson. Examined by the magmfying- glass, the eruption appears distinctly vesicular, though by the naked eye they can scarcely be distinguished. Notwithstanding the observation of Mr. Pearson, the disorder sometimes proves fatal, and Alley tells us that of forty-three cases which he witnessed within ten years eight patients died. The morbid effects of mercury do not seem to depend upon the quantity gi- ven er the preparation administered. The mercurial erythema may arise from calomel or corrosive subli- mate, from a few grains of the former as well as from a few drops of a solution of the latter. Hence every practitioner is aware how serious are at times the mis- chiefs of the mildest mercurial preparations, even in small doses, in some constitutions; and the same re- mark applies to the mercurial force that is requisite in inducing salivation. From a careful examination of the recorded cases ofthe mercurial erythema, Professor Francis gives it as his result, that the disease is of more frequent origin from the external application of mercury than from its internal administration, and in- asmuch as unguents are most frequently applied inside of the thighs, so we find th3 disorder very commonly to commence at those parts. Mr. Carmichael has done »iiu aiieruard EXO EXO 361 promoting their discharge. In all these examples, the eyeball is displaced from the orbit gradually, and vision is at length impeded. Instances, however, are on re- cord, where the sight was never lost, though the eye was protruded for years.—(Soe Richter's Chirurg. Bibli- othek, band 4, stuck 2, p. 243. White's Cases in Sur- gery^. 135.) In an instance lately reported, the sight was not at all lessened, and the iris retained its natural mobility.—(Langenbeck, Neue Bibl. b. 2, p. 245.) Experience proves also, that after the reduction, the motion of the eye and power of seeing may be re- gain-d, in cases where the eye has been gradually pushed out ofthe orbit, and been displaced a consider- able time, even as long as several years, during all which period vision was lost.—(Acrell. Brocklesby, in Med. Obs. and Inquiries, vol. 4, p. 371.) Langenbeck relates a very curious case of exophthalmia from a Bteatoma in the orbit, wuere, though vision was en- tirely prevented during the displacement, the pupil was of its regular shape, and the iris capable of mo- tion : after the extirpation of the tumour, the eyesight became so good, that the patient couid discern the smallest objects.—(Neue Bibl. b. 2, p. 240.) In order to reduce the eye into its natural position, it is neces- sary to remove the cause by which its protiusion is occasioned. Suppuration and fungous tumours in the antrum must be treated according to directions laid down in the article Antrum. After the cure of such diseases, the antrum is often reduced to its natural di- mensions, and in this circumstance, the orbit may be- come so wide, that the eyeball will return into it again. Should this not happen, the extirpation of the organ will be proper. The induration and swelling of the cellu- lar substance in the orbit may be sometimes dispersed by means of mercury.—(Louis, Sur plusieurs Maladies du Globe de PlF.il, in M m. de l'Acad. Roy ale de Chi- rurgie, t. 13, id. 12mo.) When such treatment fails, we are recommended to extirpate the eye.—(Richter, Anfangsgr. der Wundarzn. b. 3, p. 413.) Exostoses situated in the anterior part of the orbit may some- limes be removed. The continental surgeons generally advise us to expose the tumour by an incision, and to apply caustic or the actual cautery to it, in order to kill the protuberant part ofthe bone and make it exfoliate. In this country, most practitioners would prefer the employment of cutting instruments for removing such exostoses. When, however, the tumour lies deeply in the orbit, if it cannot be got at, and it should resist the effect of mercurial medicines and mezereon, we are di- rected to extirpate the eye.—(Richter, op. et loco cit.) Abscesses in the orbit ought to be opened, and after this has been done, the eye generally returns into its proper position.—(Pellier.) When encysted tumours in the orbit admit of being extirpated in the customary manner, the plan should be adopted; but when this cannot be done, Richter's advice may be followed, which is to open them, press out tbe contained matter, und afterward extract the cyst. Considerable diffi- culty, however, frequently attends every effort to re- move the whole cyst, and unless this be done, a perma- nent cicatrization cannot be expected.—(See Travers's Synopsis, p. 225. See Tumours, Encysted.) On account ofthe vicinity ofthe brain, and the com- munication between the parts within the orbit and the dura mater, the extirpation of tumours from that cavity is not exempt from risk of fatal consequences, as two cases recently published by Langenbeck, fully prove.— (Neue Bibl. b. 2, p. 241. 244.) A young lady was re- ferred to Mr. Lawrence and myself, some time ago, by Mr. Maul, of Southampton, for advice respecting a tu- mour o.»opying the inner and upper portion of the orbit, and attended with a degree of exophthalmia, con- stant exacerbation at the period ofthe menses, and oc- casionally double vision.—(See Diplopia.) We re- frained from advising any immediate attempt at extir- pation, the swelling being so firm and immoveable, that the disease was suspected to be partly of a bony nature. However, on seeing this case about a fortnight afterward, 1 w is surprised to find the tumour not more than half its former size, and all the firm and (what was conceived to be) bony induration below the superciliary ridge of the os frontis gone, as well as the e.xoph'.halmia and derangement of vision. Some sharp bony irregularities, however, could now be most plainly felt, projecting in front of the diminished swelling. In a late publication, a memorable case of exophthal- mia is related by Mr. Travers: the globe of the eye appears to have been gradually forced upwards and outwards, and to have had its motions considerably impeded, in consequence of the orbit being partly occu- pied by two swellings, which were of the nature ofthe aneurism by anaslomosis.--iSee Aneurism.) The swellings could not have been removed, without at the same tune extirpating the eye. Mr. Travers was there- fore induced to try whether applying a ligature to the carotid artery would have the effect of checking and curing the disease; an expectation which was warranted by analogous instances, in which the growth of swellings and their dispersion are brought about by lessening the quantity of blood determined to them. The experiment completely succeeded; the swellings in the vicinity of the eye subsided; the patient was freed from several grievous complaints, to which she had been previously subject; and, among other bene- fits, a cure of the exophthalmia was one result, which most interests us in the present place. The case is also highly important on other accounts, and more par- ticularly as confirming the fact, that the carotid artery ma^f be tied without any dangerous effects on the brain, and as proving, that in cases of aneurism, the surgeon should not be afraid of proceeding to such an operation.—(See Med. Chir. Trans, vol. 2, art. 1.) The judgment and decision with which Mr. Travers acted in this case, appear to me highly meritorious. The carotid artery was also tied by Mr. Dalrymple, surgeon at Norwich, in a case very similar to the pre- ceding, and with equal success.—(See Med. Chir. Trans. vol. 6, p. Ill, Ac.) Mr. Guthrie has seen an exophthalmia on each side, the result of an aneurism of each ophthalmic artery, and other disease in the orbits.—(Operative Surgery of the Eye, p. 158.) When the causes of exophthalmia have been removed, the eye must be put into its natural situation. If the organ has been long displaced, the surgeon often finds the fulfilment of this indication attended with difficulty. Indeed, he is frequently obliged to employ methodical bandages for the purpose of promoting the gradual re- turn of the eye into the orbit. Yet, even in such cases, the eyesight is often regained ; but if this should not happen spontaneously, stiinulants and tonics are to be tried.—(See Amaurosis.) Fab. Hildan. centur. 6, obs. 1. Vander Wiel, centur. 2, obs. 9. Paw. Obs. Anat. 23. Tulpius, lib. 1, cap. 28. Hope, in Phil. Trans, for 1744. Louis, Sur plusieurs Maladies du Globe de PiEil, i-c. in Mem. de l'Acad. de Chirurgie, t. 13, in 12mo. Brocklesby, in Medical Obs. and Inquiries, vol. 4, p. 371. White's Cases in Sur- gery, p. 131—135,, it is very slight; the tumour grows slowly, and although it sometimes attains a considerable size, its increase is attended with no particular sensibility, and no disturbance ofthe ani- mal economy.- (Boyer, op. cit. t. 3, p. 546.) Our ignorance ofthe pnthology of exostoses, particu- larly their causes, accounts for the imperfection of our treatment of them. With the exception of the vene- real exostosis, or node, there is no species of this affec- tion, for which it can be said that we have any one me- dicine of efficacy. Boyer and other writers on the diseases of the bones seein to regard some exostoses as a perfectly inorganic mass of lime, and consequently they entertain no idea that the absorbent vessels can possibly take away the particles of the tumour, just as the secerning arteries have laid them down. Such writers, however, are well aware, that nodes are capable of being dimi- nished, and this can only be effected by ihe actionmf the absorbent system. Boyer does acknowledge, indeed, that he has seen a venereal exostosis of the humerus, as well as a few other bony swellings, subside; but he represents the event as extremely rare; and he advances it as a prin- ciple, that the resolution of exostoses hardly ever hap- pens, and that the greater part of the examples recorded in proof of the occurrence, were nothing more than pe- riostoses.—(P. 547.) When an exostosis is hard, chronic, and free from pain and alteration of the structure of the bone, it is a much more common thing for it to cease to enlarge, and remain stationary during life, without producing incon- venience, provided it be so situated as not to impede the functions of any vital organ. But in the cellular exostosis of Boyer, which I take to be the same disease as the fungous exostosis of the medullary membrane of Sir Astley Cooper, the acute and rapid progress of the disease indicates a deeper and more serious alteration of the texture of the bone. A part of the tumour usually consists of a pultaceous or. gelatinous matter, and the rest still, endued with its na- tural organization, though altered by the disease, soon presents one or several cavities, in winch there is sup- puration. At the same time, the external soft parts, being excessively and rapidly distended, inflame, ulcer- ate, and ieave exposed a more or less extensive portion of the tumour, the disease of which has in many cases been very wrongly supposed to be caries. It is not, ob- I serves Boyer, ihat the part of the swelling denuded by ulceration is not sometimes affected with caries; but then i*. exists as a complication of the original disease, and as a particularity by no means the result of the ul- ceration of the soft parts, and of the exposure of the diseased bone to the contact ofthe air. When the soft parts are thus ulcerated, the opening contracts to a cer- tain point, and becomes fistulous. The suppuration is always of bad quality, and in a quantity proportioned to the size ofthe cavity of the abscess and the strength of the. patient. The fever, which commences at an early period of the disorder, assumes a slow type, and its continuance, together with the copiousness of the ichorous discharge, the irritation, Ut if an opening be made on^ blood is discharged. The surface of the tumour next becomes tuberculated, and the prominences tender, and their surface is often slightly inflamed. The rest 13 now broken, the appetite impaired, and tbe bowels ex- tremely irregular. At length the tubercles ulcerate ; the skin secretes pus; but when the swelling itself is exposed, it discharges a bloody-coloured serum. A fungus then forms, which sometimes bleeds pro- fusely, and after it has risen very high, sloughing oc- curs, and considerable portions of the swelling are thrown off. But although the swelling may be les- sened by this process, Sir A. Cooper has never known the disease cured by it; and in the end the patient is destroyed by the effects of the repeated bleeding, im- mense discharge, and constitutional irritation." In this disease, as in common fungus b.E?matodes, tu- mours of a similar nature are often formed in other parts of the body, and after the amputation of the af- fected bone frequently make their appearance in organs of the greatest importance to life. The swelling is de- scribed as originating from the medullary membrane, and as removing the muscles to the distance of three inches or more from the bone, so that they represent a thin layer spread over the tumour. The blood-vessels and large nerves are also similarly displaced. The tu- berculated appearance of the skin, whieh is itself sound, is caused by projecting small masses on the surface of the tumour. Under the muscles is the peri- osteum, pushed to a considerable distance from the bone. A part of the swelling itself is yellow, like fat; another portion resembles brain ; and a third is com- posed of coagulated blood with interstices filled with serum. In some parts the white substa-ce is found nearly as firm as cartilage; but in general it presents a more spongy appearance; and is interspersed with spicule? of bone. The shell of the bone itself is in pt. i absorbed ; in some places it is only thinner than usuai, while in others it is immensely expanded, so as to form a case, like wire-work, over the tumour. The fungous granulations, proceeding from the medullary mem- brane itself, are exceedingly vascular, and often shoot from the cavity of the bone beyond the level of the in- teguments.—(A. Cooper, Surgical Essays, part 1, p. 165-168.) According to Boyer, spherical exostoses, with an in- ternal cavity, and hypersarcosis, are only attended with violent pain in the beginning, and when they have at- tained a considerable size they become almost indolent. But the successive formation of the fungosities, con- tained in their cavity, has the effect of distending its parietes, and rendering them thin, so that such exosto- ses are exposed to fractures and ulceration. This last effect may, indeed, be a consequence of the progress of the disease, and give rise to a series of consecutive symptoms, which may be compared with those which have been described in the preceding case. The spheri- cal exostosis, however, is less dangerous, perhaps, be- cause the disease extends less deeply. Such tumours admit of being directly attacked ; and operations for the destruction of the bony shell, and of the fungous growth which it includes, may be successfully practised; an attempt which would certainly be useless and dan- gerous in the foregoing instance. One termination of exostosis, not spoken of by wri- ters, but which has been observed, especially Ui the hard and stalactical exostosis, is that by necrosis. Tu- mours of this description, after acquiring a large size, have been attacked -with mortification, separated from the bone, which served them as a base, and been sur- rounded with a reproduction in every respect similar to that with which nature surrounds sequestra formed under any other circumstances. This termination is' undoubtedly the most favourable of all, because nature proceeds in il slowly, without any violent disturbance; but, unfortunately, it is the least common. Art can imitate it; but her means are very inferior to those of nature. A most interesting case of an enormous exos- tosis of the upper maxillary bone, which followed the preceding course, was lately under my notice.—(Boyer, Traiti des Mai. Chir. t. 3, p. 547—550.1 The hardest exostosis, which has grown slowly, and without causing severe pain, is the least dangerous of all, especially when the constitution is sound, and the patient not of a bad habit. After the disease has at- tained a certain size, it may become stationary, and continue in this state without inconvenience during life. This is most frequently observed in the ivory ex- ostosis. Without having precisely this extreme hard- ness, however, some exostoses which are tolerably solid, and in which the natural organization of bone is still distinguishable, are capable of undergoing a slight reduction, after the removal of their cause by nature or art. Boyer states, that this sometimes happens in a few scrofulous exostoses, and particularly in such as are venereal, and not of very large size. The cellular exostosis of Boyer, the fungous exos- tosis of Sir A. Cooper, and the cases which are named osteosarcomata, are the most serious of all, especially when the texture of the bone is considerably altered, and the disease is in a state of ulceration. The rapid formation of the disease, the violent shock which it im- parts to the constitution, and the hectical disturbance which it excites, generally bring the patient into immi- nent danger, and commonly leave no other resource but that of amputating the limb. The treatment of exostoses is to be considered in, a medical and surgical point of view. When any gene- ral cause of the disease is known or suspected, such cause is to be removed by those means which expe- rience has proved to be most efficacious. Thus Boyer recommends mercurial and antiscrofulons remedies, &c, according to the nature of the case. Whatever may be the species of exostosis, or the na- ture of its cause, relief, says Boyer, may be derived from the outward use of opium, whenever the disease is attended with severe pain. He speaks favourably of the application of a linseed-meal poultice, made with a decoction of the leaves of nightshade and henbane, to which a strong solution of opium has been added. But he thinks that an antiphlogistic plan, with bleeding, is hardly ever admissible, because it weakens the patient too much in so tedious a disease, and can only be a palliative, incapable of curing or preventing the ravages of the disorder. When there is no pain, or it has been appeased, during or after any general method of treatment which may have been indicated, the surgeon may try resolvent ap- plications, particularly soap and mercurial plasters, the tincture or ointment of iodine, the liniment of ammonia, bathing in water containing a small quantity of soda, or potassa, hydro-sulphuraled washes, Sec. Boyer ac- knowledges, however, that the progress of exostoses can scarcely ever be checked by any general methodi- cal treatment. The muriatic and ascetic acids have been administered, but without effect; nor am I ac- quainted with any remedies which possess efficacy, excepting- iodine and mercury, which last we know will rarely answer, except in cases of nodes. In the commencement of any deep-seated disease in a bone, however, Sir A. Cooper thinks that the best medicine for internal exhibition, is the oxymuriate of quicksilver in small doses, together with the compound decoction of sarsaparilla.—(Surgical Essays, part 1, p. 169.) Boyer is firmly of opinion that, with the exception of recent small exostoses, the nature of which is even doubtful, the resolution of such tumours is almost im- possible. A slight diminution of the swelling, and its becoming perfectly indolent, are the most favourable changes which can be hoped for, whether they occur spontaneous! v, or are the fruit of surgical assistance.— (Traiti des Mai. Chir. t. 3, p. 554—557.) Whether any exostoses might be lessened by keeping open a blister over them for a considerable time, is a point, perhaps, worthy of farther investigation. It is certain that such applications tend to diminish venereal nodes, after they have been lessened as much as they can be by mercury; and we also know that blisters kept open promote the absorption of the dead bone ui cases of necrosis In the local treatment, Sir Astley Cooper approves of the use both of leeches and blisters, a discharge from the latter being kept up with equal parts of the mercurial and savin ointments.—(Surgical Essays, part 1, p. 169.) When exostoses merely occasion a deformity, ani no pain nor inconvenience from the pressure which they produce on the neighbouring parts, it is certainly most advisable not to undertake any operation for tbeir remo- val ; for, as Boyer has truly observed, in by far the greater number of instances, the local affection is muclc less to be dreaded than the means used for remov ing it. EXO Caustics and the cautery have occasionally been ap- plied to exostoses ; but they mostly do nusehief. Boyer mentions an unfortunate woman, in whom some caustic was applied to an exostosis at the inside of the tibia; but which instead of removing the tumour, caused a necrosis, of which she was not well two >ears after- ward. In a few instances, however, after the removal of fungous or cartilaginous exostosis ofthe interior of a bone with cutting instruments, the application of the cautery has prevented a reproduction of the diseased miss, as we find exemplified in a case recorded by Sir Astley Cooper, where such a disease of the jaw was thus extirpated.—(Surgical Essays, part 1, p. 15s.) The bold and successful manner, also, in which tlie hydatid exostosis of the head was attacked with the saw, caustics, and the actual cautery, by Mr. R. Keate, is particularly entitled to the attention of the surgical practitioner.—(Med. Chir. Trans, vol. 10, p. 2o8, s c.) As far as my information extends, no attempt to stop the progress, or effect the cure of a fungous exostosis, by tying the main artery of the limb, has ever yet suc- ceeded. Two cases, proving the inefficacy of this prac- tice, are detailed by Sir A. Cooper.—(Vol. cit. p. 170.) As the fungous exostosis of the medullary mem- brane is evidently connected with a state of the consti- tution analogous to what prevails in fungus nematodes (see this word), the permanent supcess of amputation should never be too boldly promised ; but as no medicines have any material power over the disease, and the operation is the only chance of relief, it ought to be advised. Cartilaginous exostoses of the medullary membrane may sometimes be extirpated by removing their outer bony covering, and then cutting away the cartilaginous matter closely from the bony surface to which it is at- tached. Sometimes, as I have noticed, those measures are followed by the use of the actual cautery. Periosteal exostoses are also either cartilaginous or fungous, which latter are attended with less genera! spelling of the limb, and are more prominent than fun- gous exostoses of the medullary membrane. Ulcera- tion, bleeding, sloughing, and great discharge ensue; and unless some operation be performed, the patient loses his life.—(A. Cooper, Surgical Essays, part 1, p. 180.) The cartilaginous exostosis, between the periosteum and bone, arises from inflammation of the periosteum and subjacent part of the bone; and a deposition of firm cartilage adherent to both these surfaces takes place. In this substance bony matter is secreted, which is first thrown out from the original bone. As the car- tilage increases in bulk, the quantity of phosphate of lime augments, and fresh cartUage is constantly deposited upon the outer surface of the tumour. On dissection; — 1st,the periosteum is found thicker than natural; 2dly, immediately below the periosteum cartilage; and 3dly, ossific matter, deposited within the latter, from the shell of the bone, nearly to the inner surface of tlie perios- teum. When the growth of such a swelling ceases, and the disease is of long standing, the exterior surface consists of a shell of osseous matter, similar to that of the original bone, and communicating with its cancelli, in consequence of the primitive shell having been ab- sorbed. -(A'. Cooper, Surgical Essays, part 1, p. 186.) The periosteal cartilaginous exostoses constitute the indolent, very hard forms of the disease. In their early stage they may sometimes be checked by small doses of mercury, the decoction of sarsaparilla, and the em- plastrum ammoniac! cum hydrargyro.—(Vol. cit. p. 196.) When large or troublesome they may be sawed away, as .Sir A. Cooper states, without danger, if the disease be well discriminated from the fungous swell- ing- When exostoses are productive of much pain, and injure the health, and their situation admits of their be- ing safely removed with the aid of suitable saws, or even with that of a gouge and mallet, the operation may be undertaken. Many tumours of this kind, how- ever, have basis so very extensive and deep, that when situated on the limbs, amputation becomes preferable, to any attempt made to saw or cut away the exostoses and preserve the members on which they are situated. In removing an exostosis, its base must be as freely- exposed by the knife as circumstances will allow, and to this part a small fine saw may be applied. In cut- ling away some exostoses, the flexible saw, described bv Dr. Jeffrey, of Glasgow (see Amputation), wtil be EYE 365 found useful. Mr. Hey's saws, and the semicircular trephine, are now so well known to the profession, that I scarcely need recommend them to be remembered in the present cases. Mr. Machell, a surgeon in London, has invented a saw, well calculated for cutting a bone at a great depth, without injuring the muscles. It is a small, fine, perpendicular wheel-like saw, turned by means of a handle connected with machinery*. It is highly com- mended by Sir A. Cooper, who has given a drawing of it in his Surgical Essays, part 1. An orbicular saw, invented and used by Professor Graefe, of Berlin, like- wise merits particular notice on account of its inge- nuity.—iSee C. G. E. Schivalb, De Serra Orbiculari, 4to. Berol. 1819.) I would likewise recommend to the notice of surgeons the ingenious rotation saw, contrived by Professor Thai, of Copenhagen, and of which a de- scription and engraving may be found in the Edin. Med. and Surgical Journ. No. 74. A strong pair of bone-nippers, and especially Mr. Liston's forceps, the edges of which are in the line with the handles, will also be useful. E. Victorin, De Ossibus tuberosi*. Upsal, 1717. Haller, Disp. Chir. t. 4, p. 581. P. H. Mahring, De Exostosi Steatomatode Clavicula, ejusdem fetid Sec- time, Gedani, 1732. J. Caspart, De Exostosi Cranii rariore, Argent. 1730. /. it. Fayolle, De Exostosi; Monsp. 1774. Abernethy, in Trans, for the Improve- ment of Med. and Chir. Knowledge, vol. 2, p. 309. Bonn, Descriptio Thesauri Ossium Huviani. Dumont, Journ. de Med. 1.13. Hist, de PAcad. des Sciences, 1737, p. 28. Houstet, in Mem. de PAcad. de Chir. t. 3. Malani, De Csseis Tumoribus, p. 20. Petit, Traite des Mai. des Os, t. 2, Morgagni, De Sedibus, ire. ep. 50. art. 56. Kulmus, De Exostosi Clavicula. Haller, Collect. Diss. Chir. t. 4. R. Keate, in Med. Chir. Trans, vol. 10*. Sir A. Cooper, Surgical Essays, part 1, Svo. Lond. 1818. J. F. Lobstein, Compte de son Muse Anatomique, p. 24, i-c Svo. Slrasb. 1820. EXTRAVASATION. (From extra, out of, and vas a vessel.) A term apptied by surgeons to the passage of fluids out of their proper vessels or receptacles. Thus, when blood is effused on the surface, or in the ventricles of the brain, it is said that there is an extra- vasation. When blood is poured from the vessels into the ca- vity of the peritoneum, in wounds of the abdomen, or when the contents of any of the intestines are effused in the same way, surgeons call this accident an extra- vasation. The urine is also said to be extravasated, when, in consequence of a wound, or of sloughing, or ulceration, it makes its way into the cellular substance, or among the abdominal viscera. When the bile spreads among the convolutions of the bowels in wounds of the gall-bladder, this is a species of extra- vasation. In wounds of the thorax an extravasation of blood also frequently happens in the cavity of the pleura. Large quantities of blood are often extravasated in consequence of vessels being ruptured by violent blows: in the scrotum, on the shoulder, and under the scalp this effect is observed with particular frequency. In the articles Head, Injuries of, and Wounds, I have treated of extravasations of blood in the cranium, chest, and abdomen. EVE, Calculus in the interior of. Scarpa dissected an eye which was almost entirely transformed into a stony substance. It was taken from the body of an old woman, and was not above half as large as the sound one. The cornea appeared dusky, and be- hind it the iris, of a singular shape, concave, and with- out any pupil in its centre. The rest of the eyeball, from the limits ofthe cornea backward, was unusually hard to the touch. The particulars of the dissection of this case will befead with interest, in Scarpa's Treatise on the Diseases of tlie Eye. Haller met with a simtiar case.—(See Obs. Pathol. Oper. Min. obs. 15.) Fabricius HUdanus, Lancisi, Morgagni, Morand, Zinn, and Pellier make distinct mention of calculi in the interior of the eye. Ossifica- tions of the capsule of the lens, of that of the vitreous humour, and of what was supposed to be the hyaloid membrane are noticed by Mr. Wardrop.—(Morbid Anatomy of the Human Eye, vol. 2, p. 128, Svo. Lond. 1818.) EYE, Canckr and Extirpation of. One of the well-known characters of carcinoma in general is te attack persons advanced in age rather than chUd-tu 366 j? and young subjects. Hence, an observation made by the experienced Desault, that cancer of the eye is most frequent in childhood, could not but appear a position inconsistent with the usual nature of the disease in general. Yet how was this statement to be contra- dicted, while it was confirmed by the testimony of Bi- chat himself, who says, that more than one-third of the patients on whom Desault operated in the H6tel-Dieu for cancer of the eye were under twelve years of age" Here truth and accuracy as in many other questions relative to disease would never have been attained without the aid of morbid anatomy, whereby distem- pers which bear a superficial resemblance to each other, while they are in reality of a totally different na- ture, are prevented from being confounded together. Now, when Scarpa even goes farther than Bichat, and asserts, that in twenty-four individuals affected with what is called carcinoma of the eye, twenty of those at least are children under tivelve years of age, this decla- ration, considered with the acknowledged propensity of cancer on al) other occasions to attack o'd rather than young subjects, might have remained a mysterious anomaly in the history of disease, had not the valuable investigations of Mr Wardrop proved, beyond all doubt, that the afflicting disease which rendered it necessary for so many young subjects to undergo a severe opera- tion, was not true cancer, but what is now denominated by modern surgeons, fungus Iiamatodes.—(Obs. on Fungus Hamatodes, 8vo. Edin. 1809.) As Scarpa ob- serves, this author has afforded a solution of the ques- tion, by showing from careful observation, founded on pathological anatomy, that the morbid change of struc- ture in the eyeball of a child, commonly called carci- noma, is not in reality produced by cancer, but by an- other species of malignant fungus, to which the epithet ha?matodes is applied ; a disease, indeed, equally, and, with regard to the eye, more formidable and fatal than cancer, but distinguished from it by peculiar characters, which, not being confined to age, sex, or part of the body, attack the eyeball both of the infant and adult.— (Scarpa, Transl. by Briggs, p. 502, ed. 2.) According to Scarpa, and, indeed, the sentiments of Heveral other surgeons of the present day, cancer is al- ways preceded by seirrhus, or a morbid induration of the part affected. As the disorganization increases in this hard scirrhous substance, an ichorous fluid is formed in cells within it, and afterward extends towards the external surface of the tumour, causing ulceration of the investing parts. The compact and apparently fibrous mass is then converted into a malignant fun- gous ulcer, of a livid or cineritious colour, with edges everted and irregularly excavated, and with a discharge of acrid, offensive sanies. The seirrhus composing the base of the malignant fungus, instead of increasing in size, now rather diminishes, but retains all its ori- ginal hardness, and, after rising a certain way above the ulcerated surface, is destrbyed at various points by the same ulcerated process from which it originated. And if any part ofthe livid fungous'sore seem disposed to heal, it is a deceitful appearance, as, in -a little time, the smooth points are again attacked by ulceration. To relate in this place all the differences between cancer and fungus hsematodes ofthe eye would be superfluous, as the subject is considered in a future article (see Fungus Hamatodes); but I may briefly advert to a few remarkable points of diversity. 1st, The primary origin of fungus hasmatodes is generally in the retina, especially that point at which the optic nerve enters the cavity of the eye. 2dly, True cancer of the eyeball, when it begins on any part of the organ itself, instead of commencing as fungus haematodes at the deepest part of the eye. originates on its surface in the con- junctiva; and, as far as present evidence extends, if we exceDt the lachrymal gland, this membrane is the only texture connected with the eye ever prima- rily affected with carcinoma.—(.Scarpa, On Diseases of the Eye, p. 526, edit. 2; and Tr rivers, Synopsis of the Diseases of the Eye, p. 99.) 3dly, Cancer of the eye, as Scarpa truly observes, is less destructive than fungus hsematodes, and that for two important reasons. In the first place, because carcinoma begins on the ex- terior parts of the eye, so that whatever relates to the origin and formation of the disease is open to observa- tion ; and, secondly, because the cancerous fungus of the eye, on its first appearance, is not actually malig- nant, but becomes so in process of time, or from im- proper treatment, previously to which period good sur- gery maybe employed with effect. In this light ."-.'tirpa views many excrescences on the conjunctiva and ante- rior hemisphere ofthe eye, which appear in consequence of a staphyloma of the cornea, long exposed to the air and ulceration; those which arise from relaxation and chronic inflammation of the conjunctiva; from ulcera- tion of the cornea, neglected or improperly treated; from violent ophthalmy, not of a contagious nature, treated in the acute stage with astringent and irritating applications; from suppuration of the eye, rupture of the comea, and wasting of the eyeball; or from blows or burns on the part. Nothing, says Scarpa, is more pro- bable, than that all these ulcerated fungi were, on their first appearance, notof malignant character, or certainly not cancerous, and that many of them were not actually so at the time of a successful operation being done. Now, in the opinion of the same valuable author, there is no criterion as yet known of the precise time when a sarcoma of the eye changes from the state of a common ulcerated fungus to that of carcinoma; for the exquisite sensibility, darting pains, rapidity of growth, colour, and ichorous discharge are not an adequate proof of cancer. The symptom, however, on which he is inclined to place the greatest dependence, as a mark of the change in question, is the almost cartilagi- nous hardness of the malignant ulcerated fungus, which induration, he, asserts, is not met with in the benign fungus, and never fails to precede the formation of cancer.—(See Scarpa, On tlie Eye, transl. by Briggs, edit. 2, p. 511— 513.) 4thly. The last difference of fungus hiematodes from cancer of the eye here to be noticed, is the pulpy soft- ness of the whole of the diseased mass in the first of these diseases; a character completely opposite to the firm almost cartilaginous consistence of the carcino- matous fungus. Before describing the operation of removing an eye affected with malignant disease, the following corolla- ries, drawn by Scarpa, should be recollected. 1. Tlie complete extirpation of the eye for the cure of fungus1 ha?matodes, although performed on the first appear- ance of the disease under the form of a yellowish spot deeply seated in the eye, is useless, and rather acce- lerates the death of the patient. But although this statement, made by Scarpa, may ■be mostly true, I am happy to say, that modern expe- rience begins to raise a hope that exceptions to the fore- going melancholy inference are possible. Thus Mr. Wishart removed from a boy nine years old an eye that had been affected with fungus hsematodes about four months, and no relapse had taken place eighteen months after the operation.—(See Edin. Med. and Surg. Journ. No. 74, p. 51.) 2. The exterior fungous excrescence of the eye, com- monly called carcinoma, beginning on the conjunctiva and anterior hemisphere, while it is soft, flexible, and pulpy, although accompanied with symptoms similar to those of carcinoma, is not actually this disease, nor does it become malignant and strictly cancerous until it is rigid, hard, coriaceous, warty, and in every re- spect scirrhous. 3. The inveterate fungous excrescence, hard to the touch in all its parts, covered with ulcerated warts, which has involved the whole of the eyeball, optic nerve, and surrounding parts, and rendered the bones of the orbit carious, and contaminated the lymphatic glands behind the angleof the jaw andin the neck, is incurable. 4. On the contrary the partial or total extirpation of the eye will succeed when attempted before the exter- nal fungous excrescence has changed from the state of soilness to that of a scirrhous, warty, and carcinoma- tous badness.—(Vol. cit. p. 526.) The operation of removing the eye was first per- formed in the sixteenth century by Bartiseh, a Ger- man, who employed a coarsely constructed instrument shaped like a spoon, with cutting edges, and by means of which the eye was separated from the surrounding parts, and taken out of the orbit. This instrument was too broad to admit of ready introduction to ttii deep contracted part of the orbit, so that when it was used either a part of the disease was likely to be left be- hind, or the thin bones of the orbit to be fractured in the attempt to pass it more deeply into that ca- vity. Fabricius HUdanus learned these inconveniences from experience, and in order to avoid them, devised a sort of probe-pointed bistoury. Bidloo made use of scissors and a pointed bistoury. EYE La Yauguyon is the first French surgeon who spoke of this operation; and all his countrymen may be said to have regarded the operation as useless, cruel, and dangerous, until St. Ives performed it with success. Heister preferred operating with the bistoury alone. Several Hnglish surgeons used a sort of curved knife, an engraving of which is given in B. Bell's system ; but for dissecting out the tumour this instrument was regarded by Louis as less convenient than a straight bistoury. Thus far the plans of operating advised by authors were not guided by any fixed rules. Louis endea- voured to lay down such rules, and for a long while his method was mostly adopted in France. It consists in dividing the attachments of the eye to the eyelids; then those of the small oblique muscle; next those of the great oblique muscle ; then those of the levator palpebra? superioris. varying, according to their inser- tions, the manner of holding the knife. The eyeball is afterward detached, and the four straight muscles and optic nerve divided with a pair of scissors. This way of operating, founded upon anatomical principles, seems at first glimpse to offer a method in which, as Louis remarks, each stroke of the instru- ment is guided by the knowledge of the parts. But it is to be noticed, that these parts, being altered by dis- ease, most commonly do not present the same struc- ture and relations which they do in the natural state ; and that the flattened, lacerated, destroyed muscles, on their being confused with the eye itself, cannot serve, as in lithotomy, for the foundation of any precept re- lative to the operation. Desault considered the scis- sors unnecessary, because the inclination of the outer side of the orbit will always allow a bistoury to be carried to the bottom of this cavity, so as to divide, from above downwards, the optic, nerve and muscular attachments. Hence, after having practised and taught the method of Louis, he returned to Heister's advice, who directs only a bistoury to be employed. To have an exact idea of the mode of operating, which is always easy and simple with this one instrument, we must sup- pose the carcinoma to be in three different states. 1. When the tumour hardly projects out of the orbit, so that the eyelids are free. 2. When it is much larger, projects considerably forwards, and pushes in this di- rection the healthy eyelids, which are in contact with it, together with a portion of the conjunctiva which invests them, and is now detached from them. 3. When, at a much more advanced period, the eyelids participate in the cancerous state. In the first case, the eyelids must be separated from the eye, by cut- ting through the conjunctiva, where it turns to be re- flected over the globe of the eye. In. the second in- stance, the eyelids and conjunctiva, which aie in con- tact with the diseased eye, must be dissected from it. In the third, these parts must be cut away, together with the eye.—((Euvres Chir. de Desault, t. 2.) After the above observations, and the additional in- formation on the subject, contained in the last edition of the First Lines ofthe Practice of Surgery, I shall conclude this article with a few brief directions. When the eyeball is exceedingly enlarged, it is ne- cessary to divide the eyelids at the external angle, in order to facilitate the operation. The surgeon ean in general operate most conveniently when he employs a common dissecting knife, and when his patient is lying, down with his face exposed to a good light. In cutting out a diseased eye, it is necessary to draw the part for- wards regularly as its surrounding attachments are divided, in order that its connexions, which are still more deeply situatiljjjlmay be reached with the knife. This ojyect cannot be very well accomplished with the fingers or forceps, aft***, therefore most surgical writers recommend us either* f.o introduce a Ugature through the front of the tumour (see Travers, Synopsis, p. 30b>1. or to employ a hook for'the purpose of drawing the part in any direction during the operation, which the ne- cessa* proceedings may require. When the eyelids are diseased, they must be removed; but if prudence sanctions their being preserved, this is an immense advantage. The eye must not be drawn out too forci- bly before the optic nerve is divided, and care must be taken not to penetrate any of the foramina, or thin parts EYE 367 i of the orbit with the point of the knife, for fear of in- juring the brain. Great care should also be taken to leave no diseased parts in the orbit unremoved. The hemorrhage may be stopped by filling the orbit with scraped lint, and applying a compress and bandage. It is constantly advisable to remove the lachrymal gland, as this part seems to be particularly apt to be the source of such inveterate fungous diseases as too often follow the operation. Mr. Travers, with a straight double-edged knife, freely divides the conjunctiva and oblique muscles, so as to separate the eyeball and lachrymal gland from the base of the orbit. Drawing the eye then gently forwards with the ligature, he introduces a double-edged knife, " curved breadthwise." at the temporal commissure of the lids, for the purpose of dividing the muscles, vessels and nerves, by which the globe remains at- tached. The hemorrhage he represses -with a small bit of fine sponge put into the orbit, and a light com- press applied over the eyelids, and supported with a bandage. The sponge, he says, should not be suffered to remain longer than the following day, when a soft poultice in a muslin bag may be substituted for the compress. He approves of giving an opiate at bed- time, and joins the late Mr. Ware in condemning the practice of cramming the orbit with lint, or charpie, and leaving it to be discharged by suppuration.—(Sy- nopsis of the. Diseases of the Eye, p. 308.) For a few days after the operation, antiphlogistic treatment is proper. The patient should be kept in bed until all risk from inflammation is past, and sup- puration has been freely established. In one case ope- rated upon by Mr. Guthrie, the symptoms of inflam- mation were so violent that it was necessary to take away 250 ounces of blood in the course ofthe first three days.—(Operative Surgery of the Eye, p. 183.) Sometimes fungous granulations continually form in the orbit, notwithstanding they are repeatedly destroyed; and sometimes the disease extends even to the brain, and produces fatal consequences. When malignant fungous excrescences grow from the comea alone, it is clearly unnecessary to extirpate the whole eyeball. For information relating to the subjects of this article, consult particularly M moire sur plusieurs Maladies du Globe de PiF.il; ou Pon examine particuliirement les cas qui exigent Pextirpation de cet organe, et la methode d'y procider; par M. Louis, in Mim. de PAcad. de Chir. 1.13, p. 262, edit, in 12mo. C. F. Kailtschmeid, Programma de oculo ulcere canceroso laborante fe- liciter extirpato, ic. Jena, 1748. J. G. G. Voit, Oculi Humani Anatomia et Pathologia ejusdemque in statu morboso Extirpatio, 8-uo. Norimb. 1810. Ber- trandi, Traiti des Opirations de Chirurgit, p. 519, ed. 1784, Paris. Sabatier, De la Mrdecine Operatoire, t. 3, p. 54, ed. 1. Richter, Anfangsgr. der Wundarzn. b. 3, p. 415, Gott. 1795. M moire svr PExtirpation dt PtEil Carcinomateux, in (Euvres Chir. de Desault par Bichat, t. 2, p. 102. Richerand, Nosographie Chir. t. 2, p. 103, ic. idit. 2. Ware, in Trans, of the Medical Society of London, vol. 1, part 1, p. 140, <$ c. Lassus, Patkologie Chir. t. 1, p. 450, edit. 1809. Wardrop on Fungus Hamatodes, p. 93, i-c. Scarpa on the Princi- pal Diseases of the Eye, chap. 21, edit. 2, transl. by Briggs, 8vo. Lond. 1818. B. Trovers, A Synopsis of the Diseases of the Eye, sec. 4, 8vo. London, 1820. /. H. Wishart, in Edin. Med. and Surg. Journ. No. 74. G. J. Guthrie, Operative Surgery of the Eye, p. 178, i-c. 8vo. Lond. 1823. EYE, DISEASES OF. See Amaurosis ; Cataract, Cornea; Encanthis; Exophthalmia; Fungus Ha- matodes; Gutta Serena; Hemeralopia; Hydroph- thalmia; Hypopium ; Iris; Leucoma; Nyctalopia; Ophthalmy; Pterygium; Pupil, Closure of; Staphylo- ma, i-cmirc. EYELIDS, DISEASES OF. SeeEctropium; Hor- deolum ; Lagopht.halmus; Ptosis ; Trichiasis; and Tumours, Encysted. In the examination of the Ulte- rior of the upper eyelid, a modem and very convenienl plan is now pursued, namely, that of everting the part over a probe placed just across the upper edge of the cartilage of the tarsus, which is then to be suddenly inclined outwards, when the whole inner surface of the lid will be exposed, the part continuing Ui thia everted state until replaced by the surgeon. ( 368 ) FEV F FEV "CIEVERS, SURGICAL. Under this head may be -■- comprehended two species of fever, viz. the in- flammatory and the hectic, which are particularly in- teresting to surgeons, because frequently attendant on surgical disorders. In treating of inflammation, I have mentioned that a febrile disturbance of the constitution is attendant on every considerable inflammation. In the present irticle, some account will be offered of the particulars of this disorder. The fever about to be described is known and dis- tinguished by several names, some calling it inflam- maiory, some symptomatic, and others sympathetic. It is supposed by certain writers to be sometimes idio- pathic; that is, to originate at the same time with the local inflammation, and from the same causes.—(/. Burns.) In other instances, and, indeed we may say, in all ordinary surgical cases, it is symptomatic; or, in other words, it is produced, not directly by the causes which originally produced the inflammation, but ui consequence of the sympathy of the whoie constitution with the disturbed state of a part- Mr. Travers's opinions seem partly to coincide with those of Mr. Burns, though differently expressed. He considers constitutional irritation to be of two kinds, direct and reflected ; by which he implies, " that the first is wholly and immediately derived from the part, commences and is identified with the local mischief, and the constitution has no share in its production. The second, on the contrary, originates in a peculiar morbid state of the constitution, to which the injury or inflammation has given birth, or it may be previously existing. The first is truly symptomatic, never ori- ginating spontaneously, and, being immediately in- duced by the local irritation, is capable of being essen- tially mitigated or arrested, by its removal. The se- cond is occasionally purely idiopathic, and, being oftener the cause than the effect of the local action, is seldom influenced by the local treatment. In the first, the local changes are dependent on local causes; in the second they depend on constitutional causes."— (See Travers on Constitutional Irritation, p. 47.) As the expression reflected irritation, if understood in its literal sense, involves the reader in an hypothesis which is perhaps not correct, I do not see any advan- tage in the employment of it. Used figuratively,how- ever, it may -be as allowable as many other expres- sions in medical language. Idiopathic inflammatory fever is said to be always preceded by chilliness. The symptomatic or sympa- thetic inflammatory fever sometimes takes place so quickly in consequence of the violence of the exciting cause or of the local inflammation, that no preceding coldness is observable. If, however, the local inflam- mation be more slowly induced, and consequently ope- rate more gradually on the system, then the coldness is evidently perceived. The symptomatic fever, in- duced by scalding or burning a part, is quickly pro- duced, and we have very little time to attend to the earliest period of its formation. On the other hand, the symptomatic fever induced by wounds is excited more slowly, and the period of its formation is longer. This fever is not produced when the inflammation only affects parts in a slight degree; but it makes its ap- pearance if the local inflammation be considerable, or if it affect very sensible parts.—(Burns.) The degree in which the symptomatic fever is ex- cited, does not altogether depend upon the absolute quantity or violence of the inflammation ; buf, in a great measure, upon the degree of the local inflamma- tory action, compared with the natural power and ac- tion of the part affected. Parts in which tbe action is naturally low, are extremely painful when inflamed, and the system sympathizes greatly with them. Hence the constitution is very much affected when tendons, bones, or ligaments are the parts inflamed. Severe inflammation of a large joint, every one knows, is apt to excite the most alarming and even fatal derange- ment of the system. When very sensible parts are inflamed, as, for instance, the eye, the symptomatic fever is generally mors considerable than it would be, were it to arise from an equal quantity and degree of inflammation in a less sensible organ. In common parts, as muscles, cellular membrane, skin, &c, the symptoms wUl be acute; the pulse strong and full, and the more so if the inflammation be near the heart; but perhaps not so quick as when the part is far from it: the stomach will sympathize less, and tbe blood will be pushed farther into the small vessels. If the inflammation be in tendinous, ligamentous, or bony parts, the symptoms will be le^s acute, the sto- mach wUl sympathize more, the pulse will not be so full, but perhaps quicker; there will be more irrita- bitity, and the blood, not being propelled so well into small vessels, wUl forsake the skin It seems to be a material circumstance whether the inflammation be in the upper or lower extremity; that is, far from or near the heart; for the symptoms are more violent, the censtitution more affected, and the power of resolution less, when tlie part inflamed is far from the source of the circulation, than when near it, even when the parts are simUar, both in texture and use. If the heart or lungs are inflamed,either immediately or secondarily, by sympathy, the disease has more vio- lent effects upon the constitution than the same quan- tity of inflammation would have if the part affected were not a vital one, or one with which the vital parts did not sympathize. If the part be such as the vital ones readily sympathize with, then the sympathetic action of the latter will affect the constitution, as in an inflammation of the testicle. In such cases the pulse is much quicker and smaller, and the blood is more sizy than if the inflammation were in a common part, such as muscle, cellular membrane, and skin. When the stomach is inflamed, the patient feels an oppression and dejection through all the stages of the inflammation; the pulse is generally low and qnick, and the pain obtuse, strong, and oppressive ; s-uch as the patient can hardly bear. If the intestines are much affected, the same symptoms take place, especially if the inflammation be in the upper part of the canal; but if only the colon be affected, the patient is more roused, and the pulse is fuller than when the stomach alone is inflamed. When the uterus is inflamed, the pulse is extremely quick and low. When the inflammation is either in the intestines, testicle, or uterus, the stomach generally sympathizes. In inflammation of the brain, the pulse varies more than Ui the same affection of any other part; and perhaps we must, in this instance, form a judgment of the complaint more from other symptoms than the pulse. When inflammation is situated in a part not very es- sential to life, and occasions the general affection of the system, called inflammatory fever, the pulse is fuller and stronger than common, and the blood is pushed farther into the extreme arteries than when the inflam- mation is in a vital part. The patient, after many oc- casional rigours, is at first rather roused. The pulse is as above described, when the constitution is strong and not irritable; but if this be extremely irritable and *eak, as in many women who lead sedentary lives, the pulse may be quick, hard, and small, at the com- mencement of the inflammation, just as if the vital parts were concerned. The blood may also be sizy ; but it will be loose and flat on the. suriace.—(Hunter.) The kind of constitution makes a great difference; and, as Mr. Travers has justly observed, "it is scarcely necessary to illustrate the influence of an ir- ritable temperament upon the consequences of casual injury or disease. Practically, we all know it well. We say, such a person would be a bad subject for a compound fracture; and whoever has had opportuni- ties of watching several subjects of compound frac- ture under treatment at one and the same time, weU knows the import of this phrase, and that the greatest degree of mischief is often accompanied by the least constitutional disturbance, and for this reason ia soonest and most perfectly restored. The first few hours will enable an experienced observer to determine whether the subject of a serious injury or operation FEVERS. , 369 will do well or otherwise. How vastly different in different individuals is the inconvenience attending such minor derangements as a bile, an enlarged gland, a whitlow, or a simple ophthalmia! In some, the con- stitution seems ignorant of the affair, and the indivi- dual pursues his ordinary occupations. In others, the whole system sympathizes; the spirits are ruffled; the nights are restless, the appetite fails; the pulse acquires an undue bound; and the white tongue, the creeping chilliness, and slight erratic pains of symp- tomatic fever are present."—(Travers on Constitu- tional Irritation, p. 15.) We may set down the ordinary symptoms of inflam- matory fever, occurring in consequence of local in- flammation in common parts and in a healthy habit, ks follows: The pulse is frequent, full, and strong; all the secretions are diminished; the patient is vigi- lant and restless; the perspiration is obstructed, and Ihe skin is hot and dry; the urine is high-coloured and in small quantity; the mouth is parched and the tongue furred; an oppressive thirst is experienced; with dis- turbance of the nervous system; loss of appetite and sleep; and, in some cases, delirium. TREATMENT OF INFLA.MMA.T0RY FEVER. Upon this part of the subject very little is to be said; for as, in almost every instance, the febrile disturbance of the system is produced and entirely kept up by the local inflammation, it must be evident that the means employed for diminishing the exciting cause, are also the best for abating the constitutional effects. Hence it very seldom happens that any particular measures are adopted expressly for the fever itself; us this af- fection is sure to subside in proportion as the local in- flammation is lessened or resolved. But when the febrile disturbance is considerable, and the inflamma- tion itself is also considerable, the agitated state of the system may have in its turn a share in keeping up and even increasing the local affection, and should be quieted as much as possible. However, in these very instances, in all probability, we should be led to a more rigorous adoption of the antiphlogistic plan of treatment, by an abstract consideration of the state of the local inflammation itself, without any reference to that of the constitution. Indeed, the increased action of the heart and arteries, and the suppression of the secretions, require the employment of antiphlogistic means and antimonials, the very same things which are indicated for the resolution of the local inflamma- tion itself. Bleeding, purging, cold drinks, low diet; the exhibition of the antimonium tartarizatum, James's powder, or the common antiiponial powder; and bath- ing the feet and body in warm water, are measures which have the greatest efficacy in tranquillizing the constitutional disturbance implied by the term inflam- matory fever. But I think it right to repeat, that it is hardly ever necessary to have recourse to such an eva- cuation as general bleeding merely on account of the fever; as this is only an effect which invaria- bly subsides in proportion as the local cause is dimi- nished. As Dr. Thomson has remarked, " the inflammatory fever, succeeding to external injuries or to chirurgical operations, undergoes a kind of natural crisis, by the appearance of suppuration. In these instances, there- fore, unless when the patient is strong andmfull health, when the disease is seated in an organ of much im- portance to life, or is in danger of spreading, as is the ca i.- in all inflammations of the membranes lining the three great cavities of the body, the lancet ought to be used with caution. For we may, by too free a detrac- tion of blood, produce a sudden sinking of the powers of life, and convert the existing constitutional symp- toms into fever of a different type or character. But in all cases of inflammation in which any doubt arises with regard to the farther general detraction of blood, it may, I believe,"ue laid down as a general rule, that it is safer to employ local than general blood-letting."— (Lectures on Inflammation, p. 170.) • HECTIC FEVEB. The sympathetic or symptomatic fever already de- scribed i* an immediate affection of the constitution, in consequence of some local disorder; hectic fever is a remote effect. When hectic fever is a consequence of local disease, it has <«mmonly been preceded by in- flammation and suppuration; but there is an inability Vol. I.-A « to produce granulation and cicatrization ; and the cure, of course, cannot be accomplished. The constitution may now be said to be oppressed with a local disease or irritation from which it cannot deliver itself. A distinction should be made between hectic fever arising entirely from a local complaint in a good con- stitution, which is only disturbed by too great an irrita- tion, and hectic fever arising principally from the bad- ness of the constitution, which does not dispose the parts to heal. In the first species it is only necessary to remove the part (if removable), and then all will do well; but in the second, nothing is gained by a removal of the part, unless the wound made.in the operation is much less, and more easily put into a local method of cure; by reason of which the constitution sinks less under this state and the operation together, than under the former disease. Here the nicest discrimina- tion is requisite.—(Hunter.) « Owing to a variety of circumstances, hectic fever comes on at very different periods after the inflammation, and commencement of suppuration. Some constitu- tions, having less powers of resistance than others, must more easily fall into this state. Hectic fever takes its rise from a variety of causes, which have been divided into two species with regard to diseased parts; viz. parts called vital, and others not of this nature. Many of the causes of hectic fever, arising from diseases of the vital parts, would not produce this constitutional affection if they were in any other part of the body; such, for instance, is the situation of tumours, either in, or so situated as to press upon a vital part, or one whose functions are immediately connected with life. Scirrhi in the sto- mach and mesenteric glands, diseased lungs, liver, &c. very soon produce hectic fever. When hectic, fever arises from a disease of a part that is not vital, it commences sooner or later, accord- ing as it is in the power ofthe part to heal or continue the diseasy. If the part be far from the source of the circulation, the fever will come on sooner with the same quantity of disease. When the disease is in parts which are not vital, and excites hectic fever, it is gene- rally in situations where so much mischief happens as to affect the constitution, and where the powers of healing are little. This is the case with diseases of many of the joints. We must also include parts which have a tendency to such specific diseases as are not readily cured in any situation. Although hectic fever commonly arises from some incurable local disease of a vital part, or from an ex- tensive disease of a common part, yet it is possible for it to be an original disease in the constitution, without any local cause whatever that can be specified. Hectic is a slow mode of dissolution; the general symptoms are those of a low or siow fever, attended with weakness. But there is rather weak action than real weakness; for upon the removal of the hectic cause, the action of strength is immediately produced, and every natural function is re-established, however much it may have been previously impaired. The particular symptoms are debility; a small, quick, and sharp pulse; the blood forsakes the skin; loss of appetite; frequently a rejection of all aliment from the stomach; wasting; a great readiness to be thrown into sweats; spontaneous perspirations, when the patient is in bed ; pale coloured and very copious urine; and often a constitutional purging. Hectic fever has been imputed to the absorption of pus into the circulation; but no doubt much exaggera- tion has prevaUed in the doctrine which ascribes to this cause many ofthe bad symptoms frequently attacking persons who have sores. When suppuration takes place in particular parts, especially vital ones, hectic fever almost constantly arises. It also attends many inflammations before, suppuration has actually; hai»- pened, as in cases of white swelling ofthe large joints. The same quantity and species of inflammation and suppuration in any of the fleshy parts, especially such as are near the source of the circulation, have in gene- ral no such effect. Hence, in the first instances, the fever is only an effect on the system, produced by a local complaint that has a peculiar property The constitution sympathizes more readily with dis- eases of vital organs, than with those of any othei parts; their diseases are also in general more difficult of cure than the same affections of parts which are nol vital. All diseases of bones, ligaments, and tendons 370 FEV FIN affect the constitution mpre readily than those of mus- cles, skin, cellular membrane, &c. When the disease is in vital parts, and is such as not to kill by its first constitutional effects, the system then becomes teased with a complaint which is dis- turbing the necessary actions of health. In the large joints, a disease continues to harass the constitution by attacking parts which have no power, or rather no dis- ■ position, to produce salutary inflammation and suppu- ration. Thus, the system is also irritated by the existence of an incurable disease. Such is the theorv of the cause of hectic fever. If the absorption of matter always produced the symptoms aDove described, how could any patient who has a large sore possibly escape hectic ? for there is no reason to suppose that one sore can absorb more readily than another. If absorbed matter occasioned such violent effects as have been commonly ascribed to it, why does not venereal matter do the same? We often know that absorption is going on by the progress of buboes. A large one, just on the point of bursting, has been known to be absorbed, in consequence of a few days' sea-sickness. The person continued at sea for four-and-twenty days afterward, yet no hectic symptoms followed, but only the specific constitutional effects, which were of a very different description. When the cavities of veins are inflamed, matter is sometimes formed within these vessels, and cannot faU to get into the circulation; yet hectic symptoms do not arise. Also very large collections of matter, produced without visible inflammation, as many abscesses of the scrofulous kind, are wholly absorbed in a very- short time, but no bad symptoms are the consequence. We may conclude, therefore, that the absorption of pus has no share in occasioning hectic fever. Many arguments might be adduced to expose the absurdity of the doctrine; but here it wUl be sufficient to refer the reader to what Mr. Hunter has said farther on the sub- ject, in his work on inflammation It is much more probable that hectic fever arises from the effect, which the irritation of a vital organ, or other parts, such as joints, has on the constitution, when either incurable in themselves, or are so for a time to the constitution TREATMENT OF HECTIC FEVER. There is no method of curing the consequences above related. All relief must depend on the cure of the cause, viz. the local complaint, or on its removal. Tonic medicines have been recommended, on account of the evident existence of great debility. Antiseptics have also been given, in consequence of the idea, that when pus is absorbed, it makes the blood disposed to putrefy. For these reasons, bark and wine have been exhibited. In most cases, bark will only assist in sup- porting the constitution. Until the cause is removed, however, there seems no prospect of curing a disorder of the constitution. It is true, tonic medicines may make the system less susceptible of the disease, and also contribute to diminish the cause itself, by dispos- ing the local complaints to heal. When, however, hectic fever arises from a specific disease, such as the venereal, though bark may enable the constitution to bear the local affection better than it otherwise could do, yet, as Mr. Hunter remarked, it can have Uttle effect upon the syplulitic mischief. No medicine, not even bark itself, has any direct power of communicating strength to the human con- stitution. All that can be done in the treatment of hectic fever, when it is thought inexpedient or imprac- ticable to remove the morbid part, is to combat particu- lar symptoms, and to promote digestion. It is by bringing about the latter object that bark in these cases is useful. The infusion of cinchona, and the sulphate of quinine, being more likely to agree with the stomach than the decoction or powder, should ge- nerally be preferred. Nourishing food, easy of diges- tion, should be frequently taken in small quantities at a time. Nothing is more prejudicial to a weak con- stitution than overloading the stomach. Wine may also be given, but not too freely, and not at all if it should create heartburn, as it sometimes does in hectic patients. Madeira is less apt than port to have this dis- agreeable effect. In these cases it is likewise often found useful to administer gentle cordial aromatic draughts. But of all medicines, opium is perhaps the most valu- able to those who are afflicted with hectic fever; it alleviates pain, procures sleep, and checks the diarrhcr-a, which so frequently contributes to hasten the patient's dissolution. When the local complaint connected with this fever is totally incurable, it must, if possible, be removed by a manual operation. Thus, when a diseased joint keeps up hectic fever, and seems to present no hope of cure, amputation must be performed. But when the local disease is attended with a chance of cure, pro- vided the state of the constitution were improved, tha surgeon is to endeavour to support the patient's strength. Great discretion, however, must be exercised in de- ciding how long it is safe to oppose the influence of an obstinate local disease over the system, by the power of medicine; for, although some patients in an abject state of weakness have been restored to health by a removal of the morbid part, many have been suffered to sink so low, that no future treatment could save them from the grave. Clemency in the practice of sur- gery does not consist so much in delaying strong and vigorous measures, as in boldly deciding to put them in execution as soon as they are indicated. When hectic fever arises from local diseases in parts which the constitution can bear the removal of, such parts should be taken away, if they cannot be cured consistently with the advice already given. When the disease arises from some incurable disease in an extremity, and amputation is performed, all the above- mentioned symptoms generaUy cease almost immedi- ately after the removal of the limb. Thus, as Mr. Hunter has correctly observed, a hectic pulse at one hundred and twenty has been known to sink to ninety in a few hours after the removal ofthe hectic cause. Persons have been known to sleep soundly the first night afterward, who had not slept tolerably for several preceding weeks. Cold sweats have stopped immedi- ately, as well as those called colliquative. A purging has immediately ceased, and the urine begun to drop its sediment. FICATIO, or FICUS. (A fig.) A tubercle about the anus or pudenda resembling a fig. FINGERS, ABSCESSES OF. See Whitlow. Fingers, Amputation of. See Amputation. Fingers, Necrosis of. In these cases, the surgeon is to endeavour to extract the exfoliating portions of bone immediately they become loose. For this pur- pose, he is justified in making such incisions as will enable him to fulfil the object in view. Until the pro- cess of exfoliation is sufficiently advanced, he can do little more than apply simple dressings, and keep the part in a clean, quiet state. When the separation of the dead pieces of bone wUl certainly destroy the utility of the finger, and convert the part into an inconvenient, stiff appendage to the hand; or, when the patient's health is severely im- paired by the irritation of the disease, the termination of which cannot be expected within a moderate space of time; amputation is proper. It is a truth, however, that many fingers are amputated which might be pre- served ; and surgeons ought to consider well before presuming to remove parts which, when curable, may become ofthe greatest consequence in regard to the perfection ofthe hand. The bread of many persons, it is weU known, depends on the unmutUated state of certain fingers. These remarks are offered, because I have seen several surgeons, fond of seizing every oppor- tunity of cutting then: fellow-creatures, remove fingers which might have been usefully saved, either by allot- ting a Uttle more time for the exfoliation, or by making incisions, and cutting out the dead piece of bone.—[fcee note on article Whitlow.] Fingers, Dislocations of. See Dislocation. Fingers, Fractures of. See Fracture. Fingers, supernumerary. The instances of chil- dren bom with a smaUernumber of fingers than natural are more rare than cases in which the number is greater than usual. Of the latter malformation, exam- ples were noticed in times of great antiquity. Thus, in the 1st book of Chronicles is the foUowing notice of such an occurrence: " There was war at Gath, where was a man of great stature, whose fingers and toes were four-and-twenty, six on each band, and six on each foot."—(Chap. xx. t>er. 6.) Anne Boleyn, so cele- brated for her beauty and her misfortunes, had six fingers on her right hand. Pliny, the naturalist, speaks of two sisters, who had six fingers on each "of their hands. In the Memoirs of the Royal Academy of Set- FIS FIS 371 ences for 1743, is the account of a child which was shown at one ofthe meetings, and had six toes on each foot, and the same number of fingers on each hand. In each foot there were six metatarsal bones, and in the left hand an equal number of metacarpal bones; but in the right hand there were only five, the outer one of which had two articular surfaces, one for the little, and the other for the supernumerary finger. In the Copen- hagen Transactions, T. Bartholine has inserted the description of a very curious skeleton; on the right hand there were seven fingers, on the left six; and besides these circumstances, the thumb was double. On the right foot there were eight toes, on the left, nine; the right metatarsus consisting of six bones, the left of seven. Saviard speaks of a still more curious case: he saw a new-born infant at the HOtel-Dieu, at Paris, which had ten fingers on each hand, and ten toes on each foot; the phalanges seemed as if they were all in a broken, imperfect state.—(Obs. de Chir.) The example of the greatest number of fingers and toes is recorded by Voight: including the thumb, there were thirteen fingers on each hand, and twelve toes on each foot.—(Mag. fur das neuesteder Naturkunde, b. 3, p. 174.) Individuals are occasionally born with two thumbs on the same hand.—(Panarolus, Oentec. 3, Obs. 4-8.) Since allowing the redundant number of fingers to remain would keep up deformity, and create future in- convenience, the surgeon is called upon to amputate them. The redundant fingers are sometimes with, sometimes without, a nail; seldom more numerous than one upon each hand; generally situated just on the out- Bide of the little fingers ; and, as far as my observation extends, incapable of motion, in consequence of not being furnished like the rest ofthe fingers with muscles. For the most part the phalanges are also imperfectly formed or deficient. The best plan is to cut off supe- numerary fingers with a scalpel at the place where they are united to the other part of the hand. The operation should be performed While the patient is in the infant state, that is to say, before the superfluous parts have acquired much size, and while the object can be accom- plished with the least pain. The incisions ought to be made so as to form a wound with edges which will ad- mit of being brought together with strips of adhesive plaster. As soon as the dressings are applied, the he- morrhage will almost always cease without a ligature. FISSURE. (From flndo, to cleave asunder.) A very fine crack in a bone is so called. FISTULA, in surgery, strictly means a sore which has a narrow orifice, runs very deeply, is callous, and has no disposition to heal. The name is evidently taken from the similitude which the long cavity of such an ulcer has to that of a pipe or reed. A fistula com- monly leads to the situation of some disease keeping up suppuration ; and from which place the matter can- not readily escape. No technical term has been more misapplied than this; and no misinterpretation of a word has had worse influence in practice than that of the present one. Many simple, healthy abscesses with small openings have too often been called fistulous; and being considered as in a callous state, the treat- ment pursued has in reality at last rendered them so, and been the only reason of their not having healed. FISTULA IN ANO. See Anus. FISTULA LACHRYMALIS. In correct language, this term can be applied only to one case, viz. that in which there is an ulcerated opening in the lachrymal sac, unattended with any tendency to heal, and from which opening a quantity of puriform fluid is from time to time discharged, especially when the lachrymal sac is compressed. Such has been the confusion, however, respecting the nature of the diseases of the lachrymal passages, and so great has been the force of ancient custom, that down to the present time the generality of British, as well as foreign, surgeons, imply by the expression fistula lachrymalis several forms of dis- ease, totally different from each other, and to only cne of which the name is at all applicable. In order not to assist in perpetuating this absurd and erroneous plan, from which nothing but mistakes and ignorance can result, I shall follow the examnle pointed out by Beer, Schmidt, and our countryman Mr. M'Renzie, and consider the various forms of disease to which the lachrymal pas- sages are subject, not under the head of fistula lachry- malis, but under the more sensible title, Lachrymal Organs, Diseases of the. Aa2 FISTULA IN PERINJEO. As Sir Astley Cooper has justly observed, incisions in the urethra generally heal with great faculty; a fact amply proved by the eommon result of the lateral operation; but when apertures are formed in the urethra, either from dis- eased states of the constitution and the part together, or of the latter alone, and when they are accompanied with any considerable destruction of the sides of the urethra, and of the corpus spongiosum, they are mostly very difficult to cure.—(Surg. Essays, pt. 2, p. 211.) When the methods recommended for the removal of strictures (see Urethra, Strictures of) have not been attempted, or not succeeded, nature endeavours to re- lieve herself by making a new passage for the urine, which, although it often prevents immediate death, yet if not remedied is productive of much inconvenience and misery to the patient through life. The mode by which nature endeavours to procure relief is by ulcera- tion on the inside of that part of the urethra which is enlarged, and situated between the stricture and the bladder. Thus the urine becomes applied to a new surface, irritating the part, and occasioning the forma- tion of an abscess into which the urine has access; and when the matter is discharged, be it by nature or by art, the urine passes through the aperture, and ge- nerally continues to do so while the stricture remains. —(A. Cooper, Surgical Essays, part 2, p. 212.) The ulceration commonly begins near or close to the stricture, although the stricture may be at a consider- able distance from the bladder. The stricture is often included in the ulceration, by which means it is re- moved ; but unluckily this does not constantly happen. The ulceration is always on the side of the urethra next to the external surface. The internal membrane and substance ofthe urethra having ulcerated, the urine readily gets into the loose cellular membrane of the scrotum and penis, and dif- fuses itself all over those parts; and as this fluid is very irritating to them, they inflame and swell. The pre- sence of the urine prevents the adhesive inflammation from taking place; it becomes the cause of suppuration wherever it is diffused ; and the irritation is often so great that it produces mortification, first in all f he cellular membrane, and afterward in several parts of the skin; all of which, if the patient live, slough away, making a free communication between the urethra and external surface, and producing what are termed fistula in perinao, though it is plain enough to every surgeon who knows the correct meaning of the word fistula, that a recent opening, produced in the perina?um by ulceration or sloughing, ought not to be called a fistula immediately it is formed, and at least not until it has acquired some of the characters specified in our expla- nation of the term fistula. According to Mr. Hunter, when ulceration takes place farther back than the portion of the urethra be- tween the glans penis and membranous part of the canal, the abscess is generally more circumscribed. The urine sometimes insinuates itself into the corpus spongiosum urethra, and is immediately diffused through the whole, even to the glans penis, so as to produce a mortification of all those parts. A fatal in- stance of this kind is reported by Mr. C. Bell.—(Surgi- cal Obs. vol. 1, p. 98.) Although the ulceration of the urethra may be in the perinseum, yet the urine generaUy passes easily for- wards into the scrotum, which contains the loosest cel- lular substance in the body; and there is always a hardness extending along the perinasum to the swelled scrotum in the track ofthe pus.—(Hunter.) Sir Astley Cooper is of opinion, that as soon as the abscesses, which are the forerunners ofthe fistula, can be plainly felt to contain a fluid, it is the best practice to open them with a lancet. The extensive destruction of parts by ulceration will thus be prevented; the place not unfrequently then heals up expeditiously without any fistulous orifice being left, and a tendency to those ' dangerous extravasations of urine is also prevented, which, if the abscesses are not opened early, often prove destructive to life.—(Vol. cit. p. 212.) Ulceration can only be prevented by destroying the stricture; but when the urine is diffused in the cellular : membrane, the removal of the stricture will generally be too late to prevent all the mischief, although it wUl ■ be necessary for the complete cure. Therefore, an at- ! tempt should be made to pass a bougie, for perhaps the stricture may have been destroyed by the ulceration, so 372 FIS FLU as to allow fhe instrument to be introduced. When tins is the case, bougies must be almost constantly used, in order to procure as free a passage as possible. in these cases, Sir A. Cooper expresses a preference to metaltic bougies, the size of which is to be gradually increased untU their diameter exceeds the natural dia- meter of the passage In some instances, however, he says, that it will De necessary to introduce a pewter catheter, of large size, and to allow it to remain in the bladder, so as at once to act upon the stricture, and hinder the urine from passing through the preternatural opening. In this manner a permanent cure may often be effected. Although this experienced surgeon agrees with most surgeons of the present day, respecting the general inexpediency of employing caustic for the re moval of a stricture, under the preceding circumstances, yet he admits that instances do present themselves, in which, from long neglect, the urethra and the parts surrounding the stricture are so altered in structure, that no instrument can be passed through the obstruction without danger, and where the slower action of caustic is safer than the use of a metalUc bougie.—(Surgical Essays, part 2, p. 213.) The experience of modern surgeons tends to prove, however, that there are some cases which form exceptions to the plan of employing bougies or catheters, though a fistulous opening may have occurred in the passage. These cases are the examples in which the apertures in the urethra are the consequence of ulceration and abscess, unaccompanied by stricture, and taking place in a bad constitution, and perhaps oidy preceded by a slight discharge from the urethra. Here bougies would increase the tendency to ulceration, and aggravate the local and constitutional irritation.—(A. Cooper, p. 216.) WhUe we are attempting to cure the stricture, anti- phlogistic measures, particularly bleeding, are to be adopted. The parts should be exposed to the steam of hot water; the warm bath made use of; opium and turpentine medicines given by the mouth and in glys- te*s, with a view of diminishing any spasmodic affec- tion. But, as Mr. Hunter observes, all these proceed- ings are often insufficient; and therefore an immediate effort must be made, both to unload the bladder and to prevent the farther effusion of urine, by making an opening in the urethra somewhere beyoud the stricture, but the nearer to it the better. Introduce a director, or some such instrument, into the urethra, as far as the stricture, and make the end of it as prominent as possible, so as to be felt; which, in- deed, is often impossible. If it can be felt, it must be cut upon, and the incision carried on a little farther to- wards the bladder or anus, so as to open the urethra be- yond the stricture. This will both allow the urine to escape, and destroy the stricture. If the instrument can- not be felt at first by the finger, we must cut down to- wards it; and on afterward feeUng it, proceed as above. When the stricture is opposite the scrotum, as the opening cannot be made in this situation, it must be made in the perinseum ; in which case, there cau be no direction given by an instrument, as it will not pass sufficiently far, and the only guide is our anatomical knowledge. The opening being made, proceed as di- rected in the cure of a false passage.—(See Urethra, False Passage of,) In whcihsoever way the operation is done, a bougie, or a catheter, which is better, must afterward be introduced, and the wound healed over it. When the inflammation from the extravasation of urine is attended with suppuration and mortification, the parts must be freely scarified, in order to give vent both to the urine and pus. When there is sloughing, the incisions should be made in the mortified parts. Sometimes, when thS urethra is ulcerated, and the ceUular membrane of the penis and prepuce is so much distended as to produce a phymosis, it is impossible to find the orifice of the urethra. Frequently the new passages for the urine do not heal, on account of the stricture not being removed : and even when this has been cured, they often will not heal, but become truly fistulous, and produce fresh in- flammation and suppurations, which often burst by- distinct openings. Such new abscesses and openings often form in consequence of the former ones having become too small before the obstruction in the urethra is removed. Such diseases sometimes bring on intermittent disor- ders, which do not yield to bark, but cease as soon as the fistula? and disease ofthe urethra have been cured. In order to cure fistula? in perinaeo, unattended Willi the above-described urgent symptoms, the urethra must be rendered as free as possible, and this alone is often enough; for the urine, finding a ready passage forwards, is not forced into the internal mouth of the fistulae, which therefore heal up. The cure of the strictures, however, is not always sufficient, and the following operation becomes indispensable. The sinuses are to be laid open in the same manner as other sinuses, which have no disposition to heal. In doing this, as little as possible of the sound part of the urethra must be opened. Hence the surgeon must di- rect himself to the inner orifice of the flstuls, by means of a staff, introduced (if possible) into the bladder, and a probe passed into one of the fistulous passages. The probe should be first bent, that it may more readtiy follow the turns of the fistula. When it can be made to meet the staff, so much the better; for then the ope- rator can just cut only what is necessary. When the fistula is so straight, as to admit of a di- rector being introduced, this instrument is the best. When neither the probe nor the director can be made to pass as far as the staff, we must open the sinuses as far as the first instrument goes, and then search for the continuation of the passage, for the purpose of laying it open. The difficulties of this dissection, however, in the thickened, diseased state of the parts in the scrotum and perina"um, are such as can only be duly appreciated by a man who has either made the attempt himself, or seen it made by others. I have myself seen one of the first anatomists in London fati in two instances to trace the continuation of the urethra, and baffled in the en- deavour, therefore, to pass an instrument from the orifice of that passage into the bladder. The difficulty and confusion, arising from the hardened, enlarged state of the parts, which are to be cut, have been well de- picted by Mr. C. Bell.—(Surgical Obs. vol. 1, p. 129.) Having divided the fistulae as far as their termination in the urethra, a catheter should be introduced and worn, at first, almost constantly. Tliis is better than a bougie, which must be frequently withdrawn to allow the patient to make water, and it often could not be in- troduced again without being entangled in the wounds. In many cases the employment of the catheter should not be continued after a certain period. At first, it often assists the cure; but, in the end, it may obstruct the healing, by acting at the bottom of the wound, as an extraneous body. Hence, when the sores become stationary, let the ca- theter be withdrawn, and introduced only occasionaUy. And even after the sores are well, it will be prudent to use the bougie, in order to determine whether the pas- sage is free from disease. When fistula? in perinseo have been laid open, the wounds are to be at first dressed down to the bottom as much as possible, which wtil prevent the reunion of the parts first dressed, and make the granulations shoot from the bottom, so as to consolidate the whole by one bond of union.—(Hunter on the Venereal Disease, ed. 2.) Additional observations upon this subject, and, in particular, the opinions of Desault, will be found in the article Urinary Abscesses and Fistula. Sir A. Cooper's practice, in cases where a considerable portion of the urethra has been destroyed, will be hereafter no- ticed.—(See Urethra.) FISTULA, SALIVARY. See Parotid Duct. FLUCTUATION. (From fiudo, to float.) The per- ceptible motion communicated to any coUection of puru- lent matter, or other kind of fluid, by applying the fin- gers to the surface of the tumour, and pressing with them alternately, in such a manner that the fingers of one hand are to be employed in pressing, or rather in briskly tapping upon the part, while those of the otheT hand remain lightly placed on another side of the swell- ing. When the ends of one set of fingers are thus deUcately applied, and the surgeon taps, or makes re- peated pressure with the fingers of the other hand, the impulse given to the fluid is immediately perceptible to him, and the sensation thus received is one of the prin- cipal symptoms by which practitioners are enabled to discover the presence of fluid in a great variety of cases. Great skUl in ascertaining by the touch the presence of fluid in parts, or being endued with the tadus eruditus, as it is termed, distinguishes the man of experience as remarkably, perhaps, as any quality that can be specified. When the collection of fluid is very deeply situated, the fluctuation is frequently exceedingly obscure, and FOR sometimes not at all distinguishable. In this circum- stance, the presence of the fluid is to be ascertained by the consideration of other symptoms. For example, in cases of hydrops pectoris and empyema, surgeons do not expect to feel the undulation of the fluid in the thorax with their fingers ; they consider the patient's difficulty of breathing, the uneasiness attending his lying upon one particular side, the cedema of the pa- rietes of the chest, the dropsical affection of other parts, the more raised and arched position of the ribs on the affected side, the preceding rigors, fever, and several other circumstances, from which a judgment is formed, both with regard to the presence and the peculiar na- ture ofthe fluid. r'OM ENTATION. By a fomentation, surgeons com- monly mean the application of flannel or towels, wet with warm water or some medicinal decoction. In the practice of surgery, fomentations are chiefly of use in relieving pain and inflammation, and in promoting sup puration, when this is desirable. Some particular de- coctions, however, are used for fomentations, with a view of affecting, by means of their medicinal qualities, scrofulous, cancerous, and other sores of a specific na- ture. I shall merely sul ->in a few of the most useful fomentations in common use. FOMENTUM AMMOM,*G MURIATE. * R. Fo- menti communis Ibij. Ammon. mur. ?'• Spirit. camph. 5 U- ■Just before using the hot decoction, add to it the am- monia muriata and spirit. Said to be of service to some indolent ulcers; and, perhaps, it might be of use in promoting the absorption of some tumours, and sup- puration in others. FOMENTUM CHAM^EMELI. R.Linicontusi *j. Chamaemeli 1 ij. Aq. distillat. Ibyj. Paulisper coque, et cola. A fomentation in very common use. FOMENTUM CONII R. Fol. conii recent, ibj. vel fol. conii exsiccat. § iij. Aq. comm. Ibiij. Coque usque reman. Ibij. et cola. Sometimes applied to scrofulous, cancerous, and phagedenic ulcers. FOMENTUM GALL.dE. R. Galla? contusa? --ss. Aq. ferventis Ibij. Macera per horam, et cola. Used for the prolapsus ani, and sometimes employed as a cold application, in cases of hemorrhoids. FOMENTUM PAPAVERIS ALBI. R. Papav. alb. exsiccati, "5 iv. Aq. pur. Ibvj. Bruise the poppies, put them in the water and boil the liquor, till only a quart remains, which is to be strained. This fomentation is an excellent one, for very painful inflammations of the eyes, and for numerous ulcers and other diseases, at- tended with intolerable pain. FORCEPS. An instrument much employed in surgery for a variety of purposes, and having accordingly va- rious constructions. The general design, however, of surgical forceps is to take hold of substances which cannot be conveniently grasped with the fingers; and, of course, the instrument is always formed on the prin- ciple of a pair of pincers, having two blades, either with or without handles, according to circumstances. The smallest forceps is that which is employed in the operation of extracting the cataract, and which is useful for removing any particles of opaque matter from the pupil, after the chief part of the crystalline lens has been taken away. Another forceps, of larger size, is that used for taking up the mouths of the arteries, when these vessels re- quire a ligature, in cases of hemorrhage. This instru- ment is also frequently employed for taking dressings off sores, removing pieces of dead bone, foreign bodies from wounds, and particularly for raising the fibres, which are about to be cut, in all operations where careftil dissection is required. This forceps resembles that which is contained in every case of dissecting in- struments, and is often called the artery or dissecting forceps, from its more important uses. Neither of the foregoing forceps is made with han- dles ; each opens by its own elasticity; and the ends of the blades only come into contact when pressed to- gether by the surgeon. The following kinds of forceps are constructed with handles, by means of which they are both opened and shut: 1. Tlie common forceps, contained in every pocket- case of surgical instruments, and used for removing dressings from sores, extracting dead pieces of bone, foreign bodies, Ac. 2. Larger forceps, employed for extracting polypi FRA 373 3. Forceps of different sizes and constructions, used in the operation of lithotomy, for taking the stone out of the bladder, or for breaking the calculus, when it is too large to be extracted in an entire state. 4. Cutting forceps, as the common bone-nippers, and the sharp forceps, made with the edges in the same line with the handles, used by Mr. Liston for the division of bones. FRACTURE is a. solution of continuity of one or more bones, produced in general by external force ; but occasionally, by the powerful action of muscles, as is often exemplified in the broken patella. The subject of fractures is so interesting a branch of surgery, and the accidents themselves so frequent and important, that the little which English surgeons have done for the improvement of this part of their profession cannot but cause equal surprise and regret. Mr. Pott, it is true, made many excellent observations on the treatment of fractures in general, and his remarks on compound fractures in particular are in some respects the best which are extant; but what surgeon wUl now presume to defend the weak arguments upon which he has founded the doctrine of paying unqualified attention to the relaxation of the muscles, as if this were an ob- ject which should constantly supersede every other consideration, and invariably regulate the posture of the limb? I have no hesitation in declaring my own belief, that the doctrine and practice recommended by Mr. Pott, in regard to fractured thighs has done consi- derable harm, and the more so, as coming from a man who was deservedly looked upon as one of the best and most experienced judges of surgical practice. Many a surgeon in this country implicitly believed every thing which was asserted by so able a master, and the very observations which some years ago were here consi- dered to be the glory of their author and the pride of English surgery, are now exposed by the surgeons of neighbouring countries, as specimens of wrong pre- cepts and bad practice. M. Roux, in fact, has had but too much room for animadversion upon this subject. Down to the period of his visit to this country, if we except some of Mr. Pott's observations on the use of tlie eighteen-tailed bandage, the necessity of quietude, the principles on which splints ought to be constructed, and the inestimable remarks on compound fractures by the same distinguished English surgeon, it cannot be said that we had made a single improvement of consequence in the treatment of any particular fracture, while the generality of our surgical writers had given the most faulty and imperfect account of the diagnosis, and every thing else relating to these accidents. What is worse, a view of our practice conveyed no better opinion of this part of our surgery. Observe the care and neat- ness with which a French surgeon applies the bandages and splints, and consider how well every indication is accomplished by his apparatus, and you wtil find great cause both for admiration and imitation. On the other hand, see the slovenly way in which an English sur- geon generally puts on the splints and roller, and the unscientific method in which he usually treats a frac- tured thigh or clavicle, and you cannot fail to be ashamed of the comparison. This was a matchless opportunity for M. Roux to draw a parallel in favour of French surgery, and of course he has not neglected it, many pages of his work being devoted to an explanation of the many improvements Desault made; the little, or ratherthe nothing, which we had done; and the errors, to which we unfortunately still adhere.—(See Voyagt fait a Londres en 1614, ou Parallile de la Chirurgie Angloise avec la Chirurgie Francoise, p. 173, ic.) It is to be hoped, however, that the period has now ar- rived, when we shall give to the study of fractures the time, the attention, and the importance which it claims; and when even the young hospital pupil will not be convinced, that his lecturer by one or two cursory dis- courses can have done justice to the subject. The ob- servations lately published by Sir Astley Cooper, on fractures of the joints, are indeed highly creditable to this part of English surgery, and afford satisfactory evidence of the increased attention which is now paid to the principles which ought to regulate the treatment of each individual example of the accident. In this article, my plan is to follow the arrangement adopted by Boyer, in his Traiti des Maladies Chirur- sicales, t. 3. I shall first speak of fractures in gene- ral, and allot separate sections to the consideration of, 1. Their differences ; 2. 'I'.wit causes, 3. Their synip- 374 FRACTURES. toms; 4. Their prognosis; 5. Their treatment; 6. The formation of callus. The subject will then conclude with a full account of the symptoms, causes, and treatment of the frac- tures of particular bones. 1. Differences of Fractures. The differences of fractures depend upon what bone is broken; what portion of it is fractured; the direction of the fracture; the respective position of the fragments; and lastly, upon circumstances accompanying the in- jury, and making it simple, compound,or variously com- plicated. 1. In respect to the bone affected.—Sometimes it is one of the broad bones, as the scapula, the sternum, or the os ilium. Sometimes it is a short bone, like the os calcis; but far more commonly it is one of the long bones. The situation and functions of the broad bones render their fractures unfrequent. The bones of the skuU are the only exception to this remark; for they are often broken; but here the assistance of the sur- geon is required less for .he solution of the continuity itself, than for the affection of the brain, and the extra- vasation of blood, with which the case is apt to be com- bined. Fractures of the short bones are still more un- usual, because these bones, being nearly equal in their three dimensions, are capable of greater resistance, and are not much within the reach of external vio- lence. Besides, most of them are but little exposed to the operation of outward force, by their situation or functions. Hence, except when limbs are crushed, fractures of short bones are generally caused by mus- cular action, which frequently breaks the patella, ole- cranon, and os calcis. The long bones, which serve as pillars, or arches of support, or levers, are, from the very nature of their functions, particularly liable to fractures. 2. In respect to the part of the bone broken.—Bones may be fractured at different points of their length. Most commonly, their middle portion is broken, and in this circumstance they usually break like a stick, which has been bent beyond its extensibility by a force ap- plied at each end of it. Sometimes the fracture occurs more or less near the extremities of the bone, which is always an unfavourable event. Lastly, the bone is sometimes broken in several places, and the injury may be produced by two different causes, which operate successively, or simultaneously, upon the broken parts of the bone; or it may be occasioned by one sit gle cause, whieh acts at the same moment upon several points of it. These distinctions of fractures, deduced from their particular situation (says Boyer), are not mere scholastic refinements; they have a truly import- ant influence over the prognosis and treatment. 3. In respect to tlie direction in which the bone is broken.—A bone may be fractured in various ways, Mid the fracture receives different names, according to its direction in regard to the axis of the bone. Thus, fractures are distinguished into transverse and oblique. The obtiquity renders the surface of the injury larger, and materially increases the difficulty of maintaining the ends of the bone in contact, after the fracture has been set ObUque fractures are subject to considerable variety, which depends upon the degree of their obli- quity, and whether they are partly oblique and partly transverse. When a bone is broken in different places at once, and divided into several fragments, or splinters, the fracture is termed comminuted. Duverney admitted another class of fractures, viz. lon- gitudinal.—(See Traite des Maladies des Os, t. 1, p. 167.) But such cases were regarded by J. L. Petit as only imaginary, because he conceiyed that any blow, capable of breaking a bone longitudinally, would much more readily cause a transverse fracture. For the same reason, Louis absolutely rejected the possibility of longitudinal fractures, and this sentiment has pre- vailed down to the present day. The following ease, however, is related by Leveille, in order to prove the possibility of longitudinal frac- tures. He amputated the thigh of an Austrian soldier who was put under his care in the year 1800, in conse- quence of being struck by a ball in the lower third of the leg at the battle of Marengo. The soldier had walked several miles, after receiving the injury, before he arrived at Pavia. The wound appeared simple and likely to heal as soon as the injured portion of the tibia had exfoliated. The event turned out otherwise, and the thigh was amputated. Leveille has preserved the tibia, upon which the im- pression of the ball may be distinguished, and from this point run several longitudinal and oblique lines, which extend from the lower third towards the upper head of tibia, and pass through the whole thickness of the pa- rietes of the medullary canal. They were acknow- ledged to be really longitudinal fractures, by Dubois, Chaufrier, Dumeril, Deschamps, and Roux, who were appointed by the Ecole de Medecine to inquire into the fact.— (Leveille, Nouvelle Doctrine Chir. t. 2, p. 158<.) In several cases of fractured thigh-bones from gun- shot violence, which were under the care of Dr. ( ole and myself in Holland, the bone was split longitudi- nally to the extent of seven or eight inches. The fact, however, that bullets and other balls do produce lon- gitudinal fractures, is now universally admitted ; and were there any doubt upon the subject, a specimen sent to England by my friend Dt. Cole, would soon remove it. Boyer, who, a few years ago, denied the possibi- lity of longitudinal fractures, in his late work remarks: " On trouve n-anmoins, a. la suite des plaits d'armes d feu, les os fendus suivant lew longueur, jusques dans leurs articulations,"—but he is correct when he adds, that such instances afford no proof of the possi- bility of a simple longitudinal fracture.—(See Traiti des Maladies Chir. t. 3, p. 10.) 4. In regard to the respective position of the frag- ments.—These differences are highly important to be understood, because, as Boyer remarks, the treatment of fractures consists almost entirely in remedying or preventing the displacement of the fragments. It is not to be supposed, however, that such displacement is an absolutely essential symptom of all fractures, for it seldom exists in members composed of two bones, when only one of tbem is broken. Neither does it con- stantly happen in every fracture of the neck of a bone, as is exemplified in certain fractures of the neck of the thigh-bone, the fragments of which sometimes change their relative situation only when the patient tries to walk, or the limb is imprudently moved about. Frac- tures of the leg are also observed, in which there is neither a displacement of the fragments, nor an altera- tion in the shape of the limb, especially when the tibia alone is fractured near its upper part, where it is very thick. When the ulra alone is broken at its upper part, there is hardly evei any displacement. The corres- ponding surfaces of the fragments having a large ex- tent cannot be separated, or can only be so with diffi- culty. Fractures of the fibula are also frequently un- attended with displacement. But it is a symptom, that almost constantly occurs when both bones of the leg or forearm are fractured together; as, also,in frac- tures of limbs whieh contain only one bone, on account of the little extent of the surfaces of the fracture, and the great number of muscles which tend to displace them. The displacement may happen in respect to the di- ameter, length, direction, or circumference of the bone. In respect to the diameter.—Transverse fractures are the only cases in which this kind of displacement is observed. The two fragments may either be in con- tact at a part of Iheir surfaces, or they may not be in contact at all. In the latter circumstance, the limb is shortened by the ends of the fracture slipping over each other. In respect to length.—This mode of displacement, in which the ends of the broken bone pass more or less over each other, constantly occurs in oblique fractures, and sometimes in transverse ones, when the displace- ment in the direction of the diameter of the bone has been such that the surfaces of the fracture are no longer in contact. It will be hereafter explained, that whenever the limb is shortened in fractures of the ex- tremities, ti is the lower fragment that is displaced. We may refer to the species of displacement here spoken of, that whieh takes place in fractures of tbe patella, olecranon, and os calcis; but with this differ- ence, that the fragments, instead of passing over each other separate from each other in the direction of the length of the bone, and continue separated by an inter- space more or less considerable. In respect to the direction of the bone.—In this kind of displacement, the two fragments form an angle more or less prominent, and the bone appears arched. It is principally observed in comminuted fractures. It may also happen in simple fractures; for instance, in the leg, when the limb in a straight posture does noi He upon a surface exactly horizontal, and the heel is lower than the rest of the limb. The angular projec- tion is then anterior. On the contrary, it would be pos- terior, if the heel were too much raised. In respect to the circumference of the bone.—This displacement occurs when the lower fragment performs a rotatory movement, while the upper one continues mo- tionless. Thus, in fractures of the neck of the femur, if the foot is badly supported by the apparatus, its weight, together with that of the limb and the action of the muscles, inclines it outwards, and turns the lower fragment in the same direction. Besides the simple displacements above described, there are others of a more complicated nature, which happen in several directions at once. For example, such is the displacement observed in a fracture of the thigh-bone, when the lower fragment is drawn upwards and inwards, while the foot is turned outwards. Let us next consider the causes of the displacement of fractures. The bones, being only passive instruments of loco- motion, possess not, in their own organization, any cause of the change of situation which takes place; but yield to the impulse of external bodies, the weight of the member, and the action of the muscles The displacement may be produced by an external force, either at the moment when the fracture happens, and by the very action of the fracturing cause itself: or it may be caused by the weight of the body when the fracture precedes the fall; or lastly, it may be brought on by some other external force, acting on the fragments, sooner or later, after the occurrence of the injury. The outward violence, which is productive of a frac- ture, operates sometimes directly on the situation of the breach of continuity; sometimes on parts more or less distant from it. In both cases, the action of the force is not confined to the production of tbe fracture, but is partly spent in causing a displacement of the fragments. Fractures are generally occasioned by falls. Some- times, however, the fall does not happen till after the leg or thigh is actually broken. The weight of the body then produces the displacement, by pushing the upper fragment against the soft parts, which are more or less lacerated. This is what happened to Ambrose Pare, who, being kicked by a horse, endeavoured to get out of the way, but instantly fell down, and the two bones of his left leg, whioti had been fractured, being impelled by the weight of the body, not only passed through the skin, but even through his stocking and boot. Boyer has seen a case nearly similar in a young man about twenty years of age, wIkl, in a standing posture, was struck on the middle of the thigh with the pole of a carriage, which fractured the. femur. The patient fell down, and in the faU the upper fragment was not only driven through the muscles and integu- ments, but also through his breeches. The weight of the limb itself may produce displace- ment according to the direction or circumference of the bone, as already detailed. The disturbance of the limb, also, in lifting the patient and carrying him to his bed, may sometimes alter the relative situation of the frag- ments, and cause them to be displaced. But of all the causes of the displacement of frac- tures, the action of the muscles is the common and most powerful one. Among the muscles surrounding a fractured bone, some are attached to it throughout its whole length, and are equally connected with both the fragments. Some arise from the bone above, and are inserted either into that which is articulated with the lower fragment, or into the lower fragment itself. Lastly, there are others which come from a point more or less distant, and terminate in the upper fragment. The muscles round the thigh-bone furnish examples of these three arrangements. The triceps is attached to the bone its whole length. The biceps, semi-mem- branosus, and seoii-tendinosus, come from the pelvis, and are inserted into the leg, a part with which the lower fragment is articulated, and all the motions of which it follows. The great head of the triceps is in- serted into this fragment itself. Lastly, the iliacus, psoas, pectineus, gicales. Whether the long bones can be fractured by the mere action of the^nuscles is yet an unsettled point. In the Philosophical Transactions a fracture of the humerus is ascribed tothis cause,and Botentuit saw the same accident produced by striking a shuttlecock with a baitledore. According to Debeaumarehef, as a man was descending a ladder at a quick rate, his heel got entangled in an opeiung, and he made a violent exer- tion to avoid falling. The consequence was a fracture of the lower third of the leg. Curet informs us that a cabin-boy, aged seventeen, made a considerable effort to keep himself from being thrown down by the rolling of the ship. The femur was fractured by the powerful ac- tion of the muscles of the thigh. The lad had no fall, and, with some difficulty, supported himself on the other limb till he received assistance. We are told, says Leveille, by Poup^e Desportes, that a negro, about twelve or thirteen years old, was seized with such violent spasmodic contractions of the muscles of the lower extremities, that the feet were turned backwards, and the neck of each thigh-bone was fractured, the ends of the broken bones also protniding through the skin ujioii the ouUide of the thigh. A cure was effected after an exfoliation. We read also, in the Miscellanea Curiosa Acad. Natura Curiosorum, that during a fit of epilepsy, a child ten years old had its left humerus and tibia broken, and that, upon opening the body, other solutions of con- tinuity were observed. Chamseru assisted in dressing a child, eleven or twelve years old, that had broken the humerus in throwing a stone a considerable distance.— (Leveilli, Nouvelle Doctrine Chir. t. 2, p. 1.64. 166.) Richerand, however, positively denies, that a long bone, when healthy, can ever be broken by the mere contraction ofthe muscles.—(Nosogr. Chir. t. 3, p. 12, edit. 4.) For my own part, making all due allowance for the inaccuracy of some of the reports made by writers, I think the possibiUty of the long bones being broken by Hi- violent action ofthe muscles is sufficiently proved. 1 bave never seen but one example; but it was a very- unequivocal one. I once attended, for the late Mr. Ramsden, an exceedingly strong man, at Pentonville, Who broke his os brachii in making a powerful blow, although he missed his aim and struck nothing at all. The whole limb was afterward affected with vast swelling and inflammation. This man, I remember, was also visited by Mr. Welbank, of Chancery-lane. According to Nicod, the greater number of fractures of long bones, by mere muscular action, are preceded by pains in the broken limbs; and in one ofthe cases pub- lished by this author, not only was this circumstance remarked, but an abscess and exfoliation of a portion of the fractured humerus ensued. In another instance reported by this gentleman, the clavicle in a state of preternatural fragility from disease, was fractured in an effort to carry the arm far behind the back. After the reunion of the fracture, an abscess took place, and a piece of the bone exfoliated.—(Annuaire Mid. Chir. des Hdpitaux de Paris, p. 494—498, i-c. 4to. Paris 1819.) 3. Symptoms of Fractures. Some of the symptoms of fractures are equivocal: the pain and inability to move the limb, commonly enu- merated, may arise from a mere bruise, a dislocation, or other cause. The crepitus; the separation and in- equalities of the ends of the fracture, when the bone is.superflcial; the change in the form ofthe limb; and Ihe shortening of it; are circumstances communicating the most certain information; and the crepitus, in par- ticular, is the principal symptom to be depended upon, though occasionally attendant on dislocations, and aris- ing, as Sir Astley Cooper has explained, from a change in the quality of the synovia.—(On Dislocations, i-c. p. 6.) The signs of fractures, however, are so exceed- • ingly various, according to the bones which are the subject of injury, that it cannot be said, that there is any one which is invariably present and character- istically confined to them. The writers of systems of surgery usually notice loss of motion in the injured limb, deformity, swelling, tension, pain, :ii sciio.iis; namely, that of •■ benumbing ine .rr<- FRACTURES. 381 lability of the muscles'' by the compression resulting from their regular and even application to the whole of the member. In describing the treatment of parti- cular fractures, I shall have occasion to advert to the examples in which a moderate general compression ofthe muscles may be attended with utility. " The parts of the general apparatus for a simple frac- ture, which come next in order (observes Mr. Pott), are the splints;" which are unquestionably the most efficient of all the applications made to a broken limb with a view of keeping the ends of the fracture steady and in a proper state of contact. Without them the surgeon would in vain endeavour to maintain the reduction. " Splints," says Pott, " are generally made of paste- board, wood, or some resisting kind of stuff, and are ordered to be applied lengthwise on the broken limb ; in some cases three, in others four; for the more steady and quiet detention of the fracture. That splints properly made and judiciously applied are very serviceable is beyond all doubt; but their uti- lity depends much on their size and the manner in which they are applied. The true and proper use of splints is to preserve steadiness in the whole limb without compressing the fracture at all. By the former they become very assist- ant to the curative intention; by the latter they are very capable of causing pain and other inconveniences ; at the same time that they cannot, in the nature of things, contribute to tbe steadiness of the limb. In order to be of any real use at all, splints should, in the case of a broken leg, reach above the knee and below the ankle; should be only two in number, and should be so guarded with tow, rag, or cotton, that they should press only on the joints, and not at all on the fracture. By this they become really serviceable; but a short splint which extends only a little above and a little below the fracture, and does not take in the two joints, is an ab- surdity, and, what is worse, it is a mischievous absurdity. By pressing on both joints, they keep not only them but the foot steady; by pressing on the fracture only, they cannot retain it in its place, if the foot be in he smallest degree displaced ; but they may, and frequently do, oc- casion mischief, by rudely pressing the parts covering the fracture against the edges and inequalities of it. In the case of a fractured os femoris, if the limb be laid in an extended posture, one splint should cer- tainly reach from the hip to the outer ankle, and an- other (somewhat shorter) should extend from the groin to the inner ankle. In the case of a broken tibia and fibula, there never can be occasion for more than two splints, one of which should extend from above the knee to below the ankle on one side, and the other splint should do the same on the other side."—(See Remarks on Fractures and Dislocations, in Pott's Chirurgical Works, vol. 1, p. 298, i-c. edit. 1S08.) Assalini strongly disapproves of the employment of all tight bandages, and of covering the whole of a broken limb with splints. He was called to a gentle- man of rank at Paris, who had broken the knee-pan transversely. He laid the limb upon a concave splint, the shape of which was adapted to the under surface ol" a part of the leg and thigh. No bandage was used; merely two leather straps, which crossed upon the knee, and included the fractured bone. A perfect bony union was thus easily effected. Assalini afterward extended the use of a concave splint, applied under the limb, to fractures of the leg and thigh. In the first of these cases, however, only the thigh is received in the hollow splint, and from this two branches, or lateral splints, go along the leg. The apparatus has also a kind of sole for the support of the foot. As this simple contrivance is fastened with a very few straps, and no plasters or bandages are used, the surgeon has con- stantly a view of the whole front of the limb, and of the fractured part of it, which Assalini thinks a great advantage. In compound fractures, he puts no other dressings on the wound but linen compresses, which are kept continually wet with cold water.—(Manuale di Chirurgia, parte prima, 1812.) For farther obser- vations on the subject, see Splint. In oblique flractures of the thigh, and sometimes even in those of the leg, the difficulty of accomplishing by the ordinary means a cure free from deformity, and es- pecially without a shortening of the limb, has led to the idea of employing continual extension. This ex- pression implies the operation of a bandage, or ma- chine, whieh continually draws the fragments of the broken hone in contrary directions, at the same time that it restrains them from gliding over each other, and maintains them in contact during the whole time ne- cessary for their union. In England this practice has long been relinquished. It appears to have been chased away by the dazzling theory of relaxing every muscle in such manner as to render it incapable of displacing an oblique fracture; a theory with which the surgeons of this country were but too much blinded by the per- suasive eloquence of the late Mr. Pott. Desault saw at once, however, every inconsistency in the doctrine of the possibility of relaxing the muscles, so as to in- capacitate entirely the whole set connected with a broken thigh; and he never ceased to inculcate in his school, that in such a case the assistance of a me- chanical apparatus applied to the limb was the main thing by which the shortening of the limb was to be prevented. When we consider the treatment of frac- tured thighs, we shall find that the principle of.con- tinual but moderate extension has had in France ad- vocates of great talent and eminence, though it is a method to which many surgeons in this country appear to entertain strong but highly exaggerated objections. By means of continual extension (observes Boyer), we not only succeed in uniting the fracture, while the limb preserves its natural length; but we afford the part a steadiness, which is singularly favourable to the formation ofthe callus. In order to derive from continual extension the ut- most benefit, and render the method as little painftil as possible, and supportable during the whole time of treatment, the machines and bandages, according to Boyer, should be constructed and applied conformably to the following rules. We should avoid compressing the muscles which pass over the situation of the fracture, and the elonga- tion of which organs is necessary to restore to the limb the length which it has lost by the gliding of the frag- ments over each other. With this view, the extending power ought to be ap- plied to that part of the limb which is articulated with the lower head ofthe fractured bone; and the counter- extending force to that which is articulated with the upper head. If these powers were applied to the broken bono itself, the muscles passing over the fracture would suffer such compression as would excite spasm, and ren- der the continual extension ineffectual and even hurtftd. The extending and counter-extending force ought to be divided upon as large surfaces as possible. The reason of this rule is obvious. The pressure of external bodies on parts is less painful, in proportion as the surface pressed upon is extensive and the ope- ration supported at once by numerous points. On this principle a narrow band creates stronger and more painful pressure than a broad one ; and hence, the rollers and other pieces of the apparatus for making the extension and counter-extension should be as wide as possible. The powers making continual extension should act according to the direction of the axis ofthe broken bone. The continual extension should be practised in as sloiv, gradual, and insensible a manner as possible. The muscles easily yield to a force which stretches them,when such force acts slowly, and is very gradually increased, according to the shortness of the limb, and the power ofthe muscles producing the displacement. But if one were all on a sudden to begin with making violent extension, the rough forcible elongation of the muscles would excite such a spasmodic action of them as would frustrate every attempt to restore the natural length of the limb. And if, in order to fulfil this pur- pose, the extending force were increased in a ratio to- the resistance of the muscles, there would be danger of lacerating these organs, because their fibres would not have time enough to yield. Lastly, the parts upon which the extending and counter-extending force acts should be defended; and the compression made by the tapes, or other pieces of the bandage and apparatus, ought to be equalized. These indications may be fulfilled by covering the parts on which the tapes and bandages press with tow or wool pads; and by filling up all the depressions of the limb with the same soft substances, so as to give it a circular form. The bandages will then not hurt the most projecting parts, on which they would make a strong and injurious degree of pressure, if the depres- I sious were not artificially filled up. 382 FRACTURES. By observing these rules, says Boyer, continual ex- tension may always be borne, even by the most deh- cate and irritable patients: and the important advan- tage wUl be obtained of curing the fracture with the proper length of the limb preserved.—(Traite des Mai. Chir. t. 3, p. 56.59.) 8 Means for preventing and removing the unfavour- able Symptoms liable to arise from Fractures. After having reduced the fracture, applied a suitable apparatus for maintaining the reduction, and put the part in an advantageous position, the practitioner is to attend to the third indication in the treatment, viz. the prevention and removal of any unfavourable symptoms. With the exception of a few simple fractures of the upper extremity, it is proper in all cases to allow for the first few days only very low diet, broths, tea, &c. When the patient is young and strong, and the swell- ing and inflammation are likely to be considerable, ve- nesection should be practised. In other circumstances it may in general be dispensed with, because it is well known, that for the quick formation of callus, by which the fracture is to be united, strength and a vigorous circulation are highly favourable. The patient may be permitted to drink as often and as much as he likes, of any cooling acid beverage. A very low diet is only to be continued the first few days, unless great inflam- mation arise; for experience proves that the method, when too much prolonged, has bad effects, and tends, ou the same principle as bleeding, to retard the union of the fracture. Costiveness is to be averted by the use of clysters and mild aperient medicines. It must be confessed, that in fractures ofthe lower extremity, the disturbance ofthe limb caused by the patient's being obliged to move himself, after taking a purgative, is seriously objection- able ; but perhaps in all, and certainly in some habits, a neglect to open the bowels soon after the accident would have still more pernicious consequences. In order, however, to lessen the disturbance, a bed-pan should be carefitily introduced under the patient. Here, also, I feel it my duty to recommend to the notice of the profession a very complete fracture-bed, invented by my friend Mr. Earle. One great convenience of this bed, the cost of which is moderate, is to enable the patient to void his feces, without the slightest change of posi- tion or disturbance; an object effected by the simple contrivance of a Uttle kind of trap, opening under the bed, out of which a small portion of the mattress ad- mits of being withdrawn, and a tin receptacle is placed for the reception of what is voided from the bowels and bladder. Some other advantages of this apparatus will be hereafter briefly mentioned. With respect to external applications, we should carefully avoid using all such plasters and ointments as irritate the skin, or create a disagreeable itching; for they sometimes bring on erysipelas. The emplas- trum saponis in common use is the best for all simple fractures; and it is the best rather because it does no harm, than because it does any essential good. It is, generally speaking, a good plan for the first few days to wet the bandages with cold water; for in this way, the tendency to inflammation and swelling may be con- siderably lessened. The surgeon, however, should re- collect that the bandage shrinks when wet, and may become so tight as to do harm if not attended to. So- lutions of the acetate of lead andother salts, make band- ages stiff and hard; and as they are perhaps not more efficacious than cold water alone, the latter is some- times preferred. When a fracture is well set, the position of the part right, and the bandage and splints neither too tight nor too slack, the less the broken bone is moved, and the less the apparatus and dressings are disturbed the bet- ter. Sometimes, however, the practitioner is obliged to take off the splints, and undo the bandage, in order to ascertain that the ends of the fracture lie in even contact. Were he to leave the splints on the part ten days, or a fortnight, without ever being sure of this im- portant point, he might find, when too late for altera- tion, that the fracture was in a state of displacement, and the limb seriously deformed. Hence, a strong rea- son for employing the eighteen-tailed bandage, which admits of being opened without disturbing the limb, or even without lifting it from the surface upon which it has been deposited. In fractures of the lower extremities, particularly of the legs, it sometimes happens the first two oi three nights after the reduction, that the limb is affected with convulsive spasms and cramps, which make the pa- tient start in his sleep, and displaue the ends of the bone, which must be again reduced. When the callus has acquired some firmness, th« patient should stUl keep the part or limb quiet, until the union is perfectly consolidated. And in fractures of the lower extremity, even after the union has pro- ceeded so far that the splints admit of being left off, the patient ought not to venture to get out of bed, or beai upon the limb, till several more days have elapsed. All fractures, however simple and well treated they may be, are constantly followed by weakness and stiff- ness of the limb. These unpleasant consequences are the greater, the more violently the limb has been con- tused, the nearer the fracture is to a joint, and the longer the part has remained motionless and without exercise. The stiffness always affects the inferior joint of the broken bone much more than the supe- rior. For the relief of these effects of fractures, it is customary to employ friction, liniments, emollient re- laxing applications, cold washes, and bathing ; but sometimes, notwithstanding such remedies, the mem- brane does not quickly recover its strength, but con- tinues stiff and weak for a year, or even a longer time. The most effectual plans for the prevention of this state should therefore be resorted to early. These consist in making the joints nearest the fracture exe- cute slight motions, as soon as the union is suffi- ciently advanced not to be in danger of interruption from this practice. A great deal of caution, however, is necessary in moving the part, and it is safer for the surgeon to superintend the business himself, than leave it to the patient or others. One of the best proceedings also for the hindrance of much weakness and stiffness in tbe limb after a fracture is, to discontinue the splints and tight bandages immediately the state of the caUus will allow. The manner in which their pressure re- tards the circulation, and prevents the action of the muscles, is one of the principal causes of the stiffness ofthe limb; and, consequently, the sooner they can be safely left off the sooner wtil the patient regain the free use of the limb. In France, the chief division of fractures is into simple and complicated; which last includes, among many varieties, the cases which we name compound. We shall here briefly notice a few ofthe complications, and the particular treatment which they require. Fractures (says Boyer) are always attended with a certain degree of contusion, which is constantly more severe in cases where the violence has acted directly on the situation of the fracture. But such contusion can only be regarded as a complication of the accident, when it exists in so violent a degree as to demand a different treatment from that which is employed in simple fractures. In this circumstance, the splints and bandage should be applied rather slackly, and the latter ought to be wet with cold water, or some resolvent lotion. The patient is to be bled more or less freely, according to his age, the state of his constitution, and violence ofthe contu- sion. The next day, the splints and bandage should be opened; a thing highly necessary to be observed, for where it has been neglected, the limb has been known to mortify, in consequence of the swelling having ren- dered the bandage too tight.—(Boyer, Traiti des Mai. Chir. t. 3, p. 63,64.) In cases where the contusion is severe, but unat- tended with a wound of the integuments, the tension and swelling may be so intense, that the cuticle is de- tached, forming vesicles filled with yellowish serum. These vesicles may deceive an inexperienced surgeon. and lead him to imagine that the limb is threatened, or acturally affected, with gangrene. They ought to be punctured, and covered with*, fcifeote' of simple oint- ment. Here some praetition^^ttpjsly emollient poul- tices under the apparatus; but there .is inconveni- ence in then- use, and perhaps cold lotions are generally better. • „ • ■■■- In simple fractures, it does not ofteTi ha"*<*ivtbat a large artery is wounded; but when the itijury does occur, and a diffused aneurism takes place, the surgeon is to expose the vessel by an incision, and apply a ligature above and below the opening. We are to be careful, however, before resorting to the operation, thai the tumour is not a venous extravasation, which may FRACTURES. 383 almost always be dissipated by resolvent applica- tions. Fractures are sometimes complicated with a disloca- tion. Here, if possible, the luxation should-invariably be reduced before the fracture is set. The possibility of reducing the dislocation (says Boyer) depends upon the species of articulation, the situation ofthe fracture, and other circumstances of the case. When it is a ginglymoid joint, when the ligaments are lacerated, and the swelling is not considerable, the luxation may be reduced easily enough: but when it is an orbicular joint, surrounded by numerous muscles; and when the fracture is near the articulation, and situated below the dislocation, the reduction of the latter is impossible. The attempt, indeed, would be injurious, because the necessary extension could not act upon the upper frag- ment ; and were it to operate upon the lower, it could only have the effect of painfully stretching the muscles, and perhaps lacerating them. The fracture, therefore, Ehould be at first attended to, and after its firm union,. an endeavour may be made to rectify the dislocation. Boyer conceives that there will be more probability of success, when care is taken to move the limb gently, as soon as the state of the callus will permit it. He also recommends the employment of emollient relax- ing applications. He confesses, however, that the at- tempt rarely succeeds after the perfect union of the fracture. There are, it is true, examples in which old dislocations may be reduced; but these are cases which are not complicated with a fracture; an accident which always renders the muscles and ligaments so stiff, that they cannot yield to the extension requisite for the reduction. " I do not know (says Boyer) that a lux,ation complicated with fracture has ever been re- duced, when the nature of the joint and the circum- stances of the case prevented the treatment from begin- ning with the reduction of dislocation.—(Traiti des Mai. Chir. t. 3, p. 79.) COMPOUND FRACTURES. What Mr. Pott has said upon these cases is, with one or two exceptions to which I shall advert, the es- sence of good surgery, not in the least deteriorated, as a few other parts of his precepts have been, by the more mature instructions of time and experience, or by that growing state of surgical science, which, fostered by genius and observation, is continually bringing to Ught new facts. In a compound fracture, says Mr. Pott, the first object of consideration is, whether the preservation of the fractured limb can, with safety to the patient's life, be attempted; or, in other words, whether the probable chance of destruction, from the nature and circum- stances ofthe accident, is not greater than it would be from the operation of amputation. Many things may occur to make this the case. The bone or bones being broken into many different pieces, and that for a consi- derable extent, as happens from broad wheels, or other heavy bodies of large surface, passing over or falling on such Umbs; the skin, muscles, tendons, &c. being so lorn, lacerated, and destroyed, as to render gangrene and mortification the most probable and most imme- diate consequence; the extremities of the bones form- ing a joint being crushed, or, as it were, comminuted, and the ligaments connecting such bones being torn and spoiled, are, among others, sufficient reasons for proposing and for performing immediate amputation. Mr. Pott admits that apparently desperate cases are sometimes cured, and that limbs so shattered and wounded as to render amputation the only probable means for the preservation of life, are now and then saved. This is an uncontroverted fact, but a fact which proves very little against the common opinion; because every man of experience also knows that such escapes are very rare, much too rare to admit of being made precedents.-------. ^_. _^ " This consideration relative to amputation is of the more importance, because it most frequently requires immediate determination ; every minute of delay is in many instances, to the patient's disadvantage • and a very short space of time, indeed, frequently makes all the difference between probable safety and fatality. If these cases in general would admit of deliberation for two or three days, and during that time such circum- stances might be expected to arise as ought necessarily to determine the surgeon in his conduct, without add- Uig to the patient's hazard, the difference would be considerable; the former would not seem to be so pre* cipitate in his determination as he is frequently thought to be; and the latter, being more convinced of the ne- cessity, would submit to it with less reluctance. But, unhappily for both parties, this is seldom the ease; and the first opportunity having been neglected, or not em- braced, we are frequently denied another. Here, there- fore, the whole exertion of a man's judgment is re- quired, that he may neither rashly and unnecessarily deprive his patient of a limb, nor through a false ten- derness and timidity suffer him to perish by endeavour- ing to preserve such limb." The limb being thought capable of preservation, the next consideration is the reduction ofthe fracture. " If the bone be not protruded forth, the trouble of reducing and of placing the fracture in a good position, will be much less than if the case be otherwise; and in the case of protrusion, or thrusting forth of the bone or bones, the difficulty is always in proportion to the comparative size of the wound through which such bone has passed. In a compound fracture of the leg or thigh, it is always the upper part of the broken bone which is thrust forth. If the fracture be of the trans- verse kind, and the wound large, a moderate degree of extension will in general easily reduce it; but if the fracture be oblique, and terminates, as it often does, in a long, sharp point, this point very often makes its way through a wound no longer than just to permit such extension. In this case, the very placing the leg in a straight position, in order to make extension, obliges the wound or orifice to gird the bone tight, and makes all that part of it which is out of such wound press hard on the skin of the leg underneath it. In these circumstances, all attempts for reduction in this manner will be found to be impracticable; the more the leg is stretched out, the tighter the bone will be begirt by the wound, and the more it will press on the skin un- derneath. Upon this occasion, it is not very unusual to have recourse to the saw, and by that means to remove a portion of the protruded bone. I will not say that this is always or absolutely unne- cessary or wrong, but it most certainly is frequently so. In some few instances, and in the case of extreme sharp-pointedness ofthe extremity of the bone, it may be, and undoubtedly is right.—(See Dunn's Obs. in Med. Chir. Trans, vol. 12.) But in many instances it is totally unnecessary. The two most proper means of overcoming this difficulty are, change of posture of the limb, and en- largement ofthe wound. In many cases, the former of these, under proper conduct, will be found fully suffi- cient ; and where it fails, the latter should always be made use of. Whoever will attend to the effect which putting the leg or thigh (having a compound fracture and protruded bone) into a straight position always produces, that is, to the manner in which the wound in such position girds the bone, and to the increased diffi- culty of reduction thereby induced; and will then, by changing the posture of such limb from an extended one to one moderately- bent, observe the alteration thereby made in both the just-mentioned circumstances, will be satisfied ofthe truth of what I have said, and of the much greater degree of ease and practicability of reduction in the bent than in the extended position, that is, in the relaxed than in the stretched state ofthe mus- cles." Reduction being found impracticable, either by extension or change of posture, Mr. Pott recommends an enlargement of the wound. "If the bone be broken into several pieces, and any of them be either totally separated so as to lie loose in the wound, or if they be so loosened and detached as to render their union highly improbable, all such pieces ought to be taken away; but they should be removed with all possible gentleness, without pain, violence, or laceration, without the risk of hemorrhage, and with as little poking into the wound as possible. If the extremities of the bone be broken into sharp points, which' points wound and irritate the surround- ing parts, they must be removed also.—(See Dunn, vol. cit.) But the.whole of this part of the treatment of a compound fracture should be executed with great cau- tion ; and the practitioner should remember, that if the parts surrounding the fracture be violated, that is, be torn, irritated, and so disturbed as to excite great pain, high inflammation, >!tc„ it is exactly the same thing to the patient, and to the event of the case, whether such 384 FRACTURES. violence be the necessary consequence of the fracture or of the unnecessary and awkward manner of poking into and disturbing the wound. The great objects of fear and apprehension in a compound fracture (that is, in the first or early state of it) are, pain, irritation, and inflammation ; these are to be avoided, prevented, and appeased by all possible means, let every thing else be as it may; and although certain things are always recited as necessary to be done, such as removal of fragments of bone, of foreign bodies, &c. &c. &c., yet it is always to be understood that such acts may be per- formed without prejudicial or great violence, and with- out adding at all to the risk or hazard necessarily in- curred by the disease. Reduction of or setting a compound fracture is the same as in the simple; that is, the intention in both is the same, viz. by means of a proper degree of extension to obtain as apt a position of the ends of the fracture with regard to each other, as the nature of the case will admit, and thereby to produce as perfect and as speedy union as possible. To repeat in thin place what has already been said under the head of Extension would be tedious and unneces- sary. If the arguments there used for making exten- sion, with the limb so moderately bent as to relax the muscles and take off their power of resistance, have any force at all, they must have much more when applied to the present case; if it be allowed to be found very painful to extend, or to put or to keep on the stretch muscles which are not at all or but slightly wounded, and only liable in such extension to be pricked and irritated, it is self-evident that it must be much more so when the same parts are torn and wounded." After a few additional observations in praise of the good effects of relaxing the muscles, Mr. Pott proceeds:— " The wound dilated (if necessary), loose pieces re- moved (if there were any), and the fracture reduced in the best possible position, the next tlting to be done is to apply a dressing." When Mr. Pott wrote on this subject, the plan of bringing tbe edges of the wound together with adhesive plaster, in cases of compound fracture, had not been established ; and the advantage of this mode of dress- ing in the first instance was not duly known. I do not mean the practice of drawing the edges of the wound forcibly together -with strips of plaster, nor of encir- cling and compressing the part with the same; but only the method of applying two or three short pieces of plaster, so as lightly and gently to retain the oppo- site sides of the wound in contact, and afford thein an opportunity of uniting by the first intention. Now, al- though such attempts will frequently fail, on account of the wound being generally in a contused, irregular, and lacerated state, the chance of success should be taken, because the experiment at all events will occa- sion no harm, and if it answer, it will change the case at once from a fracture with an open wound to one which has no external communication, or as might al- most be said, from a compound into a simple fracture. Some of the following directions, therefore, given by Mr. Pott, I consider in the present state of surgery as only applicable when the wound has suppurated. The dressing necessary in a compound fracture is of two kinds, viz. that for the wound, and that for the limb. By the former, we mean to maintain a proper opening for the easy and free discharge of gleet, sloughs, matter, extraneous bodies, or fragments of bone, and this-in such manner, and by such means, as shall give the least possible pain or fatigue, shall neither irritate by its qualities, nor oppress by its quantity, nor by any means contribute to the detention or lodgement of what ought to be discharged. By the latter our aim should be the prevention or removal of inflammation, in order, if the habit be good and all other circumstances fortu- nate, that the wound may be healed by what surgeons call the first intention, that is without suppuration or abscess; or, that not being practicable, that gangrene and mortification, or even very large suppuration may be prevented, and such a moderate and kindly degree of it established as may best serve the purpose of a cure. The first, therefore, or the dressing for the wound, can consist of nothing better, or indeed so good, as soft dry lint, laid on so lightly as just to ab- sorb the sanies, but neither to distend the wound, nor be the smallest impediment or obstruction to the discharge of matter. This lint should be kept clear of the edges, and the whole of it should be covered with a pledget spread with a soft easy digestive. The times of dressing must be determined by the nature of the case ; if tho discharge ho small or moderate, once in twenty-four hours will be sufficient; but if it be large, more fre- quent dressing will be necessary, us well to prevent offence as to remedy the inconveniences arising from a great discharge of an irritating sharp sanies. When, from neglect, from length of time passed with out assistance, from misconduct or drunkenness in the patient, from awkwardness and unhandiness in the as- sistants, or from any other cause, a tension has taken possession of the limb, and it is-become tumid, swol- len, and painful, Mr. Pott admits, that a warm cata- plasm is the most proper application that can be made; immediate union is impossible, and every thing which can tend towards relaxing the tense, evoilen, and irri- table state of the parts concerned, must necessarily be right. But when the parts are not in this state, the in- tention seems to be very different. To relax swollen .parts, and to appease pain and irritation by such relax- ation, is one thing; to prevent inflammatory dcflux- ion and tumefaction is certauily another; and they ought to be aimed at by very different means. In the former, a large suppuration is a necessary circumstance of relief, and the great means of cure; in the latter it is not, and a very moderate degree of it is all that is required. The warm cataplasm, therefore, although il be the best application that can be made use of in the one case, is certainly not so proper in the other, as ap- pUcations of a more discutient kind, such as mixtures of spirit, vini, vinegar and water, with the muriate of ammonia, liquor ammonia? acetatis, liquor plumbi ace- tatis, and medicines of this class, in whatever form the surgeon may choose. By these, in good habits, in for tunately circumstanced cases, and with the assistance of what should never be neglected (I mean phlebotomy* and the general antiphlogistic regimen), inflammation may sometimes be kept off, and a cure accomplished, without large collections or discharges of matter." " Compound fractures ingeneral require to be dressed every day; and the wounded parts not admitting the smallest degree of motion without great pain, perfeel quietude becomes as necessary as frequent dressing. The common bandage, therefore (the roller)^ has al- ways in this case been laid aside, and what is called the eighteen-tailed bandage substituted very judiciously in its place. Splints of proper length, which reach from joint to joint, comprehend them both, and are applied on each side of the leg only, are very useful both in the simple and in the compound fracture, as they may, thns ap- plied, be made to keep the limb more constantly steady and quiet than it can be kept without them." Mr. Pott then enters into the consideration ofthe pos- ture of the limb, which " is so principal a circumstance, that without its concurrence every other will be fruit- less. The points to be aimed at are, the even position of the broken parts of the bone, and such disposition of the muscles surrounding them, as is most suitable to their wounded, lacerated state, as shall be least likely to irritate them, by keeping them on the stretch, or to produce high inflammation, and at best large suppu- ration." According to Mr. Pott, these cases, of all others, re- quire at first the most rigid observance of the antiphlo- gistic regimen; pain is to be appeased, and rest ob- tained, by anodynes; inflammation is to be prevented or removed by bleeding and aperient medicines. And during the first state or stage, the treatment of the limb must be calculated either for the prevention ol inflammatory tumefaction by discutients, or, such tu- mour and tension having already taken possession of the limb, warm fomentation, and relaxing and emollient medicines are required. " If these, according to the particular exigence of the case, prove successful, the consequence is, either a quiet easy wound, which either heals by the first in- tention or suppurates very moderately, and gives little or no trouble, or a wound attended at first,with con- siderable inflammation, and that producing large sup- puration, with great discharge and troublesome forma- tion and lodgement of matter. If, on the other hand,our * The propriety of having recourse to venesection will depend upon the age, strength, and general habit of the patient. In the young, robust, and plethoric, the practice is, on every account, judicious. FRACTURES. 38b sary to compound for Ufe by the loss of the limb.* This, I say, does sometimes happen under the best and most rational treatment; but I am convinced that it also is now and then the consequence of pursuing the reducing, the antiphlogistic, and the relaxing plan too far. 1 would therefore take the liberty seriously to ad- vise the young practitioner to attend diligently to his patient's pulse and general state, as well as to that of his fractured Umb and wound; and when he finds all febrUe complaint at an end, and all inflammatory tu- mour and hardness gone, and his patient rather lan- guid than feverish, that his pulse is rather weak and low than hard and full, that his appetite begins to fail, and that be is inclined to sweat or purge without as- signable cause, and this in consequence of a large dis- charge of matter from a limb which has suffered great inflammation, but which is now become rather soft and flabby than hard and tumid ; that he wUl in such cir- cumstances set about the support of his patient, and the strengthening ofthe diseased Umb, tolls viribus; in which I am from experience satisfied he may often be successful, where it may not be generally expected that he would. At least he will have the satisfaction of having made a rational attempt; and if he is obliged at last to have recourse to amputation, he will perform it, and his patient wUl submit to it, with less reluctance than if no such trial had been made." According to Mr. Pott, gangrene and mortification are sometimes the inevitable consequences of the mis- chief done to the Umb at the time that the bone is broken; or they are the consequences of the laceration of parts, made by the mere protrusion of the said bone. They are also sometimes the effect of improper or ne- gligent treatment; of great violence used in making ex- tension ; of irritation of the wounded parts, by poking after, or in removing fragments or splinters of bone; of painful dressings; of improper disposition of the limb, and of the neglect of phlebotomy, anodynes, evacua- tion, Sec " When such accident or such disease is the mere consequence of the injury done to the limb, either at the time of or by the fracture, it generally makes its appearance very early; in which case also its progress is generally too rapid for art to check. For these rea- sons, when the mischief seems to be of such nature that gangrene and mortification are most Ukely to en- sue, no time can be spared, and the impending mis- chief must either be submitted, to, or prevented by early amputation. I have already said, that a very few hours make all the difference between probable safety and destruction. If we wait tUl the disease has taken pos- session of the limb, even in the smallest degree, the operation will serve no purpose, but that of accelerat- ing tlie patient's death. If we wait for an apparent alteration in the part, we shall have waited until all opportunity of being really serviceable is past. The disease takes possession of the cellular membrane sur- rounding the large blood-vessels and nerves some time before it makes any appearance in the integuments; and will always be found to extend much higher in the former part than its appearance in the latter seems to indicate. J have more than once seen the experiment made of amputating, after a gangrene has been be gun, but I never saw it succeed; it has always has tened the patient's destruction.] As far, therefore, as my experience wiU enable me to judge, or as I may from thence be permitted to dic- tate, / would advise tliat such attempt should never be made; but the first opportunity having been ne- glected, or not embraced, all the power ofthe chirurgie attempts do not succeed, the consequence is gangrene and mortification. These are the three general events or terminations ot a corhpound fracture, and according to these must the BHrgeon's conduct be regulated. In the first instance, he has indeed nothing to do but to avoid doing mischief, either by his manner of dress- ing or by disturbing the limb. Nature, let alone, will accomplish her own purpose; and art has little more to do than to preserve the due position of the limb, and to take care that the dressing applied to the wound proves no impediment. f In the second stage, that of formation and lodgement of matter, in consequence of large suppuration, all a surgeon's judgment will sometimes be required in the treatment both ofthe patient and his injured limb. Enlargement of the -present wound, for the more con- venient discharge of matter ;* new or counter-openings for the same purpose, or for the extraction of fragments of broken or esTollatod bone, will very frequently be found necessttff'Bld must be executed. In the doing this, care must Dfflaken that what is requisite be done, and no mors-; and that such requisite operations be performed with -as little disturbance and pain as pos- sible." Previous to large suppuration, or considerable col- lections and lodgements of matter, evacuation by phle- botomy, an open belly, and antiphlogistic remedies, as well as the free use of anodynes, and such applications to the limb as may most serve the purpose of relaxa- tion, are the remedies which Mr. Pott advises for the relief of the swelling, induration, and high inflamma- tion, attended with pain, irritation, and fever. " But the matter having been formed and let out, and the pain, fever, -TWbal happens in the process of unfon WuZ? ^^Ik8 a"W Pa^ularly noticed by Mr Wilson: "From the parts being exDosed (in .«,» pound fracture), the first bond o? umon viz the ccZT labia lymph, of the blood, is removed or des royed be- fore il can become vascular. Inflammation in cons* quence of the injury comes on, suppuration takes place and when the ,«rts are healthy, granulations arist' I bese granulations from the broken extremities of the bone soon assume the ossifying disposition, and when they come m contact with each other, unite "-(On tZ Sk rlHoit, Diseases of the Bones, .ye. p. 233,' 8w Lond 1.-20.) It is a cunous fact, that broken cartilages arc has united. In fractures of the lower extremity, he j ought to use crutches, and only let the weiglit of the trunk by degrees bear upon the injured limb. From I neglect of this precaution the callus has been known to be absorbed, the limb to be shortened, and the pa- I tient become a cripple. An accidental slip may also produce the fracture again; for, notwithstanding the assertion of writers, the callus, so far from being firmer than the rest of the bone, is at first considerably weaker.—(Boyer, t. 3, p. 93.) If, when the necessary time for the completion ofthe union has expired, the callus is not yet firm, we must examine, 1st, The relative position of the fragments and the consistence of the callus: 2dly, The causes which may have retarded its consolidation. . That the state of the constitution has considerable influence over the process by which broken bones are reunited, is unquestionable. Schmucker found the formation of callus, even in the most simple fractures, sometimes delayed eight months, and in one example more than a year; but the patients were all of them unhealthy subjects.—(Vermischte Chir. Schnflm. b. 1, p. 26.) There are certain indescribable constitutions, in which bones, more particularly, however, the os bra- chii, will not unite again after being broken. These temperaments are also very various; at least, I infer so from two subjects to whom I paid particular atten- tion. One was a strong, robust man, whose chief pe- culiarity seemed to be his indifference to pain: the ends of bis broken humerus were cut down too, turned out, and sawed off, by Mr. Long, in St. Bartholomew's Hospital, and the limb was afterward put in splints and taken the greatest care of; but no union followed. The other case was a broken tibia and fibula, which remained disunited for about four months; but after- ward grew together. The latter subject was a com- plete instance of hypochondriasis. I afterward saw a woman, under Sir James Earle, in the above hospital, whose os brachii did not unite in the least, though it had been broken several months. Every attempt to move the bone occasioned excruciating torture. The woman died of somo illness in the hospital, and on dissecting the arm, the cause ofthe fracture not having united was found to arise from the upper, sharp, pointed extremity of the lower portion of the broken bone having been forcibly drawn up by the muscles, and penetrated the substance of the biceps, in which it still remained. I am indebted to Mr. Earle for the description of tbe appearance in the dissection, and I do not know that this kind of impediment to the union of a fracture has been noticed by any earlier writer than Mr. Charles White, who appears to have con- ceived the possibility of the occurrence.—(Cases in Surgery, p. 70, edit. 1770.) The causes of fractures remaining disunited will 390 FRACTURES. according to Richerand, be found to depend either upon the broken ends of the bone not being properly in con- tact; the limb having bee»'moved too much; the ad- vanced age of the patient; or upon a general inertia and languor of the constitution.—(Nosographie Chir. torn. 3, p. 37, idit. 2.) It is observed by Larrey, that the gun-shot wounds ofthe extremities, compUcated with fracture, especially with that of the humerus, received by the soldiers of the French army in Syria, were almost all followed by the formation of accidental joints. The two fVag- ments of the broken bone continued moveable, their asperities and projecting angles having been destroyed by friction, and their ends being rounded and covered . with a cartilaginous substance, so as to factiitate the motions which the patients executed in various direc- tions, in an imperfect manner and without pain. Lar- rey acquaints us that many invalids were sent back to France with such infirmity. " I ascribe," he says," the causes of these accidental articulations: 1. To the continual motion to which the wounded soldiers were exposed, after their departure from Sy- ria till their arrival in Egypt, in consequence of their having been obliged either to walk this journey on foot, or to be carried it on beasts. 2. To the bad quality of the food and the brackish water which the men were under tlie necessity of drinking in this painful journey. 3. To the state of the atmosphere in Syria, almost entirely destitute of vital air, and impregnated with pernicious gases, issuing from the numerous marshes near which we were a long while stationed. All these causes may have prevented the formation of callus, either by diminishing the quantity of the phos- phate of lime, or moving the bones out of that state of cpaptation in which they should constantly lie, in order to unite. Bandages, embrocations, rest, and regimen proved quite ineffectual."—(Larrey, Mim. de Chir. Mil. t. 2, p. 131, 132. Langenbeck, Neue Bibl. b. 1, p. 81.) The presence of an ulcer, a sinus, loose splinters of bone, a necrosis, or other suppurating disease near a fracture, is a circumstance that often appears seriously to retard or completely to prevent the formation of callus. How frequently have I noticed, in cases of compound fracture, that while the wound suppurates largely, and while there are spicula? and dead portions of bone unextracted, no solid union takes place; but that, as soon as the wound, ulcer, or sinus admits of being healed, and the suppuration ceases, the callus begins to form in the most favourable manner. Schmuc- ker relates a case Ulustrating the truth of these obser- vations, where the tibia and fibula were broken so ob- liquely, that the ends of the fracture could not be made to lie well, a necrosis of a portion of the tibia followed, and no callus was formed at the end of eight months, when a sinus on each side of the leg still continued. This eminent surgeon now laid the sinuses open, and extracted the dead pieces of bone, by which means the impediment to the formation of callus was removed, and the fracture, which had tUl then remained loose and moveable, became firmly united in two months.— (Vermischte Chir. Schriften, b. 1, p. 25, 26.) False or preternatural articulations, which occur in cases of fracture without union, have been generally supposed to resemble common joints. According to Boyer, this opinion is incorrect. The ends of the frac- ture, whieh are sometimes rounded and sometimes pointed, are connected together by a cellular and liga- mentous substance. But their surfaces are not co- vered by a smooth cartilaginous matter, nor is there constantly a. capsular ligament. "lam convinced of this feet, by the dissection of several ununited fractures, the fragments of which are preserved in my museum." —(Boyer, t. 3, p. 94.) And, in another place, the same professor, speaking of these false joints, remarks: " I repeat, that I have never found in their structure any thin"- which could be compared with an articulation; neither capsular ligament nor smooth cartilaginous surfaces. On the contrary, I haye invariably found in the false joints ofthe thigh-bone and humerus, which I have had opportunities of dissecting, a fibrous Uga- mentous substance, extending from one fragment to the other, and it is very probable that, with some mo- difications, it is the same with all the other cases which I have nor seen. But, in the forearm, the ends of the fracture may assume a structure which bears a greater resemblance to an articulation. This is what happened in an ex- ample which was communicated to Bayle by Sylvestre, in the Ripublique des Lettres, Juillet, 1685, p. 718, Ac. A similar case is recorded by Fabricius HUdanus, obi. 91, centur. 3."—(Boyer, Traiti des Mat. Chir. t. 3, p. 101—103.) On this subject Langenbeck observes, that the edges of the fragments heal and resemble those of a hare-lip. " When the parts are incessantly moved, the end of one fragment becomes excavated in the form of an arti- cular cavity. I have in my possession (says he) a lower jaw and an olecranon, the fractures of which are not united. For the connecting medium, nature has pro- vided a white substance resembling ligament. In a male patient I have also seen an articular connexion es- tabtished in the body of the thigh-bone subsequently to a fracture."—(Neue Bibl. b. l,p. 93.) When a capsule is formed, it is alleged not to be of a ligamentous na- ture.—(Bichat, Anatomic Ginirale, t. 3, p. 191.) In the Hunterian collection may be seen a false joint in the bones of the forearm, where the resemblance to a natural articulation was greater than what Boyer has seen in other situations. A valuable dissertation on false joints has been pub- lished by Reisseisen, entitled " De Articulationibus analogis, qua fracturis ossium superveniunt;" but I am sorry that it has not been in my power to meet with a copy of it. A false joint in the arm or forearm does not abso- lutely prevent the motion of the limb, which may yet be of considerable use; but when the disease is in the thigh or leg, the member cannot support the weight of the body, and the patient is unable to walk without crutches. The diversity of causes which may be concerned in preventing the union of fractures, plainly shows, that the treatment should be different in different cases. When the want of union is ascribable to the ends of the fracture not being in a state of coapta tion, and to their having been moved about too fre- quently, the obvious indications are, to set the fracture better, and to take adequate measures for keeping its extremities in contact and perfectly motionless. If the union has been prevented by a portion of mus- cle or other soft part getting between the ends of the bone, the only means of affording a chance of union would be cutting through the integuments, removing the displaced soft parts, and placing the ends of the bone in contact.—(Wardrop, in Med. Chir. Trans, vol. 5, p. 363.) When the advanced age of the patient seems to be the cause of the union not taking place, the application of the proper apparatus is to be continued a consider- able time, since experience proves, that in old subjects, the cure of fractures often requires many months. In such examples, also, tonic and cordial medicines, with a nutritive diet, are highly proper. When several months have elapsed since the acci- dent, and there is reason to apprehend that a preterna- tural joint is formed, a variety of plans have been pro- posed and practised. The most ancient method of treatment is that of for- cibly rubbing the ends of the fracture against each other, so as to make them inflame and take on a dispo- sition to form callus. This plan was recommended by the late Mr. John Hunter, and has had the approbation of many other distinguished modern practitioners. Mr. Hunter used even to advise us, in the ease of a dis- united fi-acture of the leg or thigh, to let the patient get up and attempt to walk with the splints on the limb, so that the requisite irritation might be produced. The idea of exciting a degree of inflammation in the situation of the fracture, certainly appears rational, and I be- lieve the practice has been attended with a limited de- gree of success. Mr. White records an example, 'in which he cured a broken thigh on this principle, a strong leather ease having been made for the limb.— (Cases in Surgery, p, 75.) A broken tibia, treated on simUar principles, is mentioned by Mr. Amesbury.— (On Fractures, p. 211, ed. 2.) The method is spoken of in Celsus: si vetustas occupavit, membrum exten- dendum est ut aliquid ladatur: ossa inter se manu dimovtnda, ut concurrendo exasperentur, et ut ut quidpingue est, eradatur, totumque id quasi recent fiat, ic. FRACTURES. 391 The foregoing treatment, however, is only likely to answer before a new joint, or at all events, a ligament- ous fibrous connexion is completely formed, and when the limb has hitherto been kept entirely motionless. When the case is old, and there are grounds for be- lieving that a preternatural articulation or fibrous liga- mentous connexion has taken place, we are advised to cut down to the ends of the bone, rasp or Eaw them off, and then treat the limb just as if the case were a recent compound fracture. Thi3 bold practice was first suggested by Mr. C. Wnite. " Robert Elliot, of Eyham, in Derbyshire, a very healthful boy, mne years old, had the misfortune, about midsummer in the year 1759, by a fall to fracture the humerus, near the middle of the bone. He was immediately taken to a bone-setter in that neighbour- hood, who applied a bandage and splints to his arm, and treated him as properly," says Mr. White, " as I suppose he was capable of, for two or three months. His endeavours, however, were by no means produc- tive of the desired effect, the bones not being at all united. A surgeon of eminence in Bakewell was af- terward called in; but as he soon found he could be of no service to him, and as the case was very curious,, he advised the lad's friends to send him to the Infirmary at Manchester. He was accordingly brought thither Ihe Christmas following, and admitted an in-patient. Upon examination, we found it to be a simple oblique fracture, and that the ends of the bone rode over each other: his arm was become not only entirely useless, but even a burden to him, and not likely to be otherwise us there was Uttle probability that it could ever unite, it being now six months since the accident happened. Amputation was therefore proposed as the only me- thod of relief: but I could not give my consent to it, for as the boy was young and had a good constitution, it was hardly possible that it could be owing to any fault in the solids or fluids, but that either nature was disappointed in her work by frequent friction while the callus was forming, or rather, that the oblique ends of the bone, being sharp, had divided a part of a mus- cle, and some portion of it had probably insinuated itself between the twq ends of the bone, preventing their union. Whichever of these might be the case, I was of opinion," continues Mr. White, " that he might be re- lieved by the following operation, viz. by making a longitudinal incision down to the bone, by bringing out one of the ends of it, which might be done with great ease, as the arm was flexible, and cutting it off either by the saw or cutting pincers; then by bringing out the other, and cutting off that likewise, and afterward by replacing them end to end, and treating the whole as a compound fracture. The objections made by the otber gentlemen con- cerned to this proposal were, first, the danger of wound- ing the humeral artery by the knife. Secondly, the la- ceration of the artery by bringing out the ends of the bones. And, thirdly, that we had no authority for such an operation. As to the first, that was easily obviated, by making the incision on the side ofthe arm opposite to the humeral artery. The place of election appeared to me to be at the external and lower edge of the del- toid muscle, as the fracture was very near to the inser- tion of that muscle into the humerus; the danger of wounding the vessel not only being by that means avoided, but after the operation, whUe the patient was confined to his bed, the matter would be prevented from lodging, and the wound be easily come at, to renew the dressings. The second objection will not appear to be very great, when we consider that in compound fractures the bone is frequently thrust with great vio- lence through the integuments, and seldom attended with laceration of any considerable artery; and as this would be done with great caution, that danger would appear very trifling. The third and last objec- tion is no more than a general one to all improvements. This method which I have been proposing,** says Mr. White, "was at last resolved upon, and I assisted in the operation, which was performed by a gentleman of great abilities in his profession, on January 3d, in the present year (1760). The patient did not lose above a spoonful of blood vh the operation, though the tourui- 2uet was not made use of. When the operation and ressings were finished, the limb was placed in a frac- ture-box, contrived on purpose, the lad confined to his bed, and the rest of the treatment was nothing different from that of a compound fracture. The wound was nearly healed in a fortnight's time, when an erysipelas came on, and spread itself all over the arm, attended with some degree of swelling: this, by fomentations and the antiphlogistic method, soon went off, and the cure proceeded happily, without any other interruption. In about six weeks after the opera- tion the callus began to form, and is now quite firm. The arm is as long as the other, but somewhat smaUer, in consequence of such long-continued bandages: he daily acquires strength in it, and will soon be fit to be discharged."—(Cases in Surgery, p. 69, <5-e.) In another instance of a broken tibia, which con- tinued disunited an extraordinary length of time, Mr White practised an operation somewhat simtiar to the foregoing one, with complete success. He made a lon- gitudinal incision, about four inches in length, through the integuments which covered the fracture. By the appUcation of a trephine, he cut off the upper end ofthe bone, and as the lower end could not be easily sawed off, he contented himself with scraping it. In the course of the subsequent treatment he had occasion to take off, with the cutting pincers, a small angle of tibia, and to touch the lower part of the bone with the butter of antimony, as well as to introduce the same caustic between the extremities of the fracture, in order to de- stroy a substance which intervened. A trifling exfo- liation followed. In twelve weeks the bone was firmly united.—(Op. cit. v. 81,82.) Besides Mr. White's cases, there are now some other instances upon record where the operation which he first proposed has succeeded. In the year 1813 Lan- genbeck operated upon a humerus in the foregoing man- ner, and the result was perfectly successful. The un- united fracture was situated at the insertion of the deltoid.^-(Neue Bibl. b. 1, p. 95.) Mr. Rowlands, of Chester, by a similar operation, cured a fractured thigh, which had lost all disposition to unite.—(See Med. Chir. Trans, vol. 2, p. 47.) Viguerie, surgeon to the Hdtel-Dieu, at Toulouse, has also practised Mr. White's operation with success.—(See Larrey, Mim. de Chir. Militaire,t.2,p. 132.) On the other hand, the operation has frequently failed. In the instance in which I saw it executed on the humerus by Mr. Long, in St. Bartholomew's Hos- pital, it did not answer, though the ends of the bone were most fairly sawed off, and the case treated with particular care and skill. Boyer states that he once performed the same operation in a similar case ; but that it had not the desired effect.—(Traiti des Mai. Chir. t. 3, p. 110.) Dr. Physick, of New-York, when he was a student in 1785, saw this proceeding unsuccess- fully adopted in a case where the humerus remained disunited.—(See Medical Repository, vol. 1, New-York, 1804.) Besides these examples, I have heard of others, in which Mr. Cline, Mr. Green (Med. Chir. Review, Feb 1828; and Lond. Med. Gazette p. 357), and other prac- titioners, have tried the experiment with no better suc- cess. What is still more discouraging, the operation has sometimes proved fatal.—(Richerand, Nosogr. Chir. t. 3, p. 39, ed. 2. Larrey, Mem. de Chirurgie MM- taire, t. 2, p. 132.) The difficulties, the danger, and the frequent Ul suc- cess of the foregoing operation, rendered another mode of treatment extremely desirable, when Dr. Physick, of New-York, suggested the plan of introducing a seton through the preternatural joint, with a view of exciting inflammation, and bringing about a union of the bone. This suggestion promises to be a considerable improve- ment in modern surgery. Dr. Physick had an oppor- tunity of performing the new operation on the 18th De- cember, 1802, in an example of disunited humerus, twenty months after the occurrence of the accident. " Before passing the needle (says Dr. Physick), I de- sired the assistants to make some extension ofthe arm, in order that the seton might be introduced, as much as possible, between the ends of the bone. Some lint and a pledget were applied to the orifices made by the seton- needle, and secured by a roller. The patient suffered very little pain from the operation. After a few days the inflammation (which was not greater than what is commonly excited by a similaripperation through the flesh of any other part) was succeeded by a moderate suppuration. The arm was now again extended, and splints applied. The dressings were renewed daily for twelve weeks, during which time no amendment was perceived; but soon afterward the bending of the arm at the fracture was observed not to be so easy as i: imd 392 FRACTURES. been, and the patient complained of much more pain than usual, whenever an attempt was made 10 bend il at that place. From this tune the formation of the new bony union went on rapidly, and on the 4th of May, 1803, was so perfectly completed, that the patient could move his arm in all directions as well as before the ac- cident happened. The seton was now removed, and the small sores occasioned by it healed up entirely in a few days. On the 28th of May, 1803, he was discharged from the hospital perfectly weU, and he has since re- peatedly told me his arm is as strong as ever it was."— (Physick, in Medical Repository, vol. 1, New- York.) In the London Medical Repository for Aug. 1823, a case is also noticed, in which Dr. Physick cured an ununited fracture of tbe lower jaw by means of a seton. On this subject an interesting memoir was read by Laroche to the Ecole de Medecine al Paris (Germinal, an 13). It was entitled " Dissertation sur la non-re- union de quelques fractures, et en particulier de celles du bras, et sur un may en nouveau de gutrir les fau- lts articulations qui en resultent." The author of this production affirms, that when be was at Augsburg, he saw Baron Percy, then with the army of the Rhine, pass a seton through the imperfectly healed cicatrix of a compound fracture of the thigh, which fracture seemed to have lost all disposition to unite. The me- thod answered so well, that in two months the patient was able to walk without crutches. Mr. Brodie has also successfully employed the seton in a case of ununited broken thigh. The patient was a boy about 13.-(See Med. Chir. Trans, vol. 5,p.387, ic.) In this country the same operation has been practised for the cure of a disunited humerus by Mr. Stansfield, of Leeds.—(See op. cit. vol. 7, p. 103, Src.) It appears, also, that Mr. Charles Bell applied the method to a fracture of the leg, at the tune when Roux was in England. The patient was a chUd six years old, and the broken bones had continued without union three years. The case had been originally mistaken by some unskilful surgeon for a mere contusion. Roux knew not whether the operation succeeded or not.—(Paral- lile de la Chir. Angloise, ire. p. 195.) We are not to expect, however, that Dr. Physick's new operation will succeed in every instance. Like most other surgical means, it is liable to occasional failures, among which, I believe, we must include the attempt made on a disunited thigh by Mr. Wardrop (see Med. Chir. Trans. vol. i, p. 365), though a partial amendment is men- tioned. In a case recorded by Mr. Amesbury, the seton did not answer. Mr. Hutchison was also obliged to take out the seton in a case of ununited humerus, and no cure was effected.—(See Practical Obs. p. 162.) Three in- stances of failure were seen by Mr. Amesbury (On Frac- tures, p. 224), and an additional one has been recorded by Mr. Earle.—(See Med. Chir. Trans, vol. 12, p. 195.) In the same case, and also in another which 1 saw under this gentleman's care, the plan of cutting down to the ends of tbe fracture, and rubbing them with caus- tic potassa was tried, but without success. Instead of several of the foregoing severe and often unsuccessful plans, Mr. Amesbury has tried, with much encouragement, tbe influence of local pressure and rest. He maintain^ he ends ofthe fracture closely pressed together, the pressure, when the fracture is transverse, operating longitudinally, and when oblique, transversely. A short sling, pads, and a particular ap- paratus are used accordingly.—(On Fractures, p. 236.) Mr. Buchanan, of Hull, has related two cases, in which a union of the fractures followed a perseverance in the appucatiou of tincture of iodine.—(On Diseased Joints, p. 75.) [This tribute to the ingenuity and skill of our coun- tryman, Dr. Physick, is without doubt well merited; for the use of the seton in cases of artificial joint has found advocates in almost every country, and been at- tended with great utility and success. Its occasional fati- ure, however, has led to the trial of local pressure by Mr. Amesbury'; and in the London Med. and Phys. Journal for 1827, Mr. Brodie has recorded an instance ofthe suc- cess of this practice, after the failure of the seton. Dr. Thos. H. Wright, of Baltimore, and Dr. Webster, of PhUadelphia, have each reported successful cases of Mr. Amesbury's treatment of ununited fracture, and pressure seems to promise to take the place of the seton in this country' among surgeons generaUy. Dr. Wright's cases may be found in the Am. Journal of the Med. Sciences for 132-?.- Reese.] FRACTURES OF THE OSSA NASI. These bones, from their situation, are much exposed to fractures. The fragments are sometimes not de- ranged ; but most frequently they are depressed. In order to replace them the surgeon must pass a fe- male catheter, a ring-handled forceps, or any such in- strument into tbe nostrUs, and using it as a lever, push the fragments outwards ; while, with tbe index finger of the left hand, he prevents them from being pushed out too far. When the firagments are disposed to fall in- wards again, some authors advise supporting them with an elastic gum cannula, or lint, introduced into the nos- tril ; but I am inclined to beUeve, with Mr. C. Bell, that no tubes can be employed so as to support the broken bones; and when these have been replaced, they will not readily change their position, as they are acted upon by no muscles.—(See Operative Surgery, t. 2, p. 222.) Besides, as Delpech remarks, since the tubes cannot reach tbe fragments, they cannot support them, and they must be attended with all the inconvenience of fo- reign bodies placed in contact with parts already in- flamed, or about to become so.—(Precis des Mai. Chir. t. 1, p. 222.) As fractures of the ossa nasi are the result of falls, and direct blows on the face, the soft parts are always either very much contused or wounded. Fractures of the ossa nasi are sometimes attended with very dangerous symptoms; depending either upon the concussion of the brain, produced by the same blow which causes the fracture, or on the cribriform lamella and the crista galli of the os ethmoides being driven in- wards, 60 as to injure and compress the brain. Tliis last danger, however, some modern surgeons consider as void of foundation; and whenever the symptoms in- dicate an affection of the brain, tbe nature of the case is referred to the intimate connexion between the bones of the nose and the os frontis.—(Delpech, Pricis des Mai. Chir. t. 1, p. 221,8tio. Paris, 1816.) When there are symptoms of pressure on the brain (see Head, Injuries of), and the ossa nasi are much de pressed, the surgeon must immediately raise them, and endeavour to draw gently forwards the perpendicular process of the os ethmoides, which is connected with the cribriform lamella and crista galli. Perhaps a pair of closed common forceps, introduced into each nostril, might best enable the surgeon to do what is necessary. Bleeding and the antiphlogistic treatment are always proper: for the vicinity of the eye renders it liable to become inflamed ; and when there are symptoms of in- jury of the brain, extravasation, Sec, the necessity of such practice is still more strongly indicated. FRACTURES OF THE LOWER JAW.' This bone is sometimes fractured near the clUn ; but seldom so as to produce a division of the symphysis, the solution of continuity generally happening between this part and the insertion of the masseter. In other in- stances the fracture occurs near the angles of the jaw, that is to say, between the insertion ofthe masseter and the root of the coronoid process. The bone may also be broken in two places at the same time; in which event the middle portion is axtremely difficult to keep right, because many of the muscles which draw the lower jaw downwards are attached to that part. The condyles and coronoid processes are also some- times broken ; the former the most frequently. Fractures of the lower jaw may be either perpendi- cular to its basis, oblique, or longitudinal: of the latter, examples have been known in which a portion ofthe al- veolar process, with the teeth in it, was detached from the rest ofthe bone. The soft parts are generally contused and wounded. J. L. Petit mentions one case in which the bone wad broken, and the coronoid process quite denuded, by the kick of ahorse. Fractures of the lower jaw are subject to displace- ment in the following way. When the fracture is near the symphysis, the side on which the processus inno- minatus is situated is drawn downwards and back- wards by the sub-maxillary muscles, while the other fragment is supported by the muscles which close the jaw. When the fracture is more backwards, the displacement occurs in the same way, but not so easily When the bone is fractured in two places, the middle portion is always pulled downwards and backwards by the muscles attached to Ihe chin, v. hi'e tU- two FRACTURES. 393 lateral pieces are kept up by the levator muscles. When the ramus of the jaw is broken, the masseter, being attached to both pieces, prevents any considera- ble degree of displacement Wheu the neck of the condyle is fractured, the pterygoideus externus may pull the condyle forwards. When a blow is received on the lower jaw, or the bone is injured by a fall, or by Ihe pressure of some heavy body ; when an acute pain is experienced in the part, and an inequality can be felt at the basis of the bone; when some of the teeth, corresponding to that inequality, are lower than the others; and when a cre- pitus is perceptible on moving the two pieces of the jaw on each other; there can be no doubt of a fracture. When the gums are lacerated, or the bone denuded by a wound, the case is (if possible) still more manifest. Fractures of the rami and condyles produce great pain near the ear, particularly when the jaw is moved; and a crepitus may also be felt. Fractures of the lower jaw, whether simple or dou- ble, are easily set by pushing the displaced part up- wards and a little forwards, and then pressing on the basis of the bone, so as to bring it exactly on a level with the portion which has preserved its natural posi- tion. Indeed, the correctness of the reduction can al- ways be rightly judged of by attending to the line which the base of the jaw ought to form, and observing that Ihe arch ofthe teeth is as regular as nature will allow. The maintenance ofthe reduction, however, is difficult; and can only be well executed by supporting the lower jaw, and keeping it applied to the upper one. As the latter indication cannot be properly fulfilled in persons whose teeth are very irregular, it is sometimes neces- sary to interpose an even piece of cork between the teeth on each side of the mouth, and against this cork the lower jaw is to be kept up with the bandage pre- sently noticed, while the aperture left between the in- cisores in the situation where no cork is placed, allows food and medicines to be introduced with a small spoon. As soon as the fracture is set, the surgeon should adapt some thick pasteboard, previously wet and soft- ened with vinegar, to tbe outside of the jaw, both along its side and under its basis. Over this moistened paste- board, a bandage with four tails is to be applied, the centre being placed on the patient's chin, while the two posterior tails are to be pinned to the front part of a nightcap, and the two anterior ones fastened to a part of the same cap more backwards." When the paste- board becomes dry, it forms the most convenient appa- ratus imaginable for surrounding and supporting the fracture. A piece of soap-plaster may now be applied to the skin underneath, which will prevent any ill effects of the hardness and pressure of the pasteboard. Until the bone is firmly united, the patient should be allowed only such food as does not require mastication, and it may be given by means of a small spoon intro- duced between the teeth. Broths, soups, jellies, tea, and olher slops appear most eligible. In order to keep the middle portion of the bone from being drawn downwards and backwards towards the larynx, it is frequently necessary to apply tolerably thick compresses just under and behind the chin; which are to be well supported by the bandage already- described. I need hardly state the necessity of enjoining the pa- tient to avoid talking, or moving the jaw more than can possibly be avoided. When the condyle is fractured, as it is incessantly * [Dr. J. Rhea Barton, of Philadelphia, to whose science and skill I have had firequent occasion to allude, has devised a bandage for fractures of the jaw, to which a preference is now generally given in this country, as well for its superiority in retaining the fragments in a state of coaptation^ for the facility it affords in securing the dressings occasionally applied to wounds of the face and chin. He commences with " a roller an inch and a half wide just below the prominence in the occipitis, arid continues it obliquely over the centre of the parie- tal bone across tbe juncture of the coronal and sagittal sutures, over the zygomatic arch, under the chin, and pursuing the same direction on the opposite side, until he arrives at the back of the head ; he then passes it obliquely around aud parallel to the base of the lower jaw over the chin ; and continues the same course on tne other side until it ends where he commenced, and repeals."—itfisi.J drawn forwards by the action of the pterygoideus ex- ternus, and on account of its deep situation cannot be pressed back, the lower portion must, if possible, be pushed fhto contact with it. For this purpose the bandage must be made to operate particularly on the angle of the jaw, where a thick compress should be placed. Compound fractures of the lower jaw are to be treated on the same principles as similar injuries of other bones. If possible, the external wound should be healed by the first intention ; and when this attempt fails, care must be taken to keep the wound clean by changing the dressings about once in three days; but not oftener, lest tbe fracture suffer too much disturbance. It is ob- served that compound fractures of the jaw, and even simple ones, which are followed by abscesses, are par- ticularly liable to be succeeded by troublesome and tedious exfoliations. In very bad fractures, in which all motion of the jaw must have the most pernicious effect, I consider it prudent to administer every kind of nourishment in a fluid form through an elastic gum catheter, introduced through one of the nostrils down the oesophagus. It now and then happens that fractures of the lower jaw continue ununited: Dr. Physick's successful treat- ment of one such case with a seton I have already noticed. FRACTURES OF THE VERTEBR*. On account of the shortness and thickness of these bones, they cannot be broken without considerable vio- lence. The spinous processes which project back- wards are the most exposed to such injury ; for they are Ihe weakest parts of the vertebra, and most super- ficially situated. On this account it is possible for them to be broken without any mischief being done to the spinal marrow. The violence, which is great enough to break the bodies of the vertebrae, must produce a greater or less concussion or other mischief of the spi- nal marrow ; from which accident much more perilous consequences are to be apprehended than from tbe in- jury of the bones abstractedly considered. The dis- placed pieces of bone may press on the spinal marrow, or even wound it, so as to occasion a paralytic affection of all the parts which derive their nerves from the con- tinuation of this substance below the fracture. Sir Astley Cooper divides fractures of the bodies of the vertebral with displacement into two classes; first, those which occur above the third cervical vertebra; and, secondly, others which happen below that bone. The first cases, he says, are almost always imme- diately fatal, if the displacement be to the usual extent. In the second description of cases, death takes place at various periods after the injury. The reason of this difference is ascribed to the circumstance of the phrenic nerve originating from the third and fourth cervical pairs, whence in the first class of cases death is imme ■ diately produced by paralysis of the diaphragm, and the stoppage of respiration.—(Ore Dislocations, p. 552.) As the mere concussion of the spine may occasion symptoms which very much resemble those usually occurring when the vertebrae are fractured, the diagno- sis is generally obscure. An inequality in the Une of the spinous processes and a crepitus may sometimes be distinctly felt. The lower extremities, the rectum, and bladder are generally paralytic; the patient is a£ flicted with retention of urine and feces, or with an in- voluntary discharge of the latter.—(Boyer.) If the lumbar vertebrae be displaced, the lower ex- tremities are rendered so completely insensible, that they may be pinched, burnt, or blistered without the patient suffering any pain. The penis in such cases is generally erect. In general, also, according to Sir Astley Cooper's observations, patients with fractured lumbar vertebras die within a month or six weeks; but he knew of one patient that lived two years, and then died of gangrene of the nates. In fractures and displacement of the dorsal vertebrae, the symptoms are very similar; but the paralysis extends higher, and the abdomen becomes excessively inflated. Death com- monly follows til two or three weeks; but Sir Astley Cooper remembers one case, in which a gentleman sur- vived the accident nine months. Fractures of the cer- vical vertebra, below the origin of the phrenic nerve, occasion paralysis of the arms, though it is seldom complete. Sometimes, when the fracture is oblique, one ami is more affected than the other. As the inter- 394 FRACTURES. costal muscles are paralytic, great difficulty of respira- tion prevails. The abdomen is also considerably in- flated. Death generally follows in from three to seven days. • Sir Astley Cooper notices the following as the ap- pearances found in the dissection of such cases. The spinous process of the displaced vertebra is depressed; the articular processes are fractured; tbe body of the vertebra is broken through, the separation rarely hap- pening in the intervertebral substance. The body of the vertebra usually projects forwards half an inch or an inch. Between the vertebra and the sheath of the spinal marrow blood is extravasated, and frequently on the lower part itself. When the displacement is slight, the spinal marrow is compressed and bruised. When greater, it is torn by the bony arch of the spinous pro- cesses, and a bulb is formed at each end, but the dura mater continues whole.—(See A. Cooper on Disloca- tions, ic.p. 554, Ac.) Fractures of the spinous processes without other se- rious mischief are not dangerous, and are the only instances of fractures of the vertebrae whioh admit of being detected with certainty. Any attempt to set fractures ofthe bodies of the ver- tebrae, even were they known to exist, would be both useless and dangerous. General treatment can alone be employed. Cupping wtil tend to prevent inflamma- tion in the situation of the injury. When the patient is affected with a flatulent distention of the abdomen, vomiting, hiccough, Sec, the belly may be rubbed with camphorated liniment, and purgative clysters and anti- spasmodics given. If requisite, the urine must be drawn off with a catheter. When the bladder, rectum, and lower extremities are paralytic, it is common to rub the back, loins, sacrum, and limbs with liniments con- taining the tinctura lyttae.—(Boyer.) With respect to the external and internal use of stimulants, however, it can never be judicious, when there is reason to appre- hend much inflammation of the injured parts; and as for the idea of thus restoring the nervous influence, there can be little chance of success, the cause of its interruption being here of a mechanical nature.—(Del- pech, Mai. Chir. t. 1, p. 222.) Some authors recommend trepanning, or cutting out a portion of the fractured bone, when the compression of the spinal marrow or its injury by a splinter is sus- pected ; but, according to my judgment, the indication can never be sufficiently clear to authorize the opera- tion, which, on account of the great depth of the inter- vening soft parts, must be very tedious, and even diffi- cult to effect without a great risk of increasing the injury which the spinal marrow may already have received. An unsuccessful operation of this kind was once performed by Mr. H. Cline, and another by Mr. TyrreU. Some cases, published by Mr C. Bell, tend to prove that the danger to be apprehended from injuries of the vertebras is the same as that which accompanies inju- ries of the brain. Hence, he joins the generality of practitioners in recommending general and local bleed- i ng, and keeping the patient perfectly quiet. And, with respect to operations for the removal of fragments of bone, it is bis decided belief that an incision through the skin and muscles covering the spine, and the with- drawing of a portion of the circle of bone which sur- rounds the marrow would be inevitably fatal, the mem- branes of that part being particularly susceptible of inflammation and suppuration. And even if a sharp spi'iila of fractured bone had run into the spinal mar- row, and caused palsy of the lower parts of the body, Mr. C. Bell thinks that exposing the medulla to extract the fragment would so aggravate ihe mischief, that in- flammation, suppuration, and death would be the in- evitable consequences.—-(Surgical Obs. vol. I, p. 157.) The same aithor describes inflammation of the spinal marrow as " attended with an almost universal nervous irritation, which is presently foUowed by excitement of the brain: in the mean time, matter is poured into the sheath ofthe spinal marrow, and either by its pres- sure causing palsy, or by its irritation disturbing tbe functions of the part, so as to be attended with the same consequences. The excitement ofthe brain being followed by effusion, death ensues."—(P. 159.) Cases are also referred to, where palsy of the lower extremi- ties comes on several months after an injury of the spine, owing to thickening of the membrane of the medulla, or disease of tbe latter part itself. Here Mr C. Bell recommends perseverance in local bleeding and deep issues.—(P. 160.) A fracture of the processus dentatus proves instantly fatal, as happened in the example mentioned by sir A. Cooper. — (On Dislocations, ic. p. 548.) In the prac- tice of Mr. Cline, a case occurred, in which a hoy with a fracture of the atlas lived a year after the accident.— (A. Cooper, op. cit. p. 549. See also L. T. Soemmering, Bemerkungen iiber Verrenkung und Bruch des Ruck- graths, Svo. Berlin, 1793. F. A. F. Cuenotte, Dis. Mid. Chir. sistens Casum Subluxation's Vertebra Dorsi cum Fractura complicata, postfactam Repos- tionem et varia dira Symptomata duodecima demum Septimana funesta. Argent. 1761. Case of Fractured Spine, Lan- cet, vol. 2, p. 97.) FRACTI'RKS OF THE STERNUM. The sternum is not frequently broken, and the rea son of this fact is imputed to the position of this bone, resting, as it were, upon the cartUages of the ribs, and also in some measure to its spongy texture. When the accident does occur, it is from the direct application of external violence to the injured part; and hence the fracture is always accompanied with great contusion, or even a wound of the integuments, and more or less injury of the thoracic viscera. As Boyer remarks, the sternum, in consequence of the elasticity of the carti- lages of the ribs, may be readily propelled backwards by pressure in this direction; and the result is an ac- tual change in the form, and a real diminution of tbe chest. Now, since this cavity is always accurately filled by its contents, these alterations cannot happen in a considerable and sudden manner, without a risk of the thoracic viscera being contused and even rup- tured. Thus, when the sternum has been fractured by violent blows on the chest, the heart and lungs have been found severely contused,and sometimes lacerated; and there will always be greater danger of such mis- chief, when Ihe fracture is attended with depression of one or more of the fragments. In some cases, a large quantity of blood is effused in the cellular membrane of the anterior mediastinum; and, in others, the acci- dent is followed by inflammation and suppuration in the same situation, and necrosis of the broken part of the bone. Since the lungs are also liable to be rup- tured by the same force which causes the fracture, or wounded by the depressed pieces of bone, emphysema may become another complication, as we see exempli- fied in a case related by Flajani.—(Collezione d'Osser- vaz. i-c. di Clur. t 3, p. 214, Svo. Roma, 1802.) A fracture of the sternum is rendered obvious by the inequalities perceptible when the surface of the bone is examined with the fingers; by a depression or eleva- tion of the broken pieces; a crepitus, and an unusual moveableness of the injured part in respiration. In many cases, the fracture may be seen, the soft parts being torn or otherwise wounded. The breathing is difficult, and mostly accompanied with cough, spitting of blood, palpitations, and inability to lie on the back. According to the observations of Petit and Baldinger, several of these latter symptoms may continue, with I less intensity, a long while after the fracture is cured. —(LeveilU, Nouvelle Doctrine Chir. t. 2, p. 243.) Fractures of the sternum, when mere solutions cf continuity, only require common treatment; viz. a piece of soap-plaster to the situation of the injury, a roller round the chest, quietude, bleeding, and a low regimen, with a view of preventing what may be considered as tbe most dangerous consequence, inflammation of Ihe parts within the chest. In cases attended with great depression of the frac- tured bone, the necessary incisions should be made, in order to raise with an elevator the portions of the bone driven inwards, or to extract with forceps any loose splinters, which seem to be similarly circumstanced. However, it is not often necessary to trephine the ster- num, either to raise a depressed portion of the bone, or to give vent to extravasated fluid. In the first of these circumstances, I believe, with Mr. C. Bell, that the formal application of tbe trephine can never be right or necessary, though the surgeon may be called upon to extract loose splinters.—(See Operative Surgery, vol. 2, p. 218.) Such an operation, however, may occasionally be proper when abscesses form under the sternum, or the bone is affected with necrosis, and the natural separation of the diseased parts is likely lo occupy ■ considerable time. FRACTURES. 395 Fractures of the sternum are more frequently pro-1 duced by gun-shot violence than any other cause; and lu these cases, there are generally many splinters re- quiring extraction. At the battle of Marengo, the French general Champeux received such a wound, with which he lived nearly a month: the injury was attended with so many splinters, that when they were removed, the pulsations of the heart were visible to a considerable extent.—(Leveille, vol. cit. p 244.) The ensiform cartilage, when ossified in old subjects, is liable to fracture. Little more, however, can be done in such a case, than relaxing the abdominal muscles by raising the thorax and pelvis, and then applying a piece of soap-plaster and a roller over the part, for the purpose of keeping it steady. When the blow has been violent, the patient should always be bled. FRACTURES OF THE RIBS. These generally happen near the greatest convexity of the bones, several of which are often broken together. The first rib being protected by the clavicle, and the lower ribs being very flexible, are less liable to be frac- tured than the middle ones. When the spicula of a fractured rib is beaten in- wards, it may lacerate the pleura, wound the lungs, and cause the dangerous train of symptoms attendant on emphysema.—(See Emphysema.) A pointed extremity of the rib, projecting inwards, may also cause an extravasation of blood; or by its irritation produce inflammation in the chest. A frac- ture which is not at all displaced is very difficult to detect, particularly in fat subjects; and, no doubt, is very frequently never discovered. The surgeon should place his hand on the part where the patient seems to experience a pricking pain in the motions of respiration, or where the violence has been applied. The patient should then be requested to cough, in which action the ribs must necessarily undergo a sudden motion, by which a crepitus will often be rendered perceptible. All the best practitioners, however, are in the habit of adopting the same treatment, when there is reason to suspect a rib to be fractured, as if this were actually known to be the case by the occurrence of a crepitus, or the projection of one end of the fracture; which, indeed, in the instances which are displaced, makes the nature of the accident sufficiently plain. A broken rib cannot be displaced either in the di- rection of the diameter of the bone, or in that of its length. The ribs, being fixed posteriorly to the spine, and anteriorly to the sternum, cannot become short- ened. Nor can one ofthe broken pieces become higher or lower than the other, because the same muscles are attached to both fragments, and keep them at an equal distance from the neighbouring ribs. The only possible displacement is either outwards or inwards.—(Boyer.) Simple fractures ofthe ribs, free from urgent symp- toms, require very simple treatment. The grand ob- ject is to keep the broken bones as motionless as pos- sible. For this purpose, after a piece of soap-plaster has been applied to the side, and over it proper com- presses, a broad linen roller is to be firmly put round the chest, so as to impede the motion of the ribs, and compel the patient to perform respiration chiefly by the descent and elevation of the diaphragm. A scapuUry will prevent the bandage from slipping downwards. When the fractured part is depressed inwards, the com- presses should be placed on the anterior and posterior part of the bone. As a roller is apt to become slack, many surgeons, with good reason, prefer a piece of strong linen, large enough to surround the chest, and laced with pack-thread, so as to compress the ribs in the due degree. When there is reason, from the symptoms, to think the lungs injured, or disposed to inflame, copious and repeated bleedings should be practised. Indeed, as peripneumony is always liable to succeed the accident, and is a most dangerous occurrence, every person free from debility, either having a broken rib, or supposed to have such, should always be bled in the first in- stance. The spermaceti mixture, with opium, is an excellent medicine, for appeasing any cough, which may disturb the fracture, and give the patient infinite pain. FRACTURES l>F THE SACRUM. Although more superficial than the other bones of the pelvis, the sacrum is less frequently fractured; a l„ !, explicable, as Boyer h is remarked, by its thick- ness, its spongy texture, and the advantageous way in which it supports tbe weight and efforts of tbe whole trunk. For the sacrum to be broken, the violence must be very great, Uke that resulting from the fall of a very heavy body, or the passage of a carriage-wheel on the convex side of the bone, or a fall from a great height on that part. On the other band, fractures of the sa- crum, when they do happen, are more serious than those of the ossa innominata, because, in addition to the great degree of contusion and laceration, with which they in common with the latter cases are complicated, there is almost always great damage done to the sacral nerves; a kind of injury which may have fatal conse quences. Hence retention of urine, inability to retain this fluid, involuntary discharge of the feces, paralysis ofthe lower extremities, &.C. Another principal danger also depends upon the injury which the pelvic viscera may have suffered from the same violence which broke the bone. When the fracture is situated at the upper part of the sacrum, which seldom happens on account of the thickness ofthe bone in that situation, there is no dis- placement, unless the bone is smashed, and the frag- ments are driven inwards by the same force whiuh produced the fracture; a case which always implies severe injury of the external and internal soft parts. But when the fracture occupies the lower portion ofthe bone, where it is less thick, the inferior fragment may be displaced inwards, towards the rectum. And, as Boyer observes, fractures ofthe higher part ofthe bone are not in general easily detected.—(Traite des Mai. Chir. t. 3, p. 152.) When the violence has been such as to make it pro- bable that it has extended its effects to the pelvic vis- cera, every means in the power of art must be adopted for the prevention of inflammation. In particular, co- pious bleeding should be practised, and, if necessary, repeated. Leeches should also be applied to the vi- cinity of the sacrum, and the parts kept cool with the lotio plumbi acetatis. Any difficulty, either in the ex- pulsion or retention of the urine and feces, wUl like- wise claim immediate and constant attention.—(See Urine, Retention of; Incontinence of, i-c.) With re gard to the particular means for promoting the union ofthe fractured sacrum, quietude is the most import ant, and after the risk of inflammation is over, all that can be done is to apply a piece of the emplastrum sa- ponis to the part, and put a roller round the pelvis, or a T bandage. FRACTURES OF THE OS COCCYGIS. Though much slighter than the sacrum, it is less fre- quently broken, because less exposed to external force, and capable of a degree of motion, by which it eludes the effect of violence. But in elderly persons, in whom the different pieces of the os coccygis are connected by anchylosis, a fall on the buttock may fracture this bone. The accident is known by the moveableness of the fragments, and the acute pain produced when the thighs are moved, the fragments being then disturbed by the action of the glutei muscles, some of whose fibres are attached to them.—(Boyer, t. 3, p. 160.) The treatment of fractures of the os coccygis consists in enjoining quietude, employing discutient or emollient applications, according to the particular state of tbe soft parts, and taking blood away from the patient; adopting the antiphlogistic regimen, and enjoining the patient to avoid lying on his back or sitting down. He should also avoid walking, so as to put the glutei mus- cles into action, which would disturb the broken bone All formal attempts at reduction are not only useless in respect to the fracture, but highly injurious to the soft parts, which are not in a state to bear handling without Ul effects. FRACTURES OF THE OSSA INNOMINATA. The situation and shape ofthe ossa innominata, and the thickness of the soft parts by which they are co- vered, explain why they are but seldom fractured. When such accidents happen, they are generally pro- duced by the passage of heavy carriage-wheels over the pelvis, falls from great heights, the kick of a horse, &c, and are always attended with considerable contu- sion of the external soft parts, and sometimes with great injury of the pelvic viscera. The anterior supe- rior spinous process of the ileum is sometimes broken off by the kick of a horse.—(B<,ycr.) 396 FRACTURES. The two ossa innominata may be broken together; but commonly only one of them is thus injured Most frequently the fracture takes place in the upper expanded portion of the bone, known under the name of the ileum, though sometimes it happens either in the ischium or the os pubis. The solution of conti- nuity may be limited to one part of the bone, or extend to several parts of it; and there may be a greater or iess number of fragments, and these attended or not with displacement. In many instances, in which the pelvis has been violently jambed between two bodies, or run over by a heavy carriage, the bones of the pel- vis, besides being fractured, are dislocated, some inte- resting examples of which accident have been recently published.—(A. Cooper's Surgical Essays, part 1, p. 49, i-c.) During my apprenticeship at St. Bartholomew's Hospital, several cases occurred in which the os Ueum, os ischium, and os pubis, were found fractured on opening the bodies after death; and when the great violence necessary to produce the accident is con- sidered, we cannot wonder that the injured state of the pelvic viscera should frequently prove fatal. Frac- tures of the ossa innominata are unavoidably attended with more or less contusion of the soft parts on the outside of the pelvis; and when the violence has been very great, the pelvic viscera may be seriously bruised, crushed, or lacerated, and the large nerves contained in the pelvis, or the spinal marrow itself, injured: hence, extravasation of blood or urine in the cellular membrane of the pelvis; ecchymoses deeply situated even in the substance of the muscles or other organs; injury of the kidneys; complete loss of motion; a pa- ralysis of the lower extremities; discharge of blood or a black bilious matter by vomiting or stool, either im- mediately or at more or less distant periods from that of the accident; retention of urine; fever; painful tension of the abdomen, from inflammation of the pe- ritoneum and bowels; the formation of abscesses, which are sometimes of great extent; sloughing; and death.—(Boyer, Traite des Mai. Chir. t. 3, p. 154.) As the same author has observed, the violence occa- sioning a fracture ofthe ossa innominata may produce a displacement of the fragments, and carry them more or less away from their natural situation. When the pubes or ischium is broken, the splinters may be pro- pelled into the canal of the urethra, or even through the bladder, and give rise to extravasation of the urine; or by merely compressing these organs, they may cause more or less interruption of their functions. But unless the fragments be displaced by the same force which caused the fracture, they can hardly be drawn out of their place by any other circumstance, since they are retained by the muscles attached to both fragments, and by surrounding ligamentous expan- sions. Owing to the deep situation of fractures of the pel- vis, and to there being no displacement nor mobiUty of Ihe fragments, the diagnosis is sometimes attended with great difficulty. A suspicion ofthe accident may be entertained, when the pelvis has suffered great vio- lence, the patient experiences great agony, and all mo- tion of the trunk and lower extremities is difficult and painful. Under these circumstances, if the fracture should be in the ileum, especially its upper and front portion, or in the os pubis, the mobility of the frag- ments or even a crepitus may be distinguished in a thin subject, if, when he is lying horizontally, with his thighs and legs bent, and his head and chest ele- vated, the projecting part of the os innominatum be taken hold of, and an attempt be made to move the fragments in opposite directions. In this business, however, one caution is given by Boyer, viz. not to mistake the crepitation of an emphysema, often attend- ing large extravasations of blood, for the grating of the fractured bone. In cases in which the fracture affects a part of the os innominatum very deeply placed, and it is limited to a single point of the os pubis or the ischium, so that no detached moveable fragment has been produced, the exact nature of the case is rarely made out with cer- tainty before the patient's death, and the dissection of the parts. Fractures of the ossa innominata are cases accom- panied with serious danger. When the fragments are displaced, and do not admit of being rectified again, the disorder arising from this cause may have fatal consequences. And, as Boyer observes, even when such displacement does not exist, these fractures are not the less to be apprehended on account ofthe injury which Ihe spinal marrow and the nerves, vessels, mus- cles, and viscera within the pelvis are likely to have sustained. These complications, which are almost in- separable from the fracture, may prove indeed directly fatal, or destroy the patient at a period more or less remote from the time of tbe accident. One terrible accident of this kind, which I saw about two years ago, with Mr. Ives, of Cobham, proved fatal in about half an hour. Sometimes, however, the fracture is not extensive, and the violence which produced it has not caused any very serious injur)' of the viscera and soft parts : but examples of this kind are uncommon. In these last cases, which are the most simple, a cure of the flracture may be easily effected by means of rest; a position in which all the chief muscles at- tached to the pelvis are relaxed; discutient applica- tions; and a roller, or T bandage.—(Boyer, Traiti des Mai. Chir. t. 3, p. 156.) The grand indication is to ob- viate the consequences of inflammation of the parts within the pelvis, and even of the peritoneum and ab- dominal viscera, by copious and repeated blood-letting. Any complaints respecting the evacuation of the urine and feces must also receive immediate attention. When there is great contusion, and the bones are very badly broken, the patient cannot move nor go to stool without suffering the most excruciating pain. To af- ford some assistance in such circumstances, Boyer, in a particular case, passed a piece of strong girth web under the pelvis, and, collecting the corners into one, fastened them to a pulley suspended from the top of the bed. This enabled the patient to raise himself v\ih very little efforts, so that a flat vessel could be placed under him. It appears to me that a bed con- structed on tbe principles recommended by the late Sir James Earle, might be of infinite service in these cases as well as in many others, particularly com- pound fractures and paralytic affections from diseased vertebrae.—(See Observations on Fractures of the Lower Limbs; to which is added an account of a con- trivance to administer cleanliness and comfort to the bed-ridden; by Sir J. Earle, 1807.) Mr. Earle has also exerted his mechanical ingenuity with great suc- cess in the invention of a bed, admirably well calcu- lated for the treatment of fractures, and other cases, in which it is an object of high importance to en- able the patient to empty ihe bowels without changing his position. Sometimes, notwithstanding the rigorous adoption of antiphlogistic measures, abscesses cannot be prevented from forming in the pelvis; particularly when there are detached splinters driven inwards. These collec- tions of matter should be opened as soon as a distinct fluctuation can be felt. The splinters may wound the urethra or bladder, and cause an extravasation of urine. Desault extracted a splinter which had had this effect from the bottom of a wound made for the dis- charge ofthe effused urine. In these cases, a catheter should be kept introduced, in oider to prevent the urine from coUecting in the bladder, and afterward insinuat- ing itself into the cavity of the abdomen.—(Chopart.) A very interesting case of fracture of the ossa inno- minata, attended with rupture of the bladder, and fol- lowed by a fatal peritonitis, has been recorded by Clo- quet.—(Nouveau Journ. de Midecine, Mars, 1820.) The ossa pubis were forced half an inch from each other. The horizontal branch of the pubes, and the ascending ramus of the ischium, were broken ; the sacrum dislocated from the ossa ileum, and driven for- wards within the cavity of the pelvis. The right sa- ero-Uiac symphysis was broken only at its fore part, and its bones still retained their connexion. Vast quantities of blood were found extravasated in the lum- bar region and about the pudenda. As soon as the abdomen was opened, three pints of a yellowish fluid, having a urinary Rmell, immediately gushed out. In this case, catheters of various sizes were introduced, even a syringe adapted to them was used, but nothing could be thus drawn off tut a few drops of blood. The possibility of mistaking a fracture of the acetabulum for a dislocation of the thigh-bone, and the differences of these cases as explained by Sir A. Cooper, have been mentioned in the article Dis- location. FRACTURES. 397 FRACTI'RES OF THK THIGH. The os femoris is liable to be broken at every point, from its condyles to its very head ; but it is at ihe mid- dle third of this extent that fractures mostly occur. The fracture is sometimes transverse, but more fre- quently oblique. The latter direction of the injury makes a serious difference in the difficulty of curing Ihe case without future deformity or lameness. Some- times the fracture is comminuted, the bone being broken in more places than one; and sometimes the case is attended with a wound, communicating with the fracture, and making it what is termed compound. As Petit remarks, however, the thigh-bone is less sel- dom broken into several pieces than other bones more superficially situated. A fractured thigh is attended with the following symptoms: a local acute pain at the instant ofthe ac- cident ; a sudden inability to move the limb; a pre- ternatural mobility of one portion of the bone ; some- times a very distinct crepitus, when the two ends of the fracture are pressed against each other; deformity in regard to the length, thickness, and direction of the limb. Tho latter change, viz. the deformity, ought to be accurately understood; for, having a continual tendency to recur, especially in oblique fractures, our chief trouble in the treatment is to prevent it.—(De- sault, par Bichat, t. 1, p. 181.) Almost all fractures of the thigh are attended with deformity. When this is considered in relation to length, it appears that, in oblique fractures, the broken limb is always shorter than the opposite one ; a cir- cumstance denoting that the ends of the fracture ride over each other. We may also easily convince our selves, by examination, that the deformity is owing to the lower end of the fractuvc having ascended above the upper one, which remains stationary. Wha» power, except the muscles, can communicate to the lower portion of the fractured boue, a motion from be- low upwards ? At one end attached to the pelvis, and at Ihe other to this part of the bone, the patella, the tibia, and fibula, they make the former insertion their fixed point, and, drawing upwards the leg, the knee, and the lower portion of the thigh, they cause directly or indi- rectly the displacement in question. In producing this effect, the triceps, semi-tendinosus, semi-membrano- sus, rectus, gracilis, sartorius, &c, are the chief agents. For the purpose of exemplifying the power of the muscles to displace the ends of the fracture, mention is made, in Desault's works, by Bichat, of a carpenter who fell from a scaffold and broke his thigh. The limb, the next day, was as long as the other; but the man had a complete palsy of his lower extremities, and could not discharge his urine. The moxa was ap- plied, the muscles soon regained their power, and then the shortening of the limb began to make its appear- ance. Besides the action of muscles, there is another cause of displacement. However firm the bed may be on which the patient is laid, the buttocks, more prominent than the rest of the body, soon form a depression in Ihe bedding, and thence follows an inclination in the plane on which the trunk lies, which, gliding from above downwards, pushes before it the upper end of the fracture, and makes it ride over the lower one. The muscles, irritated by the points of bone, increase their contraction, and draw upwards the lower part of the bone: and from this double motion of the two ends of the fracture in opposite directions, their riding over each other results. Transverse flractures are less liable to be displaced in the longitudinal direction ofthe bone, because, when once in contact, the ends of the fracture form a mutual resistance to each other; the lower ends, drawn up- wards by the muscles, meets with resistance from the upper one, which being itself inclined downwards by Ihe weight of the trunk, pushes the former before it, and thus both retain then- position in relation to each other. The deformity of a fractured thigh, in the transverse direction, always accompanies that which is longitu- dinal ; but sometimes it exists alone. This is the case, when, in a transverse fracture, the two ends of the bone lose their contact; one being carried outwards, the other Inwards; or one remaining in its place, while the other is separated. The upper end of the fracture is not now, as in the foregoing instance, motionless in re- gard to the muscular action; the contraction of the pectineus, psoas, iliacus internus, and upper part of Ihe triceps, draws it from its natural direction, and con- tributes to displace it. The deformity of the limb in regard to its direction, is either the consequence of the blow, which produced the fracture, or, what is more common, of the ill-di- rected exertions of persons who carry the patient. Thus we see that an injudicious posture bends the two portions, so as to make an angle. Whatever may be the kind of deformity, the lower end of the fracture may retain the natural position in which it is placed, or else undergo a rotatory motion on its axis outwards, which is very common, or inwards, which is more unusual. TlUs rotation always aggra- vates the displaced state of the fracture, and should be attended to in the reduction.—(Desault, par Bichat, 1.1, p. 180. 185.) Every one, at al! initiated in the surgical profession, knows that there are two very different methods of treating fractured thighs. In one, which was recom- mended and practised by Desault, and is still univer- sally preferred in France, the limb is kept in the straight or extended position. In the other, the limb is laid upon its side, with the knee bent; a mode which was extolled by the celebrated Mr. Pott, and since his time has found many partisans in this country. To these two positions for fractured thighs may now be added that in which the patient lies upon his back, with his thigh and leg in the bent position, supported on two oblique planes, or surfaces, the apex or angle of which is beneath the ham. This last position,however, has been more particularly recommended for fractures of the neck of the femur, though, if it be advantageous for them, I see no reason for not giving it a fair trial in other fractures of that bone. That Mr. Pott lost sight of certain advantages of the ■straight position ; that he was blind to the imperfec- tions of the bent posture; and that he exaggerated the power, which we have, of relaxing all the muscles of a limb by position; few reflecting surgeons of the pre- sent day will be inclined to deny. Were we to resign the privilege of thinking for our- selves, and implicitly to mould our opinions according to any authority, however high, we should often fall intoveryavoidableerrors. Were we to beUeve the literal sense of several passages in Mr. Pott's Remarks upon Fractures, we should suppose it possible and practicable to relax at once, by a certain posture of the limb, every muscle connected with a fractured bone. In the first vol. of his works, page 389, edit. 1783, he observes, in speaking of what must best answer the purpose of in- capacitating the muscles from displacing the fracture: ," Is it not obvious, that putting the limb into such posi- tion as shall relax the whole set of muscles belonging to, or in connexion with, the broken bone, must best answer such purpose ?" and in the next page, ■' What is the reason why no man, however superficially ac- quainted with his art, ever finds much trouble in set- ting a fractured os humeri ? is it not because both pa- tient and surgeon concur in putting the arm into a state of flexion, that is, into such a state as relaxes all the muscles surrounding the broken bone J" Also, in page 393, he continues, " Change of posture must be the remedy, or rather, the placing the limb in such mannei as to relax all its muscles." That to have all the mus- cles relaxed in cases of fracture would be desirable, were it also practicable, every one will admit; but the possibility of accomplishing it, so long as differenl muscles have different uses, different situations, and different attachments to the bones, every one must grant to be only a visionary project. For instance, do not the patient and surgeon, in the case of fractured os humeri adverted to above, rather concur in putting the fibres of the triceps and anconeus into a state of ten- sion, at the same moment that they relax the biceps and brachialis internus ? The position of the fractured os femoris, says Mr. Pott, should be on its outside, resting on the great tro- chanter ; the patient's whole body should be inclined to the same side; the knee should be in a middle state between perfect flexion or extension, or half-bent; the leg and foot, lying on their outside also, should be well supported by smooth pillows, and should be rather higher in their level than the thigh; one very broad splint of deal, hollowed out and well covered with wool, rag, or tow, should be placed under the thigh, from above the trochanter quite below the knee ; and 398 FRACTURES. another, somewhat shorter, should extend from the groin below the knee on the inside, or rather in this posture on the upper side. The bandage should be of the eighteen-taU kind, and when the bone has been set, and the thigh well placed on the pillow, it should not, Without necessity (which necessity in this method wUl seldom occur), be ever moved from it again, until the fracture is united; and this union wUl always be ac- complished in more or less time, in proportion as the limb shaU have been more or less disturbed.—(Pott.) Here only two spUnts are mentioned; the surgeons of the present day usually employ four. After placing the patient in a proper position, the necessary extension is to be made. Then the under splint, having upon it a broad soft pad, and an eighteen-tailed bandage, is to be laid under the thigh, from the great trochanter to the outer condyle. The surgeon, before applying the soap plaster, laying down the taUs of the bandage, and put- ting on the other three splints, is to take care that the fracture lies as evenly as. possible. In the position for a fractured thigh, Mr. Pott, we find, directs the leg and foot to be rather higher in their level than the thigh; with what particular design, I have not myself been able to make out. "Whoever me- ditates upon the consequence of elevating the leg and foot above the level of the thigh, in the bent position, wUl know that it is to twist the condyles of the os fe- moris more outward than is natural. When a patient is placed according to Mr. Pott's direction, upon a com- mon bed, the middle soon sinks so much that the leg becomes situated very considerably higher than the thigh,, and I am disposed to think that tliis is one cause why so many broken thighs are united in so deformed a manner, that the foot remains permanently distorted outwards. The great propensity of the triceps and other muscles to produce this effect, may also serve to explain the frequency of the deformity. It is not merely the depression of the middle of the bed which is disadvantageous: as the weight of the patient's body falls more upon one side of the bed than the other, in the bent position of the limb, unless the sacking be tight and the mattress very firm, it happens that such a de- cUvity is formed as to render it exceedingly difficult, if not impracticable, to make the patient continue duly upon his side. It cannot be enjoined too forcibly, that fractured thighs should always be laid upon beds not likely to sink much. When this happens, no rational dependence can be put in the efficacy of the bent posi- tion, and, as Desault has explained, the same thing is hurtful also in the straight posture. The most enthusiastic advocates for the bent position must allow, that it leaves the leg and foot too moveable and unsupported, and that, though it may relax the, muscles, which have the most power to disturb the co- aptation of a fractured thigh, it yet leaves a mass of muscle unrelaxed, quite sufficient to displace the ends of the bone. Hence, practitioners should endeavour to improve the apparatus employed, so that it may make a permanent resistance to tho action of the muscles, and in the straight position such resistance may cer- tainly be practised with most effect and convenience. The whole tenor of Mr. Pott's observations on frac- tures would lead one to suppose, that from the moment a muscle is partially relaxed, it becomes incapable of acting on or displacing a fracture. But if this were correct (which it cannot be), we should not have the power of completely bending or extending our limbs; for as soon as tbe set of muscles designed for this pur- pose were partly relaxed by the half-flexion or half- extension of the joint, they would be deprived of all farther power. Therefore, in addition to the arguments to be brought against the bent posture, arising from its not actually relaxing all the muscles connected with the broken bone, we are also to take into the account the fact, that the partial relaxation of any muscle by no means incapacitates it from acting. In* the earlier editions of this Dictionary, I expressed a preference to Mr. Pott's method of treating broken thighs. More mature reflection, however, and subse- quent experience have made me a convert to the senti- ments of Desault on this subject. The terrible com- pound fractured thighs, which I had under my care in the campaign in Holland in the year 1814, could not have been at all retained by any apparatus put merely upon the thigh itself. The superiority of long splints, extending the whole length of the lirnb, was in these cases particularly manifest With such splints, which I maintain steady the fracture itself, the knee, leg, ankle. and foot, your patient may, in fact, even be removed upon an emergency from one place to another, without any considerable disturbance of the broken part. But how could this be done in the bent position, with short splints, merely applied to the thigh, affording no support to the leg, and not confining the motions of the knee and foot ? There are some excellent remarks on the treatment of fractured thighs in the writings of Desault. It is observed, that, if we compare the natural powers of displacement with the artificial resistance of almost every apparatus, we shall find that the disproportion between such forces is too great to let the former yield to the latter. The action of the muscles, however, which is always Ut first very strong, may afterward be gradually diminished by the extension exercised on them. A power incessantly operating can effect, what another greater power, temporarily applied, cannot at once accomplish, and the compression of circular bandages tends also to lessen the force of the muscles. Desault cured in the Hotel-Dieu an immense number of fractured thighs, without any kind of deformity. This success, it is said, was owing particularly to the well-combined employment of extension and compres- sion of the muscles. The advantage of keeping the muscles a long while extended, in order to diminish their power, is especially evident in the reduction of certain dislocations, as those of the shoulder, in which we often cannot succeed till the muscles have been kept on the stretch for a greater or less time. The fracture of the patella and olecranon equally demon- strates the utility of compression for the same purpose; as when the muscles are not steadily compressed by the bandage, they draw upwards the fragment of bone with double or triple force. To the reduction of fractured thighs in the bent pos ture, Desault entertained the following objections: the difficulty of making the extension and counter-extension, when the limb is so placed; the necessity of then ap plying them to the fractured bone itself, instead of a situation remote from the fracture, as, for example, the lower part of the leg; the impossibility of comparing with precision the broken thigh with the sound one, in order to judge of the regularity of its shape; the irk- someness of this position long continued, though it may at first seem most natural; the inconvenient and painful pressure of a part of the trunk on the great trochanter of the affected side; the derangement to which the limb is exposed when the patient has a motion; the difficulty of fixing the leg firmly enough to prevent the effect of its motion on the thigh-bone; the manifest impossibility of adopting this method, when both thighs are fractured; lastly, experience in France having been little in favour of such posture. Also, what is gained by the relaxation of some mus- cles, is lost by the tension of others. For such rea- sons (certainly strong ones), Desault abandoned the bent position, and always employed the straight one, which was advised by Hippocrates. Petit, Heister, and Duverney recommend tbe extend- ing means to be applied just above the condyles of the os femoris. Dupouy remarked that this practice ren- dered it necessary to employ very great force, and he preferred extension from the foot. Fabre took also into consideration the inconvenience of the partial pressure made on the muscles, which, irritating and stimulating tbem to action, multiplies the obstacles to the setting of the fracture. For nearly similar motives Desault espoused their doctrine, introduced it at the H6tcl- Dieu, and the success which he experienced from the practice contributed materially to its more extensive adoption. Desault. as we have stated, preferred the straight posture, and laid bis patients on surfaces not likely to sink with the weight of the body. The feather-beds, formerly in common use at the Hotel-Dieu, had this in- convenience. For these, in cases of fractures, Desault substituted a firm, tolerably hard mattress, which did not allow the continual change of posture to occur which a soft bed does. The object of every apparatus being to keep the ends of the fracture from being dis- placed, the mechanism of every contrivance for this purpose should be directed against the causes of the displacement. These are, 1, the action of the muscles drawing upwards the lower end of the fracture; 2, tiie weight of the trunk propelling downwards the upper FRACTURES. 399 mid. Hence, every apparatus intended to prevent dis- placement of a thigh fractured obliquely, should, 1, draw and keep downwards the lower end ofthe fracture; 2, carry and maintain upwards the upper end of the fracture, and the trunk which is above it. This prin- ciple is of general application, and oidy subject to a few exceptions in transverse fractures, attended merely with displacement in the direction of the diameter of the limb, or else none at all. 3, There must also be in the apparatus a resistance to the rotation of the lower portion of the broken bone, so as to keep the limb steady, even in case of any sudden motion. If we compare the operation of the different pieces of our apparatus with the above indications, Desault says, we shall find, that without permanent extension they are not very effectual. With regard to bandages, whether a roller or eighteen-tailed bandage be used, they all have one common mode of operating; they press the muscles towards the ends of the fracture, so as to make them form a kind of natural case for the fracture, and thus they make lateral resistance against the parts. In this manner bandages materially aid in preventing displacement sidewise, and are particularly useful in transverse fractures. But what is there to hinder the two inclined surfaces of an oblique fracture from slipping one over the other 1 What power is there to keep the limb from receiving the effects of ac- cidental shocks 1 Is the pelvis kept back 1 Is the ac- tion of the muscles resisted! The latter is indeed somewhat diminished by the pressure, and this is the chief use of the bandage; but will such compression be enough to prevent the longitudinal displacement of the broken bone, especially if the bandage be appUed slackly as some advise* These remarks apply also to compresses: petit moyen contre une grande cause. Splints are useful in firmly fixing the limb, and guarding it from the effects of accidental shocks, or of contractions of the muscles. They operate more iHiwerftilly than bandages, in preventing lateral dis- placement ; and hence they suffice for transverse frac- tures, without permanent extension. They also resist the rotation ofthe thigh outwards or inwards. But when the breach of continuity is oblique, will they hinder the ends of the bone from gliding over each other, and the consequent shortening of the limb! They obviously could only do so by the friction of the different pieces of the apparatus, especially the tapes, which fasten it; and then, to make the resistance effectual, they must be lied so tightly as to create danger of mortification. Will the splints prevent the trunk from descending, und propelling before it the upper end of the fracture ? Will tUey hinder the action ofthe muscles ou the lower end? Will they, in short, fulfil all the above indica- tions 1 Their chief use is to prevent lateral displace- ment, and keep the limb steady. Hence, they should extend along the leg as well as the thigh, which cannot fail to be disturbed whenever the lower part of ihe limb is allowed to move. The pads serve principally to keep the limb from be- ing galled by the splints, and their action in preventing displacement of the fracture must be but trivial. According to Desault, the ordinary pieces of appara- tus, which do not execute any permanent extension, may suffice for transverse fractures; but they are al- ways ineffectual when the division is oblique, because they do not fulfil the twofold indication of drawing downwards the lower end of the fracture, and keeping the other one upwards. He inculcated that the object particularly to be aimed at was such a disposition,, that the foot, leg, thigh, and pelvis should constitute but one whole; so that, though the different parts thereof might be drawn in different directions, yet they would still, with respect to one another, preserve the same mutual relation. He in- vented the following apparatus to answer these pur- poses. A strong splint, long enough to extend from the crista of the os ileum to a certain length beyond the sole of the foot, and rather rpore than two inches and a half broad, with each of its extremities pierced in the form of a mortise, and terminating in a semicircular niche is a principal part of Desault's apparatus. It is ap- plied to the exterior side of the thigh, by means of two strong linen rollers, each more than a yard long. The middle part of one roller is to be applied to the uisidu of tbe thigh, ai its upper part; its cuds arc brought to the exterior side of the thigh, passed through the mortise, and knotted on the semicircular niche. Pads are to be previously placed under its middle part, in order to prevent any disagreeable pressure; as well as on the tuberosity of the ischium, which Desault considered as the principal point of action of this band. The inferior part of the leg is next covered with pads, on which the middle part of the second roller is placed, the extremities of which cross on the instep and upper part of the foot, then on the sole, after which they are conveyed outwards, and one end passed through the mortise, and knotted with the other on the niche, with such a degree of force as to pull the inferior por- tion of the femur downwards, and push the splint up- wards, and, by this means, the pelvis and superior portion of the fractured bone. On the internal side of the limb is placed a second spUnt, which extends from the superior part of the thigh to a certain distance be- yond the foot. A third is placed on the anterior part of the Umb from the abdomen to the knee. The superior extremities of the anterior and exterior splints are fixed by means of a bandage passed round the pelvis. A roller, the middle part of which is placed under the sole of the foot, and the extremities crossed on its su- perior surface, and fastened to the splints, operates with them in preventing the foot from moving. Before applying the apparatus, Desault covered Ihe whole limb with compresses, wet with a solution of the acetate of lead. Over these Scultetus's bandage was put, and a roller round the foot, all wet with the same lotion. For more particulars the reader is referred to the Parisian Chirurgical Journal, vol. 1. (Euvres Chir. de Desault, par Bichat, t. 1. Rosalino Siariina, Memoria sulla Fratture, con alcune Modificazione alP Apparato di Desault, Svo. Palermo, 1814. Boyer, Traiti des Maladies Chir. t. 3. Richerand, Nosogr. Chir. t. 3, idit 4. Boyer's apparatus for fractured thighs is described in the last edition of the First Lines of the Practice of Surgery. Instead of the position advised by Pott, or that re- commended by Desault and Boyer, Mr. C. Bell prefers the posture in which the patient lies upon his bad, with the limb supported in the bent attitude by means of a wooden frame. This machine is simple enough, consisting of boards ten or eleven niches in breadth, one reaching from the heel to the ham, the other from the ham to the tuberosity of the ischium. Under the knee-joint they are united at an angle, while a horizon- tal board connects their lower ends together. Thus they form two sloping surfaces, to which cushions are adapted, and over which the limb can be placed in an easy bent position. Near the edge of the inclined boards, holes are made furnished witli pegs. After the bone has been set, a long splint is applied from the hip to the side of the knee, and another along the inside of the thigh.—(See Operative Surgery, vol. 2, p. 189.) I entertain a very favourable opinion of this mode of placing fractured thighs. However, the foregoing ap- paratus does not sufficiently secure the leg and foot from motion, though, with the aid of a roller and a foot-board, this advantage might easily be obtained. The fracture-apparatus, devised by my friend Mr. Earle. is excellently calculated for this mode of treatment, with these additional recommendations, that the obh- quity of the two surfaces on which the limb reposes can be altered as occasion may require: there is a foot- board for the support of the foot, and a contrivance by which the patient is enabled to have stools without moving himself or changing his posture in the slightest degree.—(See his Practical Observations in Surgery, p. 125, i-c. Svo. Lond. 1823.) Fractures of the Neck of the Thigh-Bone. As this is a subject which has of late years excited considerable discussion, the reader cannot be too parti- cular in noticing, that three distinct kinds of fracture, very different in their nature, treatment, and result have been generally confounded together under the name of " fractures of the neck of the thigh-bone;"' for much of the dispute that has prevailed, whether these fractures will unite like those of other bones, seems to have proceeded from the three species of fracture not having been properly discriminated. Two of the cases unite by means of callus, like other frac- tures ; but the other, as it usually occurs, is conceived by some surgeons not to admit of a similar mode of union; or, at all event.-;, they declare that the fact liw 400 FRACTURES. not yet been demonstrated. Sir Astley Cooper has therefore divided these cases, first, into fractures which happen through the neck of the bone, entirely within the capsular ligament; being the examples in which he thinks a union by bone has not yet been proved • secondly, into fractures through the neck of the bone at its junction with the trochanter major, which frac- tures are of course external to the capsular ligament ■ thirdly, into fractures through the trochanter major, beyond Us juration with the neck of the bone.—{On Dislocations, i-c. p. 114—116.) Fractures of the neck ofthe thigh-bone are infinitely more frequent than dislocations at the hip, and may arise from a fall, either upon the great trochanter, the sole of the foot, or the knee. According to Desault, the first accident produces the injury much more frequently than the two latter. Of thirty cases which were seen by Desault, four-and-twenty arose from falls on the side. All those inserted by Sabatier in Ids interesting Memoir were the result of a similar accident. These authors, it is to be remarked, are not speaking particu- larly of the fracture within the capsular ligament; and hence, perhaps, the reason of their sentiments differing from those of Sir Astley Cooper, who observes, that in London tbe fracture within the capsule is most commonly produced by a person slipping off the edge of the foot-pavement. According to this eminent sur- geon, a fracture of the neck of the thigh-bone, within the capsular ligament, seldom happens but at an ad- vanced period of life; and the reason ofthe facility with which the injury takes place in old persons, he ascribes to the interstitial absorption which that part of the femur undergoes in individuals past a certain age, whereby it becomes shortened, and altered in its angle with the shaft ofthe bone. He admits, however, that Ihe accident is frequently caused by a fall upon the tr»chanter major.—(Surgical Essays, part. 2, p. 35, 36. Also, Larrey, Journ. Complim. t. 8, p. 98, 8vo. Paris, 1820.) Fractures of the neck ofthe thigh-bone within the capsule are more common in women than men.— (/. Wilson, On the Skeleton, i-c. p. 245. A. Cooper, On Dislocations, i-c. p. 122.) The division is more frequently transverse than Oblique; the neck being sometimes, in the former case, wedged in the body of the bone, as Desault found in several instances; a model of one of which, in wax, is preserved in the collection of L'Ecole de Santi, and the natural specimen of which was in the possession of Bichat. A fracture of the neck of the thigh-bone is sometimes complicated with one of the trochanter ma- jor. With respect to the diagnosis of a fracture within the capsular Ugament, an acute pain is felt, a sudden in- ability to walk occurs, and the patient cannot raise himself from the ground. The latter circumstance, however, is not invariable. In the fourth vol. of the Mem. de PAcad, de Chirurgie, a case is related, in which the patient walked home after the accident, and even got up the next day. Desault published a similar example. The locking of one end of the frac- ture in the other may offer an explanation of this cir- cumstance. The dissections made by Dr. Colles have recently led to another discovery, viz. that sometimes the solution of continuity does not extend completely through the neck of the femur.—(See Dublin Hospital Reports, vol. 2.) Three cases proving this fact are there adduced; a fact which at once explains the abi- lity of some patients to walk directly after the injury, and the absence of all retraction ofthe limb. Accord- ing to Mr. Amesbury, incomplete oblique fractures of the neck of the femur are easily produced in the recently dead subject.—(On Fractures ofthe Upper Third of the Thigh-Bone, p. 3.) A shortening ofthe limb almost always takes place: the " leg becomes from one to two inches shorter than the other; for the connexion of the trochanter major with the head of the bone, by means ofthe cervix, being destroyed by the fracture, the trochanter is drawn up by the muscles as high as the Ugament will permit, and consequently rests upon the edge of the acetabu- lum, and upon the ileum above it."—(Sir A. Cooper on Dislocations, *e.p.il7.) The action of the muscles drawing upwards the lower end of the fracture, the weight of the trunk in propelling downwards the pel- vis and upper end of the fracture, are the two causes of the shortening of the limb. In general, a slight effort suffices for the restoration ofthe natural length of the limb; but the shortness recurs almost as soon as th« extension ceases. " This evidence ofthe nature of the accident continues," as Sir A. Cooper correctly remarks, " until the muscles acquire a fixed contraction, which enables them to resist any extension which is not of the most powerful kind."—-(Surgical Essays, part 2, p. 31.) Goursault and Sabatier remark, that sometimes the shortening of the member does not take place till a long while after the accident. In opposition to the common belief that the limb is shortened, Baron Lar- rey asserts, that the member is at first actually length- ened.—(Journ. Complim. t. 8, p. 99.) This state- ment I have never seen confirmed, and it is contra- dicted by daily experience. And to prove how widely Larrey differs from Sir A. Cooper, the following passage wtil suffice. " In order to form a still more decided judgment of this accident (says the latter writer) after tlie patient has been examined in the recumbent pos- ture, let him be directed to stand by his bedside sup- ported by an assistant, so as to bear his weight upon the sound limb. Immediately he does this, the surgeon observes most distinctly the shortened state of the in- jured leg, the toes resting on the ground, but the heel not reaching it, the everted foot and knee, and the di- minished prominence of the hip."—(Surgical Essays, part 2, p. 34.) The lessened projection of the trochan- ter major arises from its not being supported by the neck of the bone, as it always is in the natural state of the parts. A swelling is observable at the upper and front part of the thigh, always proportioned to the retraction of which it appears to be an effect. The projection of the great trochanter is almost en- tirely effaced. Directed upwards and backwards, this eminence becomes approximated to the crista ofthe os ileum ; but, if pushed in the opposite direction, it rea- dily yields; and, when it has arrived at its natural level, the patient becomes capable of moving his thigh. The knee is a little bent. Abduction of the limb al- ways occasions acute pain, and it is noticed by Sir A, Cooper, that the rotation inwards is particularly pain- ful, because the broken extremity of the bone then rubs against the capsular ligament.—(Vol. cit. p. 33.) If, while the hand is placed on the great trochanter, the limb is rotated on its axis, this bony projection may be felt revolving on itself, as on a pivot, instead of de- scribing, as in the natural state, the segment of a cir- cle, of which the neck ofthe femur is the radius. This symptom, which was particularly noticed by Desault, is very manifest when the fracture is situated at the base of the neck, less so when at its middle; and it is not very perceptible when the breach is near the head of the bone. In the rotatory motions, tbe lower frag- ment rubbing against the upper one produces a dis- tinct crepitus, which, however, is not an invariable symptom, as Larrey would lead one to suppose. In fact, as Sir A. Cooper has explained, it is not discover- able while the patient is lying upon his back with the limb shortened; but if the leg be drawn down, so as to bring the lunbs to the same length, and rotation be then performed, especially inwards, the crepitus is sometimes observed, in consequence ofthe broken ends ofthe bone being thus brought into contact.—(On Dis locations, i-c. p. 121.) It appears to Mr. Amesbury, that the head of the bone moves so readily in the acetabulum, " that the least impetus, even through the periosteum and re- flected membrane (supposing them to be entire), will cause it to move simultaneously with the shaft; and if it should do so in tbe same relative proportion, cre- pitus cannot be felt. If crepitus be not elicited by bending the limb upon the pelvis, the surgeon may try to produce it by causing the Umb to'be gently ro- tated, while he endeavours to fix the. head of the bone by pressing it with his fingers back against the aceta- bulum."—(On Fractures of the Upper Third of the Thigh-Bone,p. 15.) The toes are usually turned outwards; a position which Sabatier considers as the inevitable effect of the fracture, though Pare and Petit noticed that it did not constantly occur. Two cases, adduced by these illus- trious Surgeons, were not credited by M. Louis; but the experience of Desault fully confirmed the possi- bility of the limb not being always rotated outwards: and, as Sir A. Cooper has remarked, three or four hours generally elapse before the turning of the limb outwards is rendered most obvious by the fixed con- FRACTURES. 401 traction of the muscles.—(Surgical Essays, part 2, p. 32.) Mr. Langstaff dissected one case, in which the great toe was in the first instance everted, but subsequently turned inwards when the patient began to use tbe limb. " The preparation shows the fracture to have been within the capsular ligament, close to the head of the bone, and gives a decided refutation to the opinion of the length of the broken portion attached to the tro- chanter being tbe cause of the inversion, inasmuch as this part has been removed by absorption. The point of ihe foot was everted, whUe it retained its proper length, and only became inverted by a wise provision of nature to assist progression after it had begun to be shortened. This circumstance received great illustra- tion in the person of Henry West, a boy from whom Mr. White, of the Westminster Hospital, removed the head, neck, and part of the trochanter of the left thigh- bone, in consequence of scrofulous disease of the hip- joint, attended by abscess. He recovered after the re- moval of the bone. The thigh is three inches and a half shorter than the other, and the toes turn inwards, not only in walking, but when he lies on his back in a quiescent posture, or prepared for sleep."—(Guthrie, in Med. Chir. Trans, vol. 13, p. 109.) The possibility of the foot being turned inwards directly after the acci- dent, is the subject that now more immediately inte- rests us. Of this occurrence an example is reported by Mr. Stanley. ■ " A middle-aged man fell in the street, and his hip struck the curb-stone. The immediate con- quences were, that the limb was inverted and short- ened to the extent of an inch, and no crepitus could be discovered. It was presumed that a dislocation had occurred, and accordingly an extension ofthe limb was made, and so great was the constitutional irritation oc- casioned by the repeated trials to reduce the supposed dislocation, that the man died about five months from the time of the accident. In the dissection ofthe hip, a fracture was found, extending obliquely through the middle of the neck ofthe femur, but entirely within tlie capsule. A portion of fibrous and synovial membrane on the anterior side of the neck of the boue had es- caped laceration." " In a male subject that had been brought for dissection, it was observed, that the left lower extremity was turned inwards and considerably shortened. On examining the hip, a fracture was found, extending through the neck and shaft of the fe- mur. The neck had been broken at its junction with the shaft, and a fracture had extended from the upper part of the trochanter major downwards at the poste- rior side of the femur, a little below the trochanter minor. The upper part ofthe shaft was thus spUt into two portions, one of which was of sufficient magnitude to include the trochanter minor and nearly the whole of the trochanter major. In the last two cases, it may be asked, to what cause the Ui version ofthe limb should be attributed T Whether to the direction ofthe fracture? If not, whether there be any other circumstance adequate to its explanation > In the instance of fracture within the capsule, the por- tion of the synovial and fibrous membrane which had escaped laceration on the anterior side of the neck of the bone might probably prevent the Umb from being turned outwards; but (says Mr. Stanley) why it should have been turned inwards, I confess myself unable to explain. In the instance of fracture without the cap- sule, by considering the direction ofthe fracture, in re- ference to the attachments of the muscles, we obtain an explanation of both points. For, as nearly the whole of the mnscles that rotate the thigh outwards were connected with the separated portion of bone, they must have ceased to influence the limb in one direction, and of course have left then; antagonists at liberty to turn it in the other; and the fractured sur- faces being permitted to unite without any change in the position of the limb, the inversion would become permanent."—(Med. Chir. Trans, vol. 13, p. 508.) Ttl3 merit of having first explained the cause of the inver- sion of the foot in certain fractures on the outside of the cnpsular ligament is due, I beUeve, to Mr. Guthrie " When (says he) the fracture has taken place in such a manner as to be external to the insertion of these ro- tators outwards, yet'sufficiently within the insertion of the gluteus medius and minimus, so as not to deprive them of their due action, the toe wiU be turned in- wards and must always be so; or remain without any alteration of position, according to certain variations in Vol. I. —C c the uiclination of Ihe fracture affecting the power of these muscles." In the instance recorded by Mr. Guth- rie, the little trochanter was broken off; but whether it be an essential complication, he conceives must be determined by future observation.—(Vol. cit. p. 112.) The principles on which this gentleman founds his ex- planation have since been corroborated by the parti- culars of a case that was examined by Mr. Syme.—(See Edin. Med. Journ. April, 1826.) The reason of the foot being occasionally inverted, even when the frac- ture is quite within the capsular ligament, still remains, however, a point in surgery requiring explanation. The ordinary position of the toes outwards is com- monly, and I believe correctly, imputed to the rotator muscles. Bichat conceived, however, that if this doc- trine were true, such position ought always to exist; and he reminds us, that all the muscles which proceed from the pelvis to the trochanter are, with the excep- tion of the jjnadratus, in a state of relaxation, by the approximation of the femur to their point of insertion; and that the contracted muscles would not allow the foot to be so easily turned inwards again. Hence Bi- chat thought it probable, that the weight of the foot itself might pull the limb into the position in which il is commonly found. On the other hand, it is remarked by Sir A. Cooper, that any one may satisfy himself that the rotation of the limb outwards is in part owing to the muscles, by feeling the resistance which is made to rotation inwards, which resistance, however, he thinks, may in some measure.depend upon the length ofthe portion ofthe neck of the femur, which remains attached to the trochanter major, and rests against the ileum.—(Surgical Essays, part 2, p. 32.) In addition to the foregoing observations respecting the diagnosis, it is to be remembered, that a fracture within the capsular ligament seldom happens but at an advanced period of life, and is much more frequent in women than men.—(Sir A. Cooper on Dislocations. i-c. p. 123.) A fracture ofthe neck ofthe thigh-bone, on the out- side of the capsular ligament, is attended with but little shortening ofthe limb, and is frequently met with in persons under fifty, though it may and does occur in older subjects. Also, while the fracture within the capsule takes place from very slight causes, this is generally the result of great violence, severe blows, falls, and the passage of heavy carriages over the pelvis. The-crepitus can be easily felt without previ- ously drawing down the limb, and the case is charac- terized by greater suffering than what is usually noticed when the fracture is within the capsule. But the most important circumstance in which a fracture on the outside of the capsule differs from one within it is, in its readily admitting of bony union, which it is much more difficult to accomplish in the latter case, and so rare as to be doubted by a surgeon of the highest reputa- tion and greatest experience.—(See Sir A. Cooper on Dislocations, ic. p. 185, &c.) In an oblique fracture through the trochanter major, without injury of the neck of the bone, the leg is very little, and sometimes not at all, shortened; the foot is benumbed; the patient cannot turn in bed without great difficulty and pain; in some cases the detached portion of the trochanter is drawn forwards towards the ileum; in others it falls towards the tuberosity of tbe ischium; but in general it is widely separated from that portion which remains connected with the neck of the bone. The foot is considerably turned outwards, and a crepitus not readily detected. This accident may happen at any period of life. It unites readily, and the patient recovers with a very good use of the limb.—(Vol. cit. p. 158.) Many years ago, it was supposed that fractures of the neck ofthe thigh-bone could not be cured, without some shortening of the limb and lameness. Ludwig, Sabatier, and Louis broached this doctrine, and imputed the circumstance to the destruction ofthe neck ofthe bone. That this sometimes happens has been well ascertained. A la{e surgical visiter to Paris informs us, that in several specimens which he examined in different museums, whether imperfect union or no union at all had foUowed the fracture, this absorption of the neck of the bone had taken place to a great extent, and in some to so great an extent that the articulating surface of the bone which plays in the acetabulum rested between the trochanters, consoUdated to the body of the bone by ligamentous union, and the thickening of 402 FRACTURES. the surrounding parts, while all the intervening neck ofthe bone was absorbed.—(See Sketches ofthe Medical Schools of Paris, by J. Cross, p. 90.) M. Roux has also nearly always found the neck ofthe femur shortened and deformed after its reunion.—(Parallile de la Chir. Angloise avec la Chir. Francoise, p. 178.) Desault however, in his practice, is said to have rarely met with instances of lameness from such a cause. A question that has lately been much agitated (see Earle's Practical Obs. in Surgery, Lond. 1823; and Amesbury's Obs. on the Nature and Treatment of Fractures of the Upper Third of the Tliigh-bone, i-c. Lond. 1829, ed. 2) is, whether reunion by bene ever follows cases in which the fracture is entirely within the capsule, and the head ofthe bone insulated, except ut its attachment to the acetabulum by the round liga- ment? A few years ago, the decision of the French surgeons used to be in the affirmative, and they pre- tended actually to demonstrate the fact by preparations w in their museums. M. Roux, indeed, sent over a spe- cimen to Sir A. Cooper, with the hope of producing conviction; but this eminent surgeon was not satisfied with the evidence, because the traces of reunion in the preparation appear to him to indicate a sort of fracture, where the internal fragment sttil retained some con- nexionwith the capsular ligament.—(Roux, Parallile de la Chirurgie Angloise, i-c. p. 179,180.) In fact, it was a case in which the fracture happened at the junction of the cervix with the trochanter. And Sir A. Cooper distinctly states, that in all the examinations which he has made of transverse fractures of the cervix femoris, within the capsular ligament, he has never met with a bony union, or with any which did not admit of motion of one bone upon the other.—(Surgical Essays, part 2, p. 39.) He imputes the want of bony union to the fragments not being in contact and duly pressed against each other, and to the little action in the head of the bone separated from the cervix, "its life being supported solely by the ligamentum teres, which has some few vessels ramifying from it to the head of the bone." For the particular appearances found in the dissection of these cases, I must refer to the statements of Dr. Colles (Dublin Hospital Reports, vol. 2), and to Sir Astley Cooper's own account, from which it seems that " no ossific union is produced; that nature makes slight attempts for its production upon the neek of the bone and upon the trochanter major, but scarcely any upon the head of the bone; and that if any union is produced, it is by ligament only."—(Vol. cit. p. 46.) Mr. Wilson's observations are all in confirmation ofthe same explanation (On the Skeleton^ p. 247); and he adverts to two preparations in the museum ofthe Col- lege of Surgeons, which have been supposed to be proofs of a bony reunion ofthe neck of the femur, sub- sequently to a fracture within the capsular ligament; but (says Mr. WUson) " I have very attentively ex- amined these two preparations, and cannot perceive one decisive proof in either of the bone having been actu- ally fractured." One of these cases is that which was published by Mr. Liston in the Edin. Med. and Surg. Journ. Lastly, Dr. Colles, of Dublin, dissected several cases, in which the neck ofthe femur had been broken. In one, where the injury was within the capsular liga- ment, " no effort of nature had been made to create a reunion between the two pieces of the fracture, and the stability of the limb had depended upon the strength of those ligamentous bands, by which each piece was connected with the capsular ligament of the joint, aided, no doubt, by the extraordinary thickness which the capsular ligament had acquired."—(Dublin Hospi- tal Reports, vol. 2, p. 336.) In the first two instances reported by this author, " the broken surfaces moved on each other, and were converted into a state approach- ing to ivory. No attempt had been made to reunite the fracture, and the pieces of bone were held in apposition only by new ligamentous productions from the capsular Ugament, which were inserted into the external sur- faces of each piece. In No. 3 there had been a slight attempt made at reunion. In Nos. 7, 8, and 9, we ob- served a phenomenon, which, I believe, is now for the first time mentioned, a fracture of only part ofthe bone. No. 6 presented us with that mode of reunion which some have supposed the most perfect of which this fracture is susceptible. While Nos. 10 and 11 exhibit a mode of reunion very little inferior to callus in point of firmness, but very different in its nature, and which I conceive is peculiar to the fracture of the neck of the femur." Dr. Colles also found fhat, in a"fl these cases (except, perhaps, No. 5), the capsular liga- ment was not lacerated. In every instance, however, there was an increased thickness ofthe capsule, and a removal of all or the greater part ofthe neck ofthe bone. " Although the ligamentous bands seem, in a majority of instances, to have proceeded from the capsular Uga- ment, yet it is evident from No. 6, that these may ariso merely from the broken surfaces of the bone; for in this case, not a single fibre was attached to the capsular ligament, the new bond of union being covered by the reflected portion ofthe synovial membrane or periosteum ofthe neck. We have an illustration of this in Ruysch, tab. 1, thes. 9." In Nos. 10 and 11, the fragments were united by a cartUaginous substance. In Nos. 7, 8, and 9, the unbroken portion of the neck was so softened, that it more resembled cartilage than bone, and, in this state, " it was laid down upon the fractured surface, and united to it."—(Dr. Colles, in Dublin Hospital Re- ports, vol. 2, p. 353—355.) In the Museum of the Ecole de Medecine at Paris, there are some preparations which the professors exhibit at their lectures, in order to prove that bony union may succeed a fracture of the femur. These specimens were careftilly examined by Mr. Cross; but none of them proved to him that bony union ever follows where the head of the bone becomes insulated, excepting its attachment to the pelvis by th« ligamentum teres.—(Sketches ofthe Medical Schools ai Paris, p. 93.) On the other hand, Boyer observes, thai experience fully proves the possibiUty of uniting sucl fractures of the neck of the thigh-bone as are situate* within the capsular ligament; but he acknowledges tha* there are certain circumstances which may prevent thi» desirable event. " From all that has been hitherto said on the prognosis of a fracture of the neck ofthe femur, we may conclude (says Boyer) that this fracture is more serious than that of any other part ofthe same bone, because the difficulty of keeping it reduced is greater. That it may in general be reunited, especially in young, healthy- subjects (in whom, however, be it observed, the accident hardly ever occurs); but more easily when it is situated near the base ofthe neck than near the head of the bone. That the languid vitality of one of the fragments, and the impossibility of ascer- taining whether the coaptation be exact, make the cure slow, and the time necessary for their consolidation uncertain. That the neglect of means adapted to main- taining the limb in its proper length and natural straightness, and the fragments sufficiently motionless, may cause them to unite by an intermediate substance. Lastly, that the situation of the fracture near the head of the femur; the complete laceration of the elongation of the capsule investing the neck of the bone; the great age of the patient; and particularly the constitution labouring under some diathesis, which affects the os- seous system, may render the cure absolutely impos- sible ; that, in this circumstance, one of the fragments is more or less destroyed by the friction of the other against it, and in the joint a disease is formed, which tends to carry off the patient."—(Traiti des Mai. Chir. t. 3, p. 284.) This professor lays much stress on the complete laceration of the continuation of the capsule over the neck of the bone, as an occurrence preventive of union. But he thinks it does not frequently happen, because the capsular ligament hinders much displace- ment ofthe fragment (op. cit. p. 278); a remark rather at variance with the shortened state of the limb. As for Baron Larrey, he appears to entertain no doubt of the possibility of uniting fractures of the neck of the femur -within the capsular ligament, and concludes his tract on this subject with the case of General Fririon, who was perfectly cured after a supposed injury of this description.—(See Journ. Complim. t. S,p. 118.) That some French surgeons, however, are now beginning to be less positive in their belief, is sufficiently manifest from the circumstance of a reward having been offered in France for the best explanation of the cause of such fractures not uniting by bone.—(Sir A. Cooper, Appen- dix, p. 43.) How is this discordance to be reconciledand accounted for ? After the very numerous and careful dissections which have been performed by Sir. A. Cooper and Dr. Colles, writh the view of ascertaining the state of the joint, after fractures ofthe neck ofthe thigh-bone, little doubt can be entertained that,.where the fracture ia transverse, and within the capsular ligament, a bony reunion, 3/ not absolutely impossible, is at least so FRACTURES. 403 tart an occurrence as not to be calculated upon. The difference ofthe French surgeons upon this question is to be ascribed to their not having duly discriminated from the foregoing kind of case either fractures extend- ing more or less in the direction of the axis of the neck ofthe bone, or other fractures external to the capsular ligament. How much, however, the safety of a prac- titioner's reputation will depend upon the prognosis which is given must be quite evident; for in the trans- verse fracture within the capsule, lameness is almost sure to follow, tliough its degree cannot at first be exactly estimated.—(Sir A. Cooper, Surgical Essays, part 2, p. 51.) As far as I am able to judge of this subject, Sir Astley Cooper has been the means of introducing clear and discriminate views of it, and, without his able exer- tions, the important differences in the nature, symp- toms, and curableness ofthe various kinds of fractures ofthe neck and upper part of the thigh-bone, depending U|K>n their exact situation and direction, might yet have continued very imperfectly comprehended. This re- mark is made without any intention of deducting from the merits of Desault, Platner, and Mr. John Bell; all of whom Beem to have expressed their belief, that a fracture within the capsular ligament will not admit of union by callus.—(C. Bell on Injuries of the Spine and Thigh-bone, 4to. Lond. 1824, p. 52, i-c.) Mr. Amesbury, in his late treatise, attempts to prove, that all fractures of the neck ofthe thigh-bone admit of union, whether they be situated quite within the capsular ligament or not, and whether the reflected portion of that ligament be ruptured or not; and he ascribes the usual want of success, not to the nature of the injury, not to the insufficient circulation in the pelvic portion of the bone, but to the imperfection of the mechanieal means employed in the treatment. As, however, the important point under consideration, namely, whether transverse fractures of the neck of the femur, situated entirely within the capsular liga- ment, admit of bony union, is one that can only be de- termined by experience, Mr. Amesbury follows up his arguments by a reference to cases. " Though," says he, " Sir Astley has not, I believe, yet seen a specimen sufficient to convince him that this variety of fracture has ever united by bone, there are now four prepara- tions, which satisfy the minds of many other surgeons that osseous union is occasionally produced." The first case adduced is one that was under the care of Mr. Cribbe, of Holbum, and is described by Mr. Lang- staff, who has the prepartion: " The woman was about 50 years of age when the accident occurred. The foot was everted, and there was shortening of the limb at this time; and, after death it was shorter than the other full two inches and a half. She was confined to bed nearly twelve months: during the remainder of her life, which was ten years, she walked with crutches. This (says Mr. Langstaff, alluding to the preparation) is a specimen of fracture of the neck of the thigh-bone within the capsular ligament; the principal part of the ueck is absorbed; the head and remaining portion of the neck were united principally by bone, and partly by a cartilaginous substance. The capsular ligament was immensely thickened, and embraced the joint very closely. The cartilaginous covering of the head of the bone and acetabulum had suffered partial ab- sorption ; the internal surface of the capsular ligament was coated with lymph. On making a section of the bono, it was evident, that there had been a frac- ture of the neck within the capsular ligament, and that union had taken place by osseous and cartilagi- nous media."—(See Med. Chir. Trans, vol. 13.) Mr. Amesbury then adverts to Dr. Brulatotir*s' case re- ported in the same volume of the latter work. This gentleman died about nine months after the injury The following appearances presented themselves. 1 The capsule a little thickened. 2. The cotyloid cavity sound. 3. The interarticular ligament in a natural state. 4. The neck of the femur shortened: from the bottom of the head to the lop of the great trochanter was only four lines, and from the same point to the top of the small trochanter six lines. 5. An unequal line surrounded the neck, denoting the direction of the fracture. 6. At the bottom of the head of the femur and at the external and posterior part, a considerable bony deposite had taken place. A section of the bone was made in a line drawn from the centre of the head of the femur to the bottom of the great trochanter so Cc2 ' as perfectly to expose the callus. The line of bone in- dicated by the callus Was smooth and polished as ivory. The line of callus denoted also that the bottom of the head of the femtir had been broken at its superior and posterior parts. In another example communicated to Mr. Amesbury by Mr. Chorley, of Leeds, a gentleman,died twelve months after the accident, and on examming the hip, the synovial covering was found united with the short- ened neck of the bone nearly at the head. Here nature had also thrown out broad ligamentous bands, one on each side of the joint. They were firmly united to the head of the bone. When the soft parts had been re moved, the head of the bone was seen depressed in a line with the shaft. The fracture was slightly oblique, commencing at the upper part close against the carti laginous covering of the head of the bone, and extend- ing downwards and outwards, so as to terminate in a point at the lower surface of the neck, one incli from the cartilaginous covering of the head. The posterior surface of the shell of the neck had the appearance of having been splintered, so as to make a part of the fractured end of the pelvic portion extend in one situa- tion a little on the outside of the capsular ligament, and where no union had taken place. In a fourth instance, where the necks of both thigh- bones had been broken at different periods, the parts were examined after the patient's decease. On Ihe right side, the fracture extended through the neck of the bone, in a direction downwards and outwards. In one part a portion ofthe reflected membrane remained entire; but was separated from the neck of the bone in such a manner as not to prevent the retraction of the limb. The head of the bone was somewhat excavated; and that portion of the neck attached to the trochanter was partially .absorbed. There was no soft substance be- tween the surfaces of the fracture. A bond of union, however, consisting of fibrinous matter, adhered to the sides of the ends of the fracture, and in one part it vras strong. No surgical attempt had been made to unite the fracture on the right side. On the left, the neck of the bone had been broken within the capsule, and was firmly united. The cervix was nearly absorbed; and the head was depressed, so as to come within about two lines of the trochanter minor, to which it was united at its base by a small short process of bone. Strong bands of ligament were seen connecting the pelvic portion of bone to the capsule, which had be- come thickened and much smaller than natural. There had been a longitudinal fracture of the trochanter ma- jor, but quite independent of the injury of the cervix. The fracture of the latter part was united with the head, about two inches and a half below its natural si- tuation ; which leads Mr. Amesbury to believe, that what he terms the close coverings of the neck of the bone had been nearly or quite divided. A longitudinal section of the head and neck of the bone showed, ac- cording to Mr. Amesbury, that the fracture had taken place close to the head. The uniting callus had be- come cancellated; but he says that the direction of the fracture could be seen " by the situation of the tro- chanteral portion of the neck, when examined in dif- ferent parts of its circumference."—(See Amesbury on Fractures, i-c p. 43, ire.) With respect to some of these cases and dissections, if they are correctly described, they sufficiently esta- blish the possibility of bony union in fractures entirely within the capsular ligament; but in order that the point may be completely settled, I should recommend Mr. Amesbury to submit the preparations to wlUch he refers to a committee ofthe profession, including those gentlemen who have not hitherto been satisfied with any specimens yet presented to them. The rapidity with which absorption proceeds in the head and neck of the thigh-bone after fractures, brings about such changes as must soon greatly obscure the exact origi- nal situation and direction of the injury, and particu- larly the question whether the injury reached also ou the outside of the capsular ligament. That fractures extending beyond the capsular ligament may be united by bone, is admitted by all parties, as well as the fact, that those entirely within the capsule are often united with the intervention of fibrous or ligamentous bands. In confirmation of this circumstance, I have already cited the dissections performed by Dr. Colles, of Dublin • and, in farther proof of it, I refer to the preparations' in the museum of the College of Surgeons at Edin- 404 FRACTURES. burgh, as specified by Mr. B. Bell of that city—(See Treatise on the Diseases ofthe Bones, p. 205, Ji-c. 1828.) Having spoken of the nature of fractures of the neck ofthe thigh-bone, within and without the capsular liga- ment, I come next to the consideration of the proper practice to be adopted. In the first description of the injury, as osseous union is rare, perhaps even not at- tainable, ought we to endeavour to keep the fragments as nearly in a state of apposition as possible, and sub- ject the patient to rest and confinement, with the view of promoting the other modes of union so well pointed out in Dr. CoUes' paper? Or should we, as Sir A. Cooper does, avoid confining the patient to any long or continued extension, " as being likely to be productive of ill-health, without the possibility of producing union?" Yet it appears both from this gentleman's own statements, and from those of Dr. Colles, Mr. Langstaff, Mr. B. Bell, and others, that though a bony union cannot always be effected, other connecting means may be established, and the more perfect these are, the less wall be the subsequent iameness. As long, therefore, as these facts are incontrovertible, I should be disposed to recommend surgeons to do every thing in their power to keep the limb quiet, and in a desirable posture for a due length of time. On this point all surgeons must, on reflection, be unanimous. It is one that I have always insisted upon in my surgical wri- tings, and it is one that is very properly defended by Mr. Amesbury in his recent publication. Whether, for this purpose, Boyer's apparatus, with the limb in the straight posture; or the apparatus with two in- clined surfaces, with the limb in the bent position, and the patient on his back; or, lastly, Hagedorn's ingeni- ous and scientific treatment, as explained in the last edition of the First Lines of Surgery, should be pre- ferred, time and experience must determine. Sir A. Cooper merely places one pillow under the whole length ofthe limb, and puts another transversely under the patient's knee, so as to keep the limb in an easy bent position. In a fortnight or three weeks the pa- tient is allowed to sit upon a high chair, and in a few more days he begins to take exercise upon crutches. After a time, these are laid aside, a stick substituted for them, and in a fe,w months this assistance may be dispensed with. At the end of the treatment, a shoe must be worn with a sole of equal thickness to the diminished length of the limb.—(Surgical Essays, part 2, p. 50.) For the management of fractures of the neck of the thigh-bone, Messrs. Amesbury and Earle em- ploy fracture-beds, constructed with the view of fulfil- ling all the main indications, and in particular of keep- ing the ends of the fracture at rest in the best posi- tion. Their contrivances display great ingenuity, and well deserve the attention of the profession. lu the treatment of such fractures of the neck of the femur as are situated on the outside of the capsu- lar ligament, Sir A. Cooper prefers the position in which the patient lies on his back, with the injured limb in a bent posture, supported on what is termed the double-inclined plane, the kind of instrument al- ready spoken of, as being sometimes employed by Mr. C. Bell. When the limb has been placed over this machine in an easy bent position, a long splint, reach- ing above the trochanter major, is applied to the outer side of the thigh, and fastened to the pelvis with a strong leather strap, so as to press one portion of bone towards the other. The lower part of the splint is also fastened to the outside of the knee with a strap. The limb is to belcept as quiet as possible for eight weeks, at the end of which time the patient may leave his bed, if the attempt should not cause too much pain; but the splint is to be continued another fortnight.— (Surgical Essays, part 2, p. 59.) Desault's apparatus has been described in the foregoing columns, and those of Boyer and Hagedom are explained and represented in the First Lines of Surgery. Larrey, who disapproves of the plan of continued extension, has lately proposed a particular apparatus for fractures of the neck of the femur; but as it ap- pears to me very inferior to other methods already mentioned, I shall here merely refer to the Journ. Compl. t. 8, p. 116, where a description of it may be I am glad to find the number of advocates for Pott's method of treatment annually diminishing. Indeed, the bad effects and painful consequences of having the whole weight of the trunk operating upon the frac- tured ends of the bone, which are often not property in contact, are too obvious to need any comment. Yet this injudicious pressure is made in the bent position, which also forbids the use of long effective splints, and all assistance I'ropi moderate continued extension. A fracture of the neck of the thigh-bone may be com- plicated with a dislocation of the head of the bone.— (See J. G. Haase, De Fracturd Colli Ossis Femoris, cum Luxatione Capitis ejusdem Ossis conjunda, Lips. 1798.) For farther information relative to fractures of the neck of the femur, the following authors may be consulted. C. G. Ludwig de Collo Femoris ejusque Fractura Programma, Lips. 1755. Bellocq, in Mim. de l'Acad. de Chir, t. 3. Aitken's and Gooch's machines are described in B. Bell's Surgery, vol. 4. Sabatier, in Mim. de PAcad. de Chir. t. 4. Duverney, Traiti des Mai. des Os, t. 1. Unger, in Richter's Bibl. b. 6, p. 520. Theden, Neue Bemerkungen, i-c. th. 2. Brun- ninghausen uber den Bruch des Schenkelbeinhalses, i c. Wurzb. 1789. Van Gescher iiber die Entstellun- gen des Riickgrats, und iiber der Verrenkungen und Bruch dez Schenkelbeins, aus d. Holland. Hedenus, in Bernstein's Darstellung des Chir. Verbandes, tab. 42, fig. 82 and 83. M. Hagedom iiber der Bruch del Schenkelbeinhalses, i-c. Leipz. 1808. J. N. Sauter, Anweisung die Beinbriiche der Gleidmassen vorzii- glich die complicierten und den Schenkelbeinhalsbruch nach einer neuen, i-c. Methode, ohne Schienen, si- cker zu heilen, 8vo. Konstanz. 1812. J. Wilson on the Structure and Physiology of the Skeleton, ic. p. 243, i-c. Svo. Lond. 1820. Dr. Colles, in Dublin Hos- pital Reports, vol. 2. Sir A. Cooper, Surgical Essays, part 2; and Treatise on Dislocations, &c. 4to. 1822, with Appendix, 1823. H. Ear le, Practical Obs. on Sur- gery, 1823. Lancet,Nos. 5 and 8, vol. l,p. 302. Boyer, Traiti des Mai. Chir. t. 3. John Bell, Principles of Surgery, 4to. 1801, p. 549, ic. C. Bell, on Injuries of the Spine and Thigh-Bone, 4to. 1824. G. Langstaff, Cases of Fractured Neck of the Thigh-Bone within tlie Capsular Ligament, with the Dissections and Obs. in Med. Chir. Trans, vol. 13. E. Stanley, Cases of In- juries of the Hip-Joint, vol. cit. G. J. Guthrie on the Diagnosis, and on the Inversion of the Foot in Frac- ture of the Neck, i-c. of the Thigh-Bone, vol. cit. p. 103. Syme, in Edin. Med. Journ. April, 1826. B Bell, on Diseases of the Bone, 1828. /. Amesbury, Obs. on Fractures of the Upper Third of the Tliigh- Bone, i-c. 2d ed. 1829. OBLIQUE FRACTURES OF THE EXTERNAL OR INTERNAL CONDYLE OF THE FEMUR INTO THE JOINT. In these cases, Sir A. Cooper prefers the straight po- sition, because the tibia presses the extremity of tho broken condyle into a line with that which is not in- jured. The limb is to be put in the extended posture upon a pillow, and evaporating lotions and leeches are to be used for the removal of the swelling and inflam- mation. " When this object has been effected, a roller is to be applied around the kuee, and a piece of stiff pasteboard, about sixteen inches long, and sufficiently wide to extend entirely under the joint, and to pass on each side of it, so as to reach to the edge of the pa- tella, is to be dipped in warm water, and applied under the knee, and confined by a roller. When this is dry, it has exactly adapted itself to the form of the joint, and this form it afterward retains, so as best to confine the bones. Splints of wood or tin may be used on each side of the joint; but they are apt to make nn- easy pressure. In five weeks, passive motion of the limb may be gently begun, to prevent anchylosis."— (Surgical Essays, part 2, p. 101; also. Treatise, p. 221.) This author afterward describes a compound fracture of the external condyle, a portion of which was after a time extracted, and the case ended so favourably, that the patient, who was a boy, was able to bend and extend the leg without pain. For fractures just above the condyles, Sir A. Cooper recommends the bent position, without which, he says, deformity is sure to follow. He advises the limb to be placed over the double inclined plane, and a roller ap- plied round the lower portion of the femur.—(P. 103.) FRACTURES OF THE PATELLA. Thi3 bone is most frequently broken transversely, and the accident may be produced either by the action of external bodies, or by that of the extensor muscles. In the latter case, the fall is subsequent to the fracture, FRACTURES ^^jML^r 405 and, as Camper has remarked, it is mostly only an ef- fect of it. For instance, the Une of gravity ofthe body is, by some cause or another, inclined backwards; the muscles in front contract to bring it forwards again; the extensors act on the patella; this breaks, and the fall ensues. That it is the action of the mus- cles and not the fall which usually breaks the knee- pan, Is well ascertained. Sometimes the fracture oc- curs, though the patient completely succeeds in pre- venting himself from falling backwards, as we find exemplified in two cases reported by Sir A. Cooper.— (Surgical Essays, part 2, p. 85.) A soldier broke his patella in endeavouring to kick his sergeant: the ole- cranon has been broken in throwing a stone. In the operating theatre ofthe Hdtel-Dieu, both the knee-pans of a patient were broken by the violent spasms of the muscles, which followed an operation for the stone. / '• J ..' The force of the muscles occasionally ruptures the t*V v •- <*** common tendon of the extensor muscles, or, what is t f- more frequent, the ligament of the patella. Of these 1 ** ***'V cases, Petit, Desault, and Sabatier met with examples. • 0 When the patella is broken longitudinally, the cause is ' • -.-'. - > ^always outward violence.—((Euvres Chir. de Desault, t. 1, p. 252.) A transverse fracture of the patella may also origi- nate from a blow or fall on the part; but in common cases it is produced by the violent action of the ex- tensor muscles of the leg. It is only of late years, however, that the true mode in which the bone is usu- ally broken has been understood. As Boyer observes, for the production of a transverse fracture of the knee- pan, the extensor muscles of the leg need not act with a convulsive force, their ordinary action being strong enough to produce the effect in question when the body is inclined backwards, and the patient is in dan- ger of falling upon his occiput. In this stale, the thigh being bent, tbe extensor muscles of the leg con- tract powerftilly, in order to bring the body forwards and prevent the fall backwards; and the patella, whose posterior surface then rests only by a point against the fore part of the condyles of the femur, is placed between the resistance of the ligament binding it to the tibia, and the action of the extensor muscles. A fracture now happens the more easily, because, by the flexion of the knee, the line of the extensor mus- cles and that of the ligament of the patella are ren- dered oblique, with respect to the vertical axis of this bone, which is bent backwards at the point, where it rests upon the condyles.—(Traiti des Mai. Chir. t. 3, p. 322. C. Bell's Operative Surgery, vol. 2, p. 201, 8uo. Lond. 1809. A. Cooper's Surgical Essays, part 2, p. 86.) By violent spasmodic action of the extensor muscles, however, the patella may be broken trans- versely, while the limb is perfectly straight. A very singular case is mentioned by Sir A. Cooper, where a patella, which had been formerly broken and united by ligament, was again divid«£ into two portions, in consequence of the destruction of the uniting medium by ulceration.—(Vol. cit. p. 100.) A case is also on record, where the ligamentous uniting substance was so incorporated with the skin, that when the latter happened to be lacerated, the knee-joint was laid open, and amputation became necessary.—(C. Bell, Op. Sur- gery, vol. 2, p. 204.) In transverse fractures, there is a considerable sepa- ration between the two fragments of the bone, very perceptible to the finger when the hand is placed on the knee. This separafion is not occasioned equally by both portions; the upper one, embraced by the ex- tensor muscles, is drawn upwards very forcibly by these powers, which the patella no longer resists; while the inferior portion, being merely connected with the ligament below, is not moved by any muscle, and can only be displaced by the motions of the leg to which it is attached. Hence the separation is least when the limb is extended, being then only produced by the upper fragment; greatest when the limb is bent, because both pieces contribute to it; and it may be increased or diminished by bending the knee more or less. As Uoyer has particularly noticed, the laceration or not ofthe tendinous expansion upon the front of the patella makes a material difference in these cases, because it is a part of groat Importance in the cure.' According to this author, a portion of it in simple fractures of the patellc generally escapes laceration, and the separation of the fragments is then not very considerable; but violent action of the extensor muscles, the fall subse- quent to the fracture or bending of the knee too much, may separate the pieces of bone far from each other, and rupture tbe tendinous expansion.—(Traiti des Mai. Chir. t. 3, p. 328.) According to Sir A. Cooper, " when the ligament is but little torn, the separation will be but half an inch; but under great extent of in- jury, the bone is drawn five inches upwards, the cap- sular ligament and tendinous aponeurosis covering it being then greatly lacerated."—(Surgical Essays, part 2, p. 84.) The upper portion of bone may be moved trans- versely, and pain is thus excited, but no crepitus can be felt, as the two pieces of bone are not suffi- ciently near each other. When the swelling of the knee, consequent to fractures of the patella, is very great, the symptoms of the injury may be more or less obscufe. However, in consequence of the inability of the extensor muscles to move the leg, except in a few cases where the fracture is very low, the patient can- not stand without difficulty, and is unable to walk. In the treatment, the chief indications are to over- come the action of the extensor muscles of the leg, and to keep the fragments as near each other as pos- sible, partly by a judicious position of the limb, and partly by mechanical means. The first indication is fulfilled by relaxing the above-mentioned muscles ; 1st, by extending the leg; 2dly, by bending the thigh on the pelvis, or, in other words, raising the femur, so that the distance between the knee and anterior su- perior spinous process of the ileum may be as little as possible ; which object, however, will also require the body to be raised, and the pelvis somewhat inclined forwards. In short, as Richter long ago advised, the patient should be almost in a sitting posture, the trunk forming a right angle with the thigh.—(Bibl. Chir. b. 6, p. 611, Gottingen, 1782.) 3dly, The muscles are to be compressed with a roller. The second indica- tion, or that of placing and maintaining the fragments in contact, or as nearly so as circumstances will al- low, is in a great measure already answered by the above-recommended position of the limb and trunk ; but it is not perfectly fulfilled unless the upper portion of the bone be also pressed towards the lower frag- ment, and mechanically held in this situation by the pressure of an apparatus or bandage. And, in push- ing the upper fragment towards the lower one, the surgeon should always be careful that the skm be not depressed and pinched between them. Having described the principles which ought to be observed, I do not know that any great utility would result from a detail of the various methods of treating a broken patella, preferred by different surgeons. In the last edition of the First Lines of Surgery may be found a description ofthe plan and apparatus employed by Baron Boyer. Desault's practice, which was re- lated in the third edition of this Dictionary, I now omit as not being exactly such as modern surgeons would adopt; not from any of his principles being erroneous, but because his apparatus is more compli- cated than necessary. After putting the patient to bed upon a mattress, and in the desirable posture, with the limb confined, sup- ported, and raised, as above directed, upon a well padded hollow splint, Sir A. Cooper appUes at first no bandage to the knee, but covers it with linen wet with a lotion composed of liq. plumbi acet. dilut. 1 v. and spir. vin. |j. If, on the succeeding day or two, there be much tension or ecchymosis, leeches should be ap- ■ plied, and the lotion continued; but the employment of a bandage is not to commence until the tension has subsided; for Sir A. Cooper assures us that he has seen the greatest suffering, and such swelUng as threatened gangrene, produced Ui these cases by the too early use of a roller. Instead of a circular band- age, placed above and below the» broken bone, and drawn together with tape, &c, so as to bring the upper fragment towards the lower one, this experienced sur- geon prefers the following method. A leather strap is buckled round the thigh, above the broken and elevated portion of bone, and from this circular piece of leather another strap passes under the middle of the foot, the leg being extended, and the foot considerably raised. This strap is brought up to each side of the patella, and buckled to the leather band already applied to the lower part of the thigh. It may also be fastened to the foot or any part of the leg with tapes. The Umb is 406 FRACTURES. to be confined in this position five weeks if the patient be an adult, and six if advanced in years. Then a slight passive motion is to be begun, and to be gently in- creased from day to day, until the flexion of the knee is complete.—(Surgical Essays, part 2, p. 91.) But, al- though the impropriety of making any constriction of the knee with a bandage, while the skin is swelled and inflamed, must be obvious, the surgeon ought to be apprized that such swelling and inflammation ought not to occasion the least delay in placing the limb in the right posture, and pressing the upper fragment to- wards the lower one. Mohrenheim ascribes the lame- ness formerly so frequent after this fracture, partly to the custom of not thinking of bringing the pieces of bone together until the swelling had subsided, and partly to the fashion of bending the joint too soon, with a view of preserving its motion. But, says he, nothing can be clearer than that it is most advanta- geous to attend to the union of the fracture first, and to the flexibility of the joint afterward.—(Beobach- tungen, b. 2, Svo. 1783.) Boyer has likewise re- marked, that the uniting substance is apt to yield, and become lengthened, by bending the knee too early, and he therefore never allows this motion to be performed before the end of two months. When the ligamentous substance is long, and the patient very slow in regain- ing the use of the extensor muscles, he should sit every day on a table, and endeavour to bring them into action, and as this increases, a weight may be affixed lo the foot, as Hunter, Sheldon, &c. recommend. Nothing keeps the leg more surely extended than a long, broad, excavated splint, with a suitable pad, ap- plied to the posterior part of the thigh and leg, and fixed there with a roller, while the thigh itself is to be bent by raising the whole limb, from the heel to the top of the thigh, with pillows, which, of course, must form a gradual ascent from the tuberosity of the ischium to the foot. The broken patella is almost always united by means of a ligamentous substance, instead of bone. However, that an osseous union may follow a trans- verse fracture of the patella, and still more frequently a perpendicular one, is a fact of which there is not now the slightest doubt. Thus, Lallement has published an unequivocal specimen of a transverse fracture united by bone, with the history of the case, and the appearances after the death of the patient from some other affection.—(Boyer, Traite des Mai. Chir. t, 3, p. 355, &c.) In the collection of Dr. William Hunter, there is one well-marked instance ofthe bony union of a transverse fracture of the patella, and other exam- ples have been seen in the dead subject by Mr, Wilson. ■—(On tlie Structure, Physiology, i-c. of the Skeleton, p. 240.) In Mr. Charles Bell's museum may also be seen similar specimens.—(On Injuries of the Spine and Thigh-bone, p. 57, 58.) The reason why trans- verse fractures of the patella do not commonly unite by callus, is not owing to the want of power in this bone to produce an osseous connecting substance; for, as Larrey has several times noticed, if the fragments are kept in perfect contact by means of a suitable appara- tus, their bony reunion becomes so complete, that scarcely any vestige of the injury can afterward be traced,—(Journ. Complrm. t. 8, p. 114.) Indeed, it is a fact, on which Larrey dwells, as affording a proof that callus is produced not by the periosteum, but by the vessels of the bones themselves.. And what must add strength to the purport of the foregoing remarks is the consideration, that perpendicular or longitudinal frac- tures of the patella, which are not liable to any displace- ment from the action of the extensor muscles of the leg, readily admit of bony union.—(Wilson on the Structure and Physiology, i-c. of the Skeleton, p. 239.) This is a statement which, I think, could not be rendered doubt- ful by any experiments made on animals, without the advantages of quMfcnde and proper treatment. Yet, there are other facts related, which prove that, both in longitudinal and transverse fractures, a ligamentous union is generally produced, when the fragments are separated; but, if these are not drawn asunder, an os- seous union takes place. Thus, in one case reported by Sir A. Cooper, one-third of the patella was sepa- rated from the rest of this bone, and had united by liga- ment, a free motion being left between the fragments. —(Surgical Essays, part 2, p. 94.) The same gentle- man divided the patella longitudinallyin a dog, with- out extending the division into the tendon above, or the ligament below, so that the fragments could not be se- parated. In three weeks a close bony union was the result.—(P. 95.) A case is also related, in which a gentleman fractured the patella transversely, and the lower portion likewise perpendicularly. The trans- verse fracture united as usual by ligament; the perpen- dicular one by bone.—(P. 96.) Mr. Charles Bell gives another explanation of the cause of union being by bone or ligament. In the common case, says he, of fracture of the patella by the sudden action of the'quad- riceps extensor, the pieces are separated without that degree of violence which is necessary to produce re- union by bone. But when the patella is broken by a blow or kick, there is not only less retraction, but " the injury, bloody effusion, tumefaction, and rigidity ofthe parts, resemble that which attends the fracture of any other bone, and the fragments unite by bone."—(Ore In- juries of the Spine i-c. p. 58.) The incorrect notions formerly entertained respect- ing the inconveniences of an exudation and projection of the callus into the joint after a fracture of the pa- tella, and especially when the fragments are kept in contact, were long ago refuted by Pott and Sheldon.— (Pott's Chir. Works, vol. 1, p. 332, ed. of 1808. Shel- don's Essay on the Fracture of the Patella, ire. Svo. Lond. 1789.) On the contrary, as Sir A. Cooper par- Q ticularly remarks, " the internal articular surfaee of "" the bone preserves its natural smoothness."—(Essays, /J part2,p.S6.) How such doctrine of a superabundant cal- luscouldbereconciledwiththedoubtsaboutabonyunion ' • being ever possible, appears difficult of explanation. » Pott, and some others, thought that there being com- ,'" 1 monly an interspace afterward, between the two pieces of the patella, with a certain length of the connecting substance, might be advantageous in the motion of the joint; but Desault, Boyer, Sir A. Cooper, Sir J. Earle, and others, have always found that the greater the dis- tance between the two pieces of the bone, the greater is the difficulty afterward in walking up a rising or oveT an unequal ground. In the treatment of a longitudinal or perpendicular fracture of the patella, the leg should be kept extended, leeches used, and a cold lotion applied. After a few days a roller is to be put round the limb, and then a laced knee-cap with straps buckled round the limb above and below the patella.—(A. Cooper, vol. cit. p. 96.) Theex- perience of Dupuytren confirms the fact, that a longi- tudinal fracture of the patella is soon firmly consoli- dated.—(Annuaire Med. Chir. de Paris, p. 94,4to. Pa- ris, 1819.) Compound, fractures of the patella fre- quently terminate in the death of the patient, unless amputation be done early. The injury, however, does not invariably lead either to the loss of life or limb. I saw a case in St. Bartholomew's Hospital, in the year 1820, under Mr. Vincent, where the patella was broken to pieces, and the opening so extensive that the fingers readily passed into the joint; yet, after a tedious con- finement, the fprmatiprTof abscesses, and the separa- tion of several fragments of bone, the patient reco- vered with astiff joint. In general, however, I believe, with Sir A. Cooper, that in compound fractures of the patella, if the laceration be extensive, or the contusion very considerable, amputation will be required: but if the wound be small, the patient not irritable, and no sloughing of the integuments or ligament likely to oc- cur, it will be best to try to save the limb.—(Vol. cit. p. 99.) The wound should be reunited as speedily as possible, and advantage taken of evaporating lotions, perfect rest in a desirable posture, a very low regimen, leeches, venesection, and saline opening medicines. Since writing the above remarks I have seen another case of bad compound fracture of the patella in St. Bartholomew's Hospital, where it has been about a month. No fragments of bone have yet been removed, but a good deal of matter issues daily from the wound. The case must be regarded as in a very precarious state, though, if hectic symptoms should not lower the patient too much, the limb will probably be saved. In addition to the works already cited, consult D. H. Meibomius de Patella Osse, ejusque Lasionibus et Cuxatiane, Franck. 1697. P. Camper, Diss, de Frac- turd Patella et Olecrani, 4to. Haga Comit. 1789, Buirer in v. Sicbold, Chiron, t. 1, p. 64. 7*. Alcock, in Trans, of the Associated Apothecaries, S-c. vol 1. FRACTURES OF- THE LEO May be transverse or oblique. The first case is ai- FRACTURES. 407 leged to be most common in children. Experience proves that the two bones of the leg are much more frequently broken together than singly; a fact ascribed by Boyer to the strength of the knee and ankle-joints. —(Traite des Mai. Chir. t. 3, p. 360.) The direction of on oblique fracture of the tibia is found to be pretty constantly from below upwards, and from within out- wards, the end of the upper fragment mostly present- ing itself under the skin at the front and inner part of the leg. In these cases, the longitudinal displacement of the fracture is less constant than the horizontal and angu- lar. However, when it does happen, the inferior frag- ments aredrawn outwardsand back wards, whilethe su- perior project internally and forwards. The angular dis- placement may be produced either by the action ofthe pos- terior muscles of the leg, or the weight of the foot, and in both cases the angle projects forwards. But it may be directed posteriorly, if the heel be too much raised. A rotatory displacement, most commonly happening in the direction outwards, is produced by the inclination of the foot, and if this be turned too much inwards, the rotatory displacement will be in Ihat direction. A lon- gitudinal displacement cannot take place in transverse fractures, on account of the considerable extent of the surfaces of bone; but in. oblique fractures, the inferior fragments are almost always drawn upwards by the action of the posterior muscles of the leg, in which po- sition of the parts the lower ends of the superior frag- ments project forwards, and may be felt by the hand. Sometimes, however, when the solution of continuity is obliquely downwards and outwards, the anterior pro- jection will be produced by the lower pieces. In both kinds of displacement, the pointed ends of the bones may tear and penetrate the integuments, and cause a compound fracture. The usual symptoms denoting a fracture of both bones ofthe leg are, a change in the direction and shape of the limb, pain, and incapability of waiting, or bear- ing upon the limb, mobility of the fractured- pieces, and a distinct crepitus. -A Fractures near the knee are not very subject to dis- placement, on account of the thickness of the tibia at that part; but they are more dangerous than those of the middle of the bone, because often followed by in- flammation of the knee-joint. Fractures close to the ankle are still more dangerous. Oblique fractures are very difficult of management, and when their displace- ment is upwards and outwards, the integuments are in danger of being torn by the projecting points of the su- perior portion of the tibia.— (Boyer.) To bad'com- pound fractures of the leg most of the observations are applicable already delivered on compound fractures in general. When the size of the tibia is compared with that of the fibula, and the close connexion of these bones to each other is remembered, an opinion might-be formed, that the first could never be broken without the second. Experience, however, proves the contrary.' And rea- sons for this fact, as Boyer remarks, n\ayibe deduced from the consideration that the tibia is the bone which supports the weight of the body, and thatit is situated at the fore part of the limb, simply covkjed by the skin and much exposed to the effects of violence.—(Traite des Mai. Chir. t. 3, p. 373.) When 4die tibia alone is broken, the fracture is said to be generally transverse. If the injury happens near the knee, the great extent of the fractured surfaces prevents any considerable dis- placement of the fragments; and the fibula, acting as a support on the external side, contributes also to this effect. Boyer, however, has seen one instance in which the tibia was broken by the kick of a horse, and the fragments displaced in the direction of the axis of the bone, which displacement could not be rectified, so that the bone remained permanently arched at the part. The absence of displacement often renders the diag- nosis of fractures ofthe tibia very diffioult, and the dif- ficulty is farther increased by the little pain and incon- venience produced by such a fracture, with which per- sons have been known even to walk. Whenever there is reason to suspect the accident, in consequence of a blow or a faU on the leg, the part should be minutely examined. The fingers are to be moved along the anterior side of the tibia, the slightest inequality in which may be easily perceived, on ac- count of its being covered only by the skin ; and the motion of the pieces may be distinguished by grasping the opposite ends of the bone, and pushing them in con- trary directions. However, this motion and the crepi- tus are not always very plain, on account of the fibula not allowing the fractured portions to be sufficiently moved on one another. In a review of the position and strength of the two bones of the leg, it will appear that the tibia supports alone the whole weight of the body, every shock di- rected in the axis of the limb, and many kinds of force applied also in tbe transverse direction, without ope- rating upon any particular point. Hence the frequency of fractures of the tibia; and if the fibula is generally broken at the same time, the latter injury is but subse- quent to the other, and takes place because this slen- der bone is not capable of bearing the weight of the body, the impulse of external violence, and even the ac- tion of the muscles, after the tibia has given way.— (Dupuytren, Annuaire Mid. Chir. des Hdpitaux de Pa- ris, p. 15, 4to. Paris, 1819.) On the other hand, as the same distinguished surgeon remarks, the fibula being principally designed as a support for the outside ofthe foot, it is particularly when this function is to be exe- cuted, and its lower end has to make resistance to ef- forts made in that direction, that it is fractured; and if the lower part ofthe tibia be also sometimes broken by the same force, it is almost always consecutively, and not by the effect of a diiect and simultaneous action upon the two bones.—(P. 17.) All fractures of the fibula, however, are not caused in the preceding man- ner; an* Dupuytren concurs with hoyer, Mr. C. Bell, and all the best writers on this subject, in dividing these cases into two kinds: first, those in which the force is applied directly to the bone itself; secondly, the more important arid serious cases, in which the force operates upon the fibula, through the medium of the foot. With respect to the first class of cases, the situation of the fibula on the outer side of the leg, a situation which would seem to expose it much to ex- ternal violence; its slenderness; the interspace left be- tween it and the tibia at the middle part of the leg; and the way in which each end of it rests -upon the latter bone; would lead one to expect that its middle portion must often be broken; yet the case is less fre- quent than might be apprehended. And, as Dupuytren observes, there are two reasons for this fact; viz. the protection which the fibula receives from the peronsi muscles, and the rarity of circumstances capable of producing a fracture by a direct cause. These frac- tures, which are not usually attended with deformity, and in some cases even do not hinder the patient from bearing upon the foot, cannot for the most part be ascer- tained, unless attention be paid to the manner in which the accident was produced, and to the presence of ec- chymosis, and of more or less pain in the part which has been struck, or pressed upon ; together with a de- gree of irregularity of the fibula, perceptible by the fingers, and a more or less distinct moveableness and crepitus of the ends of the fracture. The usual causes of this sort of fracture are blows on the fibula, gun-shot wounds, the fall of heavy bodies on the outside of the leg, or the passage of them over the same part. The foot is generally twisted, either inwards or outwards; and in most instances the acci- dent is easily cured by means of rest, without being accompanied by any of the symptoms so often compli- cating other fractures ofthe fibula, produced by distor- tion of the foot.—(Dupuytren, vol. cit. p. 40.) A striking analogy may be remarked between fractures of the central part of the fibula and those of the correspond- ing portion of the ulna, and this in respect to causes, symptoms, treatment, and consequences. Fractures of the middle of the ulna, like those of the body of the fibula, are always occasioned by blows or falls on the fractured part, or by violence applied directly to the bone. Such fractures are scarcely ever attended with any deformity in the limb, incaMKity of moving it, or displacement of the fragments |*and just as some indi- vidWs are able to walk with a broken fibula, others, notwithstanding a fracture of the ulna, are found capa- ble of using their forearm nearly as well as if it were free from injury. The latter case, like that of a frac- ture of the fibula, can only be known by the recoUec- tion of the way in which the hurt was received, the pain, ecchymosis, irregularities, motion, and crepitus, which last effects are also not very obvious so high up the bone. Like fractures of the body of tbe fibula, those ofthe body ofthe ulna only require rest and discutient applications, and very seldom the bandages, Sec. neces- 408 FRACTURES. sary in the treatment of fractures of both bones of the forearm, or of those of the radius alone.—< Vol. cit. p. 50.) ^ Fractures of the fibula from an indirect cause may happen from the foot being violently twisted either to- wards or outwards. In both instances the cause of tile fractjire. .is a change in the direction of the line in •which the weight of the body is transmitted. In the first case, the said Une, instead of following, as it com- monly does, the axis of the tibia, and falling upon the astragalus, crosses the lower end of the tibia and the ankle-joint, obliquely from within outwards, and after passing across the malleolus externus, extends to the outside ofthe member. The parts then supporting the weight of the body are the malleolus externus and the lower end of the tibia; besides which state of parts, the same malleolus is subjected to the traction of the external lateral ligaments, which operate with great force, in consequence of those ligaments being now nearly at a right angle with the lower end*of the fibula, while this process itself is in contact with the astraga- lus, which is propelled from witltin outwards byjthe tibia. The latter bone, being thicker and stronger than the fibula, generally resists; and if the mal- , leolus internus sometimes happens to break, it is se- condarily, as an effect of the displacement of the foot outwards. In the other example, where the foot is twisted out- wards, the centre of gravity of the body, instead of fol- lowing its usual course, obliquely crosses the lower end of the fibula, the ankle-joint, and the malleolus in- ternus, and fads on the ground at a greater or less distance from the inner edge of the foot. On the one side, the internal lateral ligaments and malleolus, and on the other, the lower end of the fibula, are then the parts which have to bear the weight ofthe whole body and the force of the muscles; and they are also the parts which are torn and fractured; first, the internal lateral ligaments, or the malleolus; and, secondly, the lower portion of the fibula.—(Annuaire Mid. Chir. de Paris, 1819, p. 66, 67.) Some of the symptoms of a fracture of the fibula, from an indirect cause, depend upon the fracture of that bone, and others upon the dis- location of the foot. They are divided by Dupuytren into two kinds; viz. presumptive and characteristic. The first are, the way in which the patient received his hurt : a noise or sort of crack heard by him at the instant of the injury; a fixed pain at the lower part of the fibula; a difficulty or inability of walking; more or less swell- ing round the ankle, especially about the malleolus ex- ternus and lower portion of the fibula. The charac- teristic symptoms are, an irregularity and unnatural moveableness of some point of the lower end of the fibula; a crepitus, which can be more or less distinctly felt by pressing upon and moving the part; mobility of the whole foot transversely or horizontally; a facility of bringing the lower end of the fibula towards the tibia by pressure; a change in the point of incidence ofthe axis of the limb upon the foot; distortion of the foot outwards, and sometimes backwards; rotation of the same part upon its axis from within outwards ; an an- gular depression, more or less manifest, at the outer and lower part of the leg; projection of the internal malleolus ; disappearance of almost all these symp- toms, as soon as reduction is effected by a force ap- plied to the foot; and their immediate recurrence when such force is discontinued, particular'; if the Umb be in the extended posture.—(Vol. cit. p. 68.) In considering the varieties of simple fi-acture of the fibula,.the first to which Dupuytren adverts is that in which the bone is broken more than three inches above the extremity of tlie malleolus externus; a case nei- ther accompanied nor followed by any displacement of the foot, and almost always produced by the direct application of violet to the broken part of the bone. . - .. ... , ■ A second variety of simple fractures of the fibula is when the bone has been broken, either by direct or indirect force, within three inches from the end of the malleolus externus, and when the foot is not displaced, though much displacement is possible, and, indeed, often arises from the sUghtest effort or movement made by the patient. The most frequent point of in- jury is about two inches and a half above the extremity of the outer malleolus. This is generally the place of a fracture caused by a twist ofthe foot outwards; but Ihe accident may happen lower down, as is common.y seen, when the fracture is occasioned by a twist ol Jjbo, foot inwards. "* These fractures of the fibula, abstractly .viewed, are not-of much importance in themselves ;*15ut with refer- ence to the manner in which they facilitate the c. p. 455.) When the lower angle is broken, the serratus major anticuslraws it forwafds, while the rest of the scapula remains in its natural situation; or if the angul* por- tion be considerable, the teres major, and some gbres of the latissimus dorsi, contribute to its displacement forwards and upwards. When the coracoid process is fractured, the pecto- ralis minor, coraco-brachialis, and short head of the biceps concur in drawing it forwards and downwards. When the neck of the scapula is fractured, the weight of the arm makes it drop down so considera- bly as to give the appearance of a dislocation; but the facility of lifting the os brachii upwards, the crepitus, and the falling of the limb downwards again, immedi- ately it is unsupported, are circumstances clearly mark- ing that the case is not a dislocation. According to Sir Astley Cooper, the crepitus is best perceived through the medium of the coracoid process. The degree in which the glenoid cavity and the head of the humerus descend, he observes, depends very much upon whe- ther the ligament between the under part of the spine of the scapula and the glenoid cavity is lacerated or not.—(On Dislocations, i-c. p. 459.) Sometimes great pains and a crepitus are experi- enced on moving the shoulder-joint after an accident; and yet the spine, the neck of the scapula, and all the above parts, are not broken. In this circumstance, it is to be suspected either that a small portion of the head of the os brachii, or a little piece of the glenoid cavity of the scapula, is broken off; which latter occurrence, I think, is not very uncommon. When the inferior angle is broken the part remains motionless, while the rest of the scapula is moved; and it is so separated, that no mistake can be made.— (Boyer.) Fractures of the spine and body of the bone are all attended with a crepitus; and in the first cases, an irregularity of the injured part may generally be felt. The prognosis of fractures of the scapula varies ac- cording to the situation of the injury, and the attendant circumstances. Fractures of the body of the bone, whatever may be their direction, are generally very simple and readily cured. Those of the acromion and lower angle are more troublesome to keep right; but the most serious cases are fractures of the coracoid process and neck of the bone, which cannot be kept right without great difficulty, and are said to be fre- quently followed by a considerable stiffness ofthe arm, inability to raise it, its atrophy, and even paralysis. In other respects, the danger of fractures of the sca- pula depends less upon the solution of continuity in the bone, than the contusion of the soft parts or injury of the thoracic viscera. However, when the fracture is comminuted and the splinters are forced into the subscapularis muscle, abscesses may form under the bone, and, according to Boyer, require a perforation to be made in it (Mai. Chir. t. 3, p. 165); a proceeding which I cannot bring myself to think would ever be judicious, as making a depending opening in the soft parts must be far better practice. In military surgery the scapula is often injured by sabre-cuts ; but as Dr, Hennen remarks, this bone, when preserved from mo- tion, is found in these cases to unite with great readi ness and without future inconvenience.—(Principles of Military Surgery, p. 48, ed. 2.) According to Boyer, when the scapula is fractured longitudinally or transversely, it is merely necessary to fix the arm to the side by means of a bandage which includes the arm and trunk from the shoulder to the elbow. Thus the motions of the shoulder, which are only concomitant with those ofthe arm, are prevented When the inferior angle is broken and drawn down- wards and forwards by the serratus major amicus, the scapula must be pushed towards the fragment by inclin ing the arm itself inwards, downwards, and forwards, where it is to be kept with a roller. The fragment is also to be kept backwards as much as possible with compresses and a roller, and the arm is to be sup- ported in a sling. The fractured acromion requires the arm to be so raised that the head of the os brachii will push up th« acromion, while an assistant pushes the scapula for wards and downwards in a contrary direction to thai of the arm. To maintain this position, a circular band age is to be applied round the arm and body. Desault used to apply also a small pUlow under tha axilla before putting on tbe bandage, in order to make 410 FRACTURES. the head of the os brachii project more upwards on bn»ging the arm near the side; but sir Astbjfy Cooper find* that a pillow so"placed does harm bythrowin-r thejiead of the os humeri outwards, and widely sepa" rating the acromion from the spine of the scapula. He approves of raising the elbow and keeping the arm fixed. He also relaxes the deltoid muscle by means of a cushion put between the elbow and the side, the elbow inclining a little backwards: the limb is to be bound to the chest in this position with a roller. The union may take place by bone, but owing to the diffi- culty of maintaining the coaptation, the uniting sub- stance is generally ligamentous.—(A. Cooper on Dis- locations, p. 455.) When the coracoid process is fractured, the muscles attached to it are to be relaxed by bringing the arm for- wards towards the breast and confining it there in a sling; while the shoulder is kept downwards and for- wards, and a compress confined just under the broken part with a roller. The treatment of a fracture of the neck of the sca- pula consists to keeping the head of the os humeri out- wards by means of a thick cushion in the axilla; in keeping the glenoid cavity and arm raised with a sling; and in preventing all motion of the arm by binding it to the trunk with a roller. In some of these cases, the apparatus proposed by Mr. Earle might be very useful—(Pract. Obs. in Surg. 1823.) FRACTURES OF THE CLAVICLE. This bone, being long and slender, unsupported at its middle, and protected externally only by the integu- ments, is very often broken. Its serving to keep the scapula at a proper distance from the sternum, and as a point d'appui for the os brachii, every impulse of which it receives makes its fractures sttil more com- mon. It may be broken at any part; but its middle, where the curvature is greatest, is most frequently the situa- tion of the injury. It is not very often fractured at its scapulary extremity. However, a direct force falling on the shoulder may break any part of the clavicle on which it immediately acts. The soft parts in this kind of case wtil also be contused or even lacerated. A comminuted fracture may be thus occasioned, and if the violence be very great, the subclavian vessels and nerves may be torn. The fall of a heavy body on the shoulder often gives rise to a paralysis of the arm. When the fracturing force is applied to the ends of the bone, as in a fall on the point of the shoulder or on the hands while the arms are extended, the clavicle may be very much bent, and fractured so obliquely, that the broken portions protrude through the skin. Fractures of this bone are usually attended with dis- placement, except when the injury takes place at the scapulary extremity and within the ligament, tyuig the clavicle and coracoid process together. The external portion of the clavicle is always that which is displaced. The internal part cannot be moved out of its natural situation, by reason of the costo-cla- vicular ligaments, and of its being drawn in opposite directions by the sterno-cleido-mastoideus and pectora- lis major muscles. The external portion, drawn down both by the weight of the arm and the action of the deltoid muscle, and forwards and inwards by the pecto- ralis major, is carried under the internal portion, which projects over it. The broken clavicle no longer keep- ing the shoulder at a due distance from the sternum, the arm falls forwards towards the breast. The pa- tient finds it impossible to put his hand to his forehead, because this act makes a semicircular motion of the humerus necessary, which cannot be done while that bone has not a firm point d'appui. Tbe shoulder and upper extremity may be observed to be nearer the breast than those of the opposite side. The motion of the pieces of bone on one another may be felt, as well as the projection of the end of the internal portion. When the shoulder is moved a crepitus may also be perceived; but this is productive of great pain, and the diagnosis is so obvious that it is quite unnecessary. The ancients, and many moderns, have supposed, that, in order to set a fracture of the clavicle, the shoul- der must be drawn back, and fixed in that position. The patient was placed on a low stool, so that an as- sistant might put his knee between the shoulders, which he drew back at the same time with both hands, while the surgeon apptiedthe bandage which was to keep the parts in this position. But when the "ItaUlflers are thus drawn towards one another, the JpfiSq^is obvi- ously pushed towards the sternum, ana wrrnit the ex- ternal portion of the clavicle, which passes under the internal fragment. The figure of 8 bandage has commonly been used for maintaining the parts in this position. While the as- sistant keeps back the shoulders, as above described, the surgeon is to apply one end of a roller to the armpit on the side affected, and then make it cross obliquely to the opposite shoulder, round which it is to pass, and from this to the other shoulder, about which it is to be applied in the same manner, and afterward repeatedly crossed before and behind. The tightness with which it is necessary to apply this bandage produces a great deal of excoriation about the armpits, and the effect is to make the ends of the fracture overlap each other, the very thing which it is wished to avoid. Boyer re- marks, that the iron cross proposed by Heister, the corslet described by Brasdor in the Mem. de l'Acad. de Chir., and the leather strap recommended by Brunning- hausen, are only modifications of the figure of 8 band- age, and are not at all better. Desault advised extension to be made by means of the limb, which is articulated with the fractured bone. This is done by converting the humerus into a lever, by carrying its lower end forwards, inwards, and up- wards, pushing the shoulder backwards, upwards, and outwards, and putting a cushion in the armpit to serve as a fulcrum. Desault used to put in the armpit a hair or flock# cushion, five or six inches long, and three inches and a" quarter thick at its base. Two strings are attached to the corners of the base, which is placed upwards: they cross the .back and breast, and are tied on the shoulder of the other arm. The cushion being thus placed in the armpit, and the forearm bent, Desault used to take hold of the patient's elbow, and carry it forwards, up- wards, and inwards, pressing it forcibly against the breast. By this manoeuvre, the humerus carries the shoulder outwards, the ends of the fracture become situated opposite each other, and all deformity is re- moved. An assistant is to support the arm in this position, while the surgeon, having a single-headed roller nine yards long, is to place one end of it in the armpit of the opposite side, and then apply the bandage over the upper part of the arm, and across the back to the same situation. The arm and trunk are to be covered with such circles of the roller, as far down as the elbow, drawing the bandage more tightly the lower it descends. Compresses, dipped in camphorated spirit, are next to be placed along the fractured bone. Desault then took a second roller, of the same length as the first, and put one end of it under the opposite armpit, whence it was carried across the breast over the compress and fracture, then down behind the shoulder and arm, and after having passed under the elbow, upwards on the breast. Desault next brought it across to the sound shoulder, under and round which he passed it, for the purpose of fixing the first turn. He then con- veyed the roller across the back, brought it over the compresses, carried it down in front of the shoulder and arm, under the elbow, and obliquely behind the back to the armpit, where the application began. The same plan was repeated, until all the roller was spent. The apparatus was secured by pins, wherever they promised to be useful, and the patient's hand was kept in a sling. Boyer has invented an apparatus for fractured clavi- cles, which is more simple than that employed by Desault. The cushion is to be applied under the arm. The apparatus consists of a girdle of linen cloth, which passes round the trunk on a level with the elbow. It is fixed on by means of three straps and as many buckles. At an equal distance from its extremities are placed externally on each side two buckles, two before and two behind the arm. On the lower part of the arm is to be laced a piece of quilted cloth, five or six fingers broad. Four straps are attached to it, which correspond to the buckles on the outside of the girdle, and serve both to keep the arm close to the trunk, and from moving either backwards or forwards. Certainly, the methods recommended by Desault and Boyer are very judicious and scientific. They are not, however, much adopted in this country, perhaos in con- FRACTURES. 411 sequence of the general aversion among English sur- geons to every apparatus which is not exceedingly sim- ple. Ii is to be hoped, at the same time, that in the Ireatment of fractured clavicles, they will alwaysa"e,nd to the principles which Desault and Boyer have incul- cated. If they understand why the position of the aim should be such as these eminent surgeons point out, they will have no difficulty in doing what is proper, ano. with a cushion, sling, and a couple of rollers, they wUl easily maintai n the proper posture. A simple and good ap- paratus for fractures of the clavicle, and those of the neck of the scapula, has been recently proposed by Mr. Earle. —(See his Practical Observations on Surgery, p.lSi, i-c.) It is also calculated for cases of dislocated cla- vicle, and other injuries of the shoulder. I cannot quit this subject without cautioning surgeons never to fall into the error of supposing the rising end of a broken clavicle to be the end which is displaced. This is the one which is truly in its right situation, and which has often been made, by injudicious pressure, to protrude through the integuments, one or two instances of which have fallen under my own observation. [Until within a few years, fractured clavicle was al- most universally treated in this country by Desault's bandage. The objections to it have been apparent for a long time, for although, properly applied, it is adequate to fulfil all the indications necessary in this kind of injury, yet its complexity, its liability to be deranged, and the pressure it makes upon the mamma? in female patients, rendered a substitute for it in many cases very desirable. Dr. Skipwith II. Coale, of Baltimore, constructed an apparatus, in 1816, for this purpose, which in his hands was entirely successfrti in bad cases of oblique fracture of the clavicle, and was highly recommended by Pro- fessors Davidge and Gibson, of the University of Ma- ryland. It was made of leather straps and buckles, performing the triple purposes for which Desault's bandage was adapted, and its simplicity as well as its permanence, together with its adaptation to female pa- tients, has brought it into general favour in the south. Dr. Stephen Brown, of New-York, has introduced to the profession an improvement or modification of De- sault's bandage, which is now in general use to many parts of the United States. It consists of a single headed roller, eleven yards long, and three and a half inches wide, the convolutions of which are so perfectly simple, that a description of his method wall be found sufficient to enable any practitioner to apply it with neatness and facility. A full description of this apparatus may be found in the 4th vol. of the Am. Med. Recorder. And as it fulfils every necessary indication, without being liable to the objections acknowledged to exist against that of Desault, it is well worthy of the confidence of surgeons gene- rally, and, indeed, it promises to this country altogether to supersede it.—Reese.] FRACTURES OF THE OS BRACHII OR HUMERUS. This bone may be fractured at any point of its length at its middle, either of its extremities, or above the in- sertion of the pectoralis major, latissimus dorsi, and teres major. The last case is termed fracture of the neck of the humerus; but that denomination has not the merit of being strictly anatomical. It is possible, however, that what is strictly called the neck of the humerus may be fractured, particularly by a gun-shot wound. By neck of the humerus, we understand that circular narrowing which separates the tuberosities tYom the head. The fractures of this bone may be transverse or oblique, simple or compound. Transverse fractures of its middle part, below the insertion of the deltoid mus- cle, are attended with but little displacement, for the brachialis internus and the triceps, being attached pos- teriorly and anteriorly to both fragments, counteract one another, and admit only a slight angular displace- ment. When the fracture takes place above the inser- tion of the deltoid muscle, the toferior portion is first drawn outwards and then upwards on the external side of the superior. Fractures of the humerus, near its lower end, such particularly as are transverse, are not subject to much displacement -. a circumstance to be attributed to the breadth of the fractured surfaces; to their being covered posteriorly by the triceps muscle, and anteriorly by the brachialis internus, which admit only a slight angular displacement, by the inferior portion being drawn a little forwards. Obliq\ie fractures are always attended with displace- ment, whatever be the part of the bone broken. The inferior portion being drawn upwards by the action of the deltoides, biceps, coraco-brachiaUs, and long portion of the triceps, glides easUy on the superior, a*hd passes above its lower extremity. Finally, fractures of the neck of the humerus are always attended with dis- placement, produced by the action of the pectoralis major, latissimus dorsi, and teres major, which, being attached to the lower portion near its superior extremity, draw it first inwards and then upwards, in which last direction it is powerfully urged by the biceps, coraco- brachialis, and long portion of the triceps. In this case, the superior portion itself is directed a little outwards by the action of the infraspinatus, supraspinatus and teres minor, which make the head of. the humerus per- form a rotatory motion in the glenoid cavity. The shortening and change in the direction of the limb, the crepitus, which may be very distinctly per- ceived by moving the broken pieces in opposite direc- tions, the pain and impossibility of moving the arm, Sec, joined to the history of the case, render the diag- nosis sufficiently plain. Fractures of the neck of the humerus, however, are not so easily ascertained, and, from want of attention, have been frequently confounded with luxations of that bone. Yet the diagnostic symptoms of these two af- fections are very different. When the neck of the humerus is fractured, a de- pression is observed at the upper part and external side of the arm, very different from what accompanies the luxation of that bone downwards and inwards. In the latter case, a deep depression is found, just below the projection of the acromion, in the natural situation of the head of the humerus; whereas, in fracture of the neck of t** A bone, the shoulder retains its natural form, the acromion does not project, and the depression is found below the point of the shoulder. Besides, on examining the armpit, instead of finding there a round tumour, formed by the head of the humerus, the frac- tured and unequal extremity of that bone wtil be easily distinguished. The motion of the broken portions, and the crepitus thus produced, serve still farther to establish the diagnosis.—(Boyer.) In a simple fracture of the body of the humerus, the prognosis is generally favourable; but fractures near the elbow are liable to be followed by more or less stiffness of the joint, often very difficult of re- moval. In ordinary fractures of the os brachii, it is usual to apply two pieces of soap-plaster, which together sur- round the limb, at the situation where the accident has happened. Extension, if necessary, being now made by an assistant, who at once draws the lower portion of the bone downwards and bends the elbow, the sur- geon is to apply a roller round the limb. The external splint is to extend from the acromion to the outer con- dyle, and being lined with a soft pad, the wood cannot hurt the Umb by pressure. The internal splint is to reach from the margins of the axilla to a little below the inner condyle, and is to be well guarded with a pad, filled with tow, or any other soft materials. Some surgeons are content with the application of two splints; but though the two above described are those on which we are to place the greatest reliance, yet as the cyUndrical form of the arm conveniently allows us completely to incase this part of the limb in splints, I consider the employment of four better: one on the outside, one on the inside, one on the front, and another on the back of the arm. These are to be care- fully fixed to their respective situations by means of tape. Throughout the treatment, the elbow and whole of the forearm are to be quietly and effectually supported to a sUng. FRACTURE OF THE HEAD OR NECK OF THE OS BRACHII. Chirurgical language here differs from that adopted by anatomists, and, under the name of fracture of the neck of the humerus, is not meant that of the circular, hardly perceptible depression, which separates the head from the tuberosities of this bone. By this expression, surgeons imply the fracture of that contracted part of the humerus, which is bounded above by these tubero- sities ; which below is continuous with the body of the bone •' which has the tendons of the pectoralis major, I latissimus dorsi, and teres major inserted below it; and 4l2 FRACTURES. which many practitioners extend even as low as the insertion of the deltoid muscle. Indisputable facts, however, prove the possibility of the anatomical neck of the bone being fractured, and C. LarbJtud showed Bichat the humerus of a young man, aged 17, the head of which bone was accurately detached from its body, by a division which had passed obliquely through the upper part of the tuberosities. Another example proved by dissection, has been very lately recorded by Delpech.—(Chirurgie Clinique.) An instance of this kind, I think, was pointed out to me in the spring of 1821, to St. Bartholomew's Hospital. The patient was a. boy, whose elbow had been strongly kept up, on the supposition that the case was a fracture of the neck of the scapula, and, consequently, the irre- gular end of the humerus formed a remarkable pro- jection in front of the acromion, yet capable of being pushed back, where, however, it would not remain. When the accident is produced by a direct blow or fall on the fleshy part of the shoulder, the deltoid is some- times contused and affected with ecchymosis. Even blood may be effused from some of the ruptured arti- cular veins or arteries, and form a collection which Desault recommended to be speedtiy opened, though the reason of such practice, as a general thing, must be questionable, because large extravasations of blood about the shoulder are usually very soon absorbed. Sir Astley Cooper has seen this accident both in old and in young persons; but, according to his observa-- tion, it rarely occurs in middle age. In the young, he says, it happens at the junction of the epiphysis, where the cartilage is situated ; and in the old it arises from the greater softness of this part of the bone.— (On Dislocations, ic. p.459.) An acute pain is experienced at the moment of the fall; sometimes the noise of something! Vreaking is heard. There is always a sudden inability to move the limb, which, left to itself, remains motionless. But, on external force being applied, it readily yields, and admits of being moved with the greatest ease in every direction. Such motion is attended with severe pain, and, if carried too far, may cause ill consequences, as has been observed in patients in whom the fracture has been mistaken for dislocation. Below the acromion a depression is remarkable, al- ways situated lower down than that which attends a dislocation. If we place one hand on the head, while the lower part of the bone is moved in various direc- tions with the other hand ; or if, while extension is made, an assistant communicates to the bone a rotatory motion, the following circumstances are perceived. 1. The head of the humerus remains motionless. 2. A more or less distinct crepitus is felt, arising from the two ends of the fracture rubbing against each other. These two symptoms are characteristic of the accident; but the swelling of the joint may prevent us from de- tecting them. Sometimes there is no displacement of the ends of the fracture, and then, as most ofthe symptoms are ab- sent, the diagnosis is stUl more difficult. In general, however, the ends of the fracture are displaced, and in this circumstance it is the lower one which is out of its proper position, and not the upper one, which is of lit- tle extent, and is not acted upon by many muscles. The displacement is generally not very perceptible ■in regard to length unless the fracture be very oblique, and its pointed spicula; irritate the muscles, and make them contract with increased power; or unless the blow, which was very violent, continued to operate after the bone had been broken, and forced the ends of- the fracture from their state of apposition. In this way the body ofthe humerus has deen drawn or driven upwards, so as to protrude through the deltoid muscle and integuments far above the height ofthe head ofthe bone. But commonly, as Petit observes, the weight of the limb powerfully resists the action of the muscles, and the displacement of the fracture is more liable to be transverse. In this circumstance the lower end of the fracture is displaced outwards or inwards, and rarely in any other direction. In the most frequent case, the elbow is separated from the trunk, and cannot be brought near it without pain; and in the instance of the bone being displaced outwards, the limb has a ten- dency to the opposite direction. According to Sir Ast- ley Cooper, the upper end of the main portion of the hu- merus sinks into the axilla, where it can be felt, and the deltoid is drawn down by it, so that the roundness of the shoulder is diminished.—(On Dislocations, ic. p. 459.) The reduction takes place of itself on employing a very little force methodically directed, according as the fracture is displaced inwards or outwards. If the surgeon put his hands on the situation of the fracture, it is rather to examine the state of the ends of the broken bone than to accomplish a thing seldom required, namely, what is implied by the term coaptation. Every apparatus for the cure of fractures being only resistances made by art to the powers causing the dis- placement ofthe broken part, it follows that the whole should act in an inverse ratio to such powers. These consist, 1. Of the action of external bodies, favoured by the extreme mobility of the arm and shoulder: 2. Of the action ofthe latissimus dorsi, pectoralis major, and teres major, which draw inwards the lower end of the fracture, or of the deltoid, which pulls it outwards: 3. Of the contractions of the muscles ofthe arm, which tend to draw the end ofthe fracture a little upwards. Hence, in the treatment, the three indications arc, 1. To render the arm and shoulder immoveable; 2. To bring either outwards or inwards the lower end of the fracture; 3. To draw downwards the same. The last object merits less attention than the two others, because the weight of the arm is alone almost sufficient for the purpose. Desault used to employ the following appa- ratus : 1. Two long rollers. 2. Three strong splints, of dif- ferent lengths, and between two and three inehes broad. 3. A cushion or pillow, three or four inches thick at one of its ends, terminating at the other in a narrow point, and long enough to reach from the axilla to the elbow. 4. A sling to support the forearm. 5. A towel to cover the whole of the apparatus. The reduction having been effected, the assistants are to continue the extension. Then the surgeon is to take the first roller, which is to be wet with the liq. plumbi acet. dil., and he is to fix one of its heads by applying two circular turns to the upper part of the forearm. The bandage is now to be rolled moderately tight round the arm upwards, making each turn over- lap two-thirds of that which is immediately below it. When the roller has readied the upper part of the limb, it must be doubled back a few times to prevent the folds which the inequality of the part would create. The bandage is afterward to be carried twice under the opposite axilla, and the rest of it, rolled up, is to be brought up to the top of the shoulder, and committed to the care of an assistant. The first splint is to be placed in front, reaching from the bend of the arm as high as the acromion. The second, on the outside, from the external condyle to the same height. The third, behind, from the olecranon to the margin of the axilla. The pillow, interposed be- tween the arm and thorax, serves as a fourth splint, which becomes useless. An assistant applies these parts of the apparatus, and holds them on by applying his hands near the bend of the arm, in order not to ob- struct the application of the remainder of the bandage. The surgeon takes hold of the bandage again, and applies it over the spUnts with moderate tightness, and the bandage ends ai the upper part of the forearm where it began. While the assistants still keep up the extension, the surgeon is to place the piUow between the arm and trunk, taking care to put the thick end upwards, if the fracture be displaced inwards; but downwards if this should be displaced outwards, which Desault found most common. Then the pillow is to be fastened with two pins to the upper part of the roller. The arm is to be brought near the trunk, and fixed upon the pillow by means of the second roller applied round the arm and thorax. The turns of this bandage should be rather tight below and slack above, if the fracture be displaced inwards; but if outwards, they should be slack below and tight above. The forearm is to be supported in a sling, and the whole of the apparatus is to be enveloped to a napkin, which will prevent the bandages from being pushed out of their places. If the effect of the above apparatus in fulfilling the indications above specified is considered, we shall easily see that they are very weU accomplished. The arm, firmly fixed against the trunk, can only move with it, and then nothing displaces the lower end of the frac- ture, which is equally motionless. The shoulder can FRACTURES. 413 not communica.e any motion to the upper end of the fracture. The pillow, differently disposed, according to the direction in which the lower extremity of the fracture is displaced, serves to keep this part in the op- posite position. Should this part of the bone project inwards, the thick end of the pillow will remove it farther from the chest. The bone will be kept at this distance from the side by the turns of the bandage, which, being very tight downwards, will act upon the limb as a lever, the fulcrum for which will be the pillow, and the re- sistance the action of the pectoralis major, latissimus dorsi, and teres major. Thus the bandage will have the effect of bringing the elbow nearer the trunk, and move the lower end of the fracture in the opposite di- rection, so that it may here be considered as an artificial muscle directly opposing the natural ones. When the lower end of the fraature is drawn out- wards, the contrary effect will be produced, both from the pressure exercised by the bandage on the upper end ofthe displaced portion ofthe bone, ami-from the situa- tion of the elbow; which is kept outwards by the thick part of the pUlow. The outer splint will also prevent the lower end of the fracture from being displaced out- wards, both by its mechanical resistance to the bone, and by compressing the deltoid muscle, which is the chief cause of such displacement. All displacement of the lower end of the fracture forwards or back- wards is prevented by the back splint; and as for the longitudinal displacement, which is already prevented by the weight of the limb, it is still more effectually hindered by the compression ofthe muscles ofthe arm both by the splints and roller.—(See (Euvres Chir. de Desault, par Bichat, t. 1.) Sir Astley Cooper recommends a roller to be applied from the elbow to the shoulder-joint; two splints to be bound on the inner and outer sides of the arm with a roller; a cushion to be placed in the axilla in order to throw out the head ofthe bone; and gently support- tog the arm in a sling; for if the elbow is much raised, he says, the bones will overlap, and the union be at- tended with deformity.—(On Dislocations, ire. p. 461.) FRACTURES OF THE LOWER ENDS OF THE OS BKACHII, WITH SEPARATION OF THE CONDYLES. Fractures of the os brachii, with detachment of its condyles, seem to have escaped the notice of most authors who have written on the diseases ofthe bones. The accident, however, is not uncommon, and Desault in particular had frequent occasion to meet with it. Whatever its causes may be, the two condyles are usually separated from each other by a longitudinal division, which, extending more or less upwards, is bounded by another transverse or oblique division, which occupies the whole thickness ofthe bone. Hence, there are three different pieces of bone and two frac- tures. Sometimes, the division is more simple; as when, taking a direction outwards or inwards, it crosses ob- liquel y down the lower end of the os brachii, terminates in the joint, and only detaches one ofthe condyles from the body of the bone. In the first case the deformity is greater, and the fractured part is more moveable. When pressure is made either before or behind, on the track of the longi- tudinal fracture, the two condyles, becoming farther separated from each other, leave a fissure between them, and the fractured part is widened. The forearm is almost always in a state of pronation. On taking hold of the condyles and moving them in different di- rections, a distinct crepitus is perceived. In the second case, the separation of the condyles from each other Is not so easy; but a crepitus can al- ways be distinguished on moving the detached con- dyle. In one case, in which only the external condyle was broken, Desault found the Umb always supine • a position which the muscles inserted into this part were doubtless, concerned in producing. In both cases, an acute pain, the almost inevitable effect of bending or extending the forearm; an habitual half-bent state of this part or the limb, and sometimes a subsequent swelling of it, together with move or less tumefaction round the joint, are observable When the blow has been very violent, or a pointed piece of the bone protrudes through the flesh, the accident may- be complicated with a wound, splinters of bone &c. When the condyles of the humerus are obliquely I broken off just above the joint, the appearances, as de- scribed by Sir Astley Cooper, are those of a dislocation ofthe radius and ulna backwards; but the nature of the case is evinced by the circumstance of the displace- ment recurring as soon as the extension is stopped, and also by the crepitus, generally perceptible when the forearm is rotated upon the humerus.—-(On Dislo- cations, Sc. p. 481.) The old writers consider the communication of a fracture with a joint a fatal kind of complication. Swelling and inflammation ofthe adjacent parts; con- tinuance of pain after the reduction ; large abscesses; even mortification of the soft parts, and caries of the bones, are, according to such authors, the almost inevi- table consequences of these fractures, and anchylosis the most favourable termination. Pare, Petit, Heister, Duverney, all give this exaggerated picture. However, analogous fractures of the olecranon and patella prove that this representation is magnified beyond truth. Modem observation has dispelled the ancient doctrine ofthe effusion of callus into the joint, and with it one of the principal causes assigned by authors for the symptoms so much dreaded. The detached condyles being drawn in opposite di- rections by the muscles of the arm and forearm, com- monly remain unmoved between these two powers, and are but little displaced. External force may, how- , ever, put them out of their proper situation, and they may then be displaced forwards or backwards, or they may separate from each other sidewise, leaving an interspace between them. Hence, the apparatus should resist them in these four directions, and this object is easily accomplished by means of four sptints kept on with a roller." The two lateral splints are particularly necessary when the condyles are separated from the body of the bone with an interspace between them. If one of them be still continuous with the humerus, no splint on this side will be requisite. The apparatus need not extend as high as when the arm is fractured higher up; but the roller should be continued over the forearm, in order that the joint may correspond to the middle of the bandage, which should here be firmer than any where else. This me- thod is also of use in producing a gentle compression ofthe muscles implanted into the condyles. Desault recommends the front and back splints to be flexible at their middle part, which should be ap- plied to the bend of the arm and elbow.—(CEuvre* Chir. de Desault, par Bichat, 1.1.) The treatment advised by Sir Astley Cooper consists in bending the arm, drawing it forwards so as to re- duce the parts, and then applying a roller. The best splint for this case, he says, is one formed at right an- gles, the upper portion of it being placed behind Ihe upper arm, and the lower under the forearm. He also directs the application of a splint to the fore part ofthe upper arm. The splints are to be fixed with straps; evaporating lotions used; and the arm kept in a bent position in a sling. In a fortnight, if the pa- tient be young, and in three weeks if he be an adult, passive motion mu/ be gently employed for the pur- pose of hindering an anchylosis.—(Ore Dislocations, ire. p. 482.) According to the same author, when the in- ternal condyle is broken off obliquely the ulna loses its natural support and projects backwards. FRACTURE OF THE FOREARM. The forearm is more frequently broken than the arm, because external force operates more directly upon it than the latter part, especially in falls on the hands, which are frequent accidents. Bichat in his account of Desault's practice, mentions, that fractures of the forearm often held the first place in the com- parative table of such cases kept at the Hdtel-Dieu. We know that the forearm is composed of two bones, the ulna and radius. The last is much more liable to fractures than the first, because it is articu- lated with the hand by a large surface, and all the shocks received by the latter part are communicated to it. The situation of it also more immediately exposes it to such causes as may break it. However, both the bones are frequently broken together. FRACTURES OF bOTH BONES May occur at the extremities or middle of the fore arm. They are frequent at the middle, very common below, but seldom happen at the upper part of the ['URES. 414 FRAC forearm, where the numerous muscles, and the con- siderable thickness of the ulna, resist causes which would otherwise occasion the accident. The bones are Usually broken to the same line, but sometimes to two different directions. The fracture is almost always single, but to a few instances it is double; and De- sault, in particular, was one day called to a patient, over whose forearm the wheels of a cart had passed, so as to break the bones at then- middle and lower part, into six distinct portions. The middle ones, notwith- standing they were quite detached, united very well with hardly any deformity. These accidents are most commonly occasioned by direct external violence; but sometimes they are pro- duced by a counter-stroke, which is generally the case when the patient falls on his hand. But in this in- stance, as the hand is principally connected with the lower broad articular surface of the radius, this bone alone has to sustain almost the whole shock of the blow, and hence is usually the only one broken. The symptoms indicating fractures of the forearm are not likely to lead the surgeon into any mistake: motion at a part of the limb where it was previously inflexible; a crepitus, almost always easUy felt; some- times a distinct depression in the situation ofthe frac- ture ; occasionally a projection of the ends of the frac- ture beneath the skin; pain on moving the part; a noise sometimes audible to the patient at the moment of the accident; an inability to perform the motion of pronation and supination; and an almost constant half-bent state of the forearm. There is one case, however, in which the fracture being very near the wrist-joint, similar appearances to those of a dislocation of this part may arise. But at- tention to whether the styloid processes are above or below the deformity wtil discover whether the case be a fracture or dislocation. In a fracture, the part is also more moveable, and there is a crepitus.—(GLuvres Chir. de Desault, par Bichat, 1.1.) According to Boyer, the two cases may be distinguished by simply moving the hand; by which motion, if there be a luxation without fracture, the styloid processes of the radius and ulna will not change then: situation; but if a frac- ture exist, they will follow the motion ofthe hand. The connexion of the two bones of the forearm by the interosseous ligament, which occupies the inter- space by which they are separated, and the manner to which the muscles attached to both are inserted into them, render any displacement of the broken pieces in the longitudinal direction very difficult; and in real- ity, such displacement is seldom observed, and never in* any considerable degree. When it does take place, it is to be ascribed to the cause of the fracture, rather than to muscular contraction. On the contrary, to the transverse displacement, the four pieces approach one another, and the interosseous space is diminished or en- tirely obliterated near the seat of the fracture; attended with evident deformity of the part. There is an an- gular displacement which the fracturing cause always produces, either forwards or backwards, according to its direction. Boyer gives the following account of the treatment ofthe fracture of both bones ofthe forearm. The forearm is to be bent to a right angle with the arm, and the hand placed in a position between the pro- nation and supination. The forearm and hand being thus placed, an assistant takes hold of the four fingers of the patient, and extends the fractured parts, while another assistant makes counter-extension by fixing the humerus with both his hands. By these means the operator is enabled to restore the bones to their natural situation, and to push the soft parts into the interosseous space, by a gentle and graduated pressure on the anterior and posterior sides ofthe arm. The bones are kept in their place by applying first on the anterior and posterior sides of the forearm two longitudinal and graduated compresses, the base of which is to be in contact with the arm. The depth of these compresses should be proportioned to the thick- ness ofthe arm, increasing as the diameter ofthe arm diminishes. In the next place, the surgeon takes a single-headed roller, about six yards long, and makes three turns of it on the fractured part; he then de- scends to the hand by circles partially placed over one another, and envelopes the hand by passing the band- age between the thumb and index finger: the bandage is next carried upwards to the same manner, and re- flected wherever the inequality of the arm may render it necessary. The compresses and bandage being tbns far applied, the surgeon lays on two splints, one ante- riorly, the other posteriorly, and applies the remainder of the bandage over them. The compresses and splints should be of tbe same length as the forearm. It would be useless to employ lateral splints in this case, unless (what is scarcely ever to be expected or met with) a displacement should have taken place in that direction. Lateral splints would counteract the compresses and two other splints, by lessening the radio-cubital diame- ter of the arm, and with the action of the pronators, tend to push the ends of the fracture into the inter- osseous space. The surgeon's attention should be par- ticularly directed to preserve the interosseous space; for, if this be obliterated, the radius cannot rotate on the ulna, nor the motion of pronation or supination be executed; and this object may be obtained with cer- tainty by applying the compresses and splints in such a manner, that the fleshy parts may be forced into and confined to the interosseous space, and by renewing tbe bandage every seven or eight days. If the fracture be simple, and the contusion inconsi- derable, the patient need not be confined to bed, but may walk about with his arm to a sling. FRACTURES OF THE RADII'S Are the most frequent of those of the forearm. The radius being almost the sole support of the hand, and placed in the same line with the humerus, is for both these reasons more exposed to fractures than the ulna. Fractures of the radius, whether transverse or ob- lique, near its middle part or extremities, may be caused by a fall or blow on the forearm, or as hap- pens in most cases, by a faU on the palm of the hand. When likely to fall we extend our arms, and let the hands come first to the ground; in which case, the ra- dius pressed between the hand on the ground and the humerus, from which it receives the whole momentum of the body, is bent, and if the fall be sufficiently vio- lent, broken more or less near its middle part. When after an accident of this kind, pain and difficulty of per- forming the motions of pronation and supination su- pervene, the probability of a fracture of the radius is very strong. The truth is fully ascertained by pressing with the fingers along the external side of the forearm. Also, to endeavouring to perform supination or prona- tion of the hand, a crepitus and a motion of the broken portions will be perceived. When the fractare takes place near the head ofthe radius, the diagnosis is mere difficult, on account of the depth of soft parts over that "part of the bone. In this case, the thumb is to be placed under the external condyle of the os humeri, and on the superior extremity of the radius, and at tbe same time the hand is to be brought into the prone and supine positions. If in these trials, which are always painful, the head of the radius rests motionless, there can be no doubt of the bone being fractured. Here the causes of displacement are the same as in fractures of the forearm; it can never take place, ex- cept in the direction of the diameter of the bone, and is effected principaUy by the action of the pronating mus- cles. The ulna serves as a splint in fractures of tbe ra- dius ; and the more effectually, as these two bones are con- nected with one another throughout their whole length. In general, when only the radius is fractured, no ex- tension if requisite. During the treatment, the elbow is to be bent, and the band put in the nud-state between pronation and supination; tbat is to say, the palm of the hand is to face the patient's breast. Having re- duced the ends of the fracture when they appear to be displaced, the soap plaster is to be applied, and over this a slack roller. This bandage is, indeed, of no utitity; but it makes the limb seem, to the unknowing bystanders, more comfortable than if it were omitted, and as it does no harm, the surgeon may honestly ap- ply it. However, no one can doubt, that tight bandages may act very perniciously, by pressing the radius and ulna together, causing them to grow to each other, or at all events, making the fracture unite in an uneven manner. Only two splints are necessary; one is to be placed along the inside, the other along the outside, of the forearm. Soft pads must always be placed be- tween the skin and the splints, in order to obviate the pressure of the hard materials of which the latter are formed. The toner splint should extend to about the last joint of the fingers; but not completely to tbe end FRACTURES. 415 of the nails, for many patients, after having had their fingers kept for several weeks in a state of perfect ex- tension, have been a very long time in becoming able to bend them again. Sometimes it may be proper to apply a compress just under the ends of the fracture, to prevent their being depressed towards the ulna too much, the conse- quence of which has occasionally been the loss of the prone and supine motions of the hand. In setting a fractured radius, the hand should be in- clined to the ulnar side of the forearm. FRACTURES OF THE ULNA. Fractures of this bone are less frequent than those of the radius, and take place generally at its lower ex- tremity, whii h is most slender and least covered. A fracture of this bone is almost always the result of a force acting immediately on the part fractured; as, for instance, when in a fall the internal side of the fore- arm strikes against a hard resisting body. On apply- ing the hand judiciously to the inside of the forearm, this fracture is easily ascertained by the depression at that part, in consequence of the inferior portion being drawn towards the radius by the action of the prona- tor radii quadratus. This displacement, however, is less considerable than what takes place in fractures of the radius. Tbe superior portion of the ulna remains unmoved.—(J. L. Petit.) In this case, the assistant, who makes whatever little extension may be necessary, should incline the hand to the radial side of the forearm, while the sur- geon pushes the flesh between the two bones, and ap- plies the apparatus as in the preceding case. In all fractures of the bones of the forearm, and particularly In those which are near the head of the radius, a false anchylosis is to be apprehended, and should be guarded against by moving the elbow gently and frequently, when the consolidation is in a certain degree advanced. Fractures of the forearm always require the part to be kept quietly in a sling. FRACTURES OF THE OLECRANON. The olecranon may be fractured either at its base, its centre, or its extremity; but the second case is the most frequent. The division is almost always trans- verse, though occasiona'ly oblique. The accident is very rarely produced by tho action of the muscles, but almost always by external violence, directly applied to the part in a blow or fall upon the elbow. With regard to symptoms, the contraction of the tri- ceps, being no longer resisted by any connexion with the ulna, draws upwards the short fragment to which it adheres, so as to produce, between it and the lower one, a more or less evident interspace. This inter- space is situated at the back part of the joint, and may be increased or diminished at will, by augmenting the flexion of the forearm, and putting the triceps into ac- tion, or extending the limb. Another symptom" is the impossibility of spontaneously extending the forearm, the necessary effect of the detachment of the triceps from the ulna. It appears from the dissections made by Sir Astley Cooper, that the extent of the separation depends upon the degree of laceration of the capsular ligament, and of that portion of ligament which pro- ceeds fl-om the side of the coronoid process to that of Ihe olecranon.—(On Dislocations, i-c. p. 487.) It must be owing to the untorn state either of the latter part, or of the aponeurosis covering the olecranon, that pa- tients occasionally retain the power of extending the forearm, as is exemplified in the case reported by Mr. Earle, where, on the sixth day after the accident (and not before) this power was destroyed by a sudden flexion of the forearm.—(Practical Obs. p. 147.) The forearm is constantly half-bent, tbe biceps and brachialis having no antagonists. The olecranon is more or less drawn up higher than Ihe condyles of the os brachii, which lat- ter parts, on the contrary, are naturally situated higher than the olecranon, when the forearm is half-bent The upper piece of bone may be moved in every di- rection without the ulna participating in the motion Besides these symptoms, we must take into the ac- count the considerable pain experienced, and the cre- pitus perceptible, when the fragment is approximated to the surface from which it is detached. The indications are, to push the retracted portion of the olecranon downwards, and to keep it in this posi- tion at tbe same time that the ulna is made to meet it. as it were, by extending the forearm. According to Desault, however, the forearm should not be com- pletely extended, as when the pieces of bone touch at their back part, they leave a vacancy to front, which is apt to be followed by an irregular callus, prejudicial to the free motion of the elbow. Hence, it was his prac- tice to put the arm between the half-bent and the com- pletely extended state, and to maintain this posture by means of a splint along the fore part of the arm. But as position operates only on the lower part of the ole- cranon, the upper one requires to be brought near the former and fixed there, which is, doubtless, the most difficult object to effect, because the triceps is continu- ally resisting. Desault used to adopt the following method: the forearm being held in the above position, the surgeon is to begin applying a roller round the wrist, and to continue it as high as the elbow. The skin covering this part, being wrinkled to consequence of the exten- sion of the limb, might insinuate itself between the ends of the fracture, and consequently it must now be pulled upwards by an.assistant. The surgeon is then to push the olecranon towards the ulna, and confine it in this situation with a turn of the roller, with which the joint is then to be covered, by applying it in the form of a figure of 8. A strong splint a little bent, jnst before the elbow, is next laid along the arm and forearm, and fixed by means of a roller. The limb is then to be evenly sup- ported on a pillow. The cure of the fractured olecranon is seldom ef- fected by the immediate reunion of its fragments •, there generally remains a greater or less interspace between them, which is filled up by a substance not of a bony consistence. Indeed, the tenor of the remarks and experiments lately published by Sir Astley Cooper on this subject is to represent the broken olecranon as similarly circumstanced with respect to bony union, as the fractured neck of the femur. He has seen union by bone effected in the living subject; but this was when the fracture had taken place very near the shaft of the ulna. The ligamentous substance, he says, which generally forms the bond of union, often has one or even several apertures in it, when it is of con siderable length. The arm is observed to be weakened! in proportion to the length of the ligament.—(On Dis- locations, i-c. p. 489.) Camper laid great stress upon the inutility of keep- ing the arm perfectly extended: he found patients re- cover sooner and better when the elbow was kept half- bent, and the joint gently exercised at as early a pe- riod as possible. " Agglutinationem scilicet motiri non debet chirurgus, sed sublatis tumore ac inflamma- tione quiete et remediis aptis, cubitum quotidie pru- denter movere, ut unio per tricipitis tendinem, seu per concretionem membranosam fometur, et os ossi non admoveatur. Verbo quemadmodum C. Celsus in Med. lib. 8, c. 10, § 4, p. 537, de cubito fracto praecepit. Quod si ex summo cubito quid fractum sit, glutinare id vinciendo aUenum est, fit enim brachium immobile, ac, si nihil aliud quam dolore occurrendum est, idem qui fuit ejus usus est."—(Camper de Fracturd Patella, p. 66, Haga, 1789.) Mr. Earle is also an advocate for placing the limb to a slightly bent position.—(Pract. Obs. p. 165.) The late Mr. Sheldon, however, does not concur -with Desault and Camper, respecting the posi- tion of the limb during the treatment, but insists upon the utility of keeping the forearm perfectly extended. When there is much swelling, Sir A. Cooper em- ploys leeches and evaporating lotions for two or three days; but when not much violence has been done to the limb, he applies the bandage at once. He places the arm in a straight position, presses down the frag- ment until it touches the ulna, and, after putting a slip of linen along each side of the joint, puts a roller round the limb above and below the olecranon. By tying the slips of linen which pass under the rollers, these are drawn nearer together, and the fragment of the ole- cranon is thus kept as near as possible to the ulna. Lastly, a splint well padded is applied along the front of the arm, and secured with a bandage, which is fre- qently wetted with spirit of wine and water.—(On Dislocations, <$c. p. 490.) On in x isl^ii, the olecranon becomes firmly united about tnetwjRy-sixth day.—(Desault.) In a month the splint is ^be removed and passive motion begun — (A. Cooper.) 416 FRA fr#: FRACTURE OF THE CORONOID PROCESS. Two examples of this accident are noticed by Sir Astley Cooper: in one case, seen by him several months after its occurrence, the same appearances pre- sented themselves as were remarked by the surgeon who first attended the patient; namely, the ulna pro- jected backwards whUe the arm was extended, but it oould be drawn forwards and the elbow bent without much difficulty, when the deformity disappeared. In the other instance, which presented itself in the dis- section-room, the coronoid process, which had been broken off, was united by ligament, and so moveable that when the forearm was extended, the ulna glided backwards upon the condyles of the humerus. Sir Astley Cooper is of opinion that the case admits of no other mode of union : he recommends keeping the arm Bteadily in the bent position for three weeks.—(.On Dis- locations, i-c. p. 434.) FRACTURES OF THE CARPAL ANn METACARPAL BONES, AND.PHALANGES OF THE FINGERS. The bones of the carpus, when broken, are usually crushed, as it were, between very heavy bodies, or the limb has been entangled in powerful machinery, or suffered gun-shot violence. It must be obvious, there- fore, that as the soft parts are also seriously injured, these cases are generally followed by severe and troublesome symptoms, and sometimes require the per- formance of amputation, either immediately or subse- quently. When an attemptis to be made to save the part, the chief indications are to extract splinters of bone, and prevent inflammation, abscesses, and mortifica- tion. The parts may at first be kept wet with a cold evaporating lotion, any wound present being lightly and superficially dressed; but afterward, as soon as all tendency to bleeding is over, emollient poultices may be applied over the dressings instead of the lo- tion. The dressings themselves, however, should not be removed for the first three or four days, all unne- cessary disturbance of the crushed parts being highly injurious. Should abscesses form, early openings should be practised, so as to prevent the matter from extending up the forearm. Duly supporting the hand and forearm in a sling is of the greatest importance. The metacarpal bones of the little finger and thumb are more frequently broken than the other three. A fracture of a metacarpal bone is generally produced by violence appUed directly to the part, as no force capable of causing the accident can well act upon the twoends of the bone so as to break it. The fracture may be simple, but more commonly it is compound, the soft parts being wounded and lacerated by the same violence which has injured the bone. In most cases, also, unless the force has operated by a very limited surface, more than one me- tacarpal bone is fractured. At first, the same kind of treatment is requisite as in the preceding cases, and, after the inflammation has subsided, a hand-board or splint may be employed. When the hand is very badly crushed, amputation is indicated. In fractures of the finger-bones, the treatment con- sists in applying a piece of soap-plaster, rolling the part with tape, covering it in paste-board, sometimes placing the hand on a flat splint or finger-board, and al- ways keeping the hand, forearm, and elbow well sup- ported in a sling. For Fractures of tlie Cranium, see Head, Inju- ries of. For information on fractures, consult particularly J. L. Petit, Traiti des Maladies des Os. Duverney, Traite des Maladies des Os. Jonathan Wathen, The Con- ductor and Containing Splints; or, a Description of two new-invented Instruments, for the more safe Con- veyance, as well as the more easy and perfect Cure, of Fractures of the Leg, 2d ed. Svo. Lond. 1767. W. Sharp, in vol. 57 of the Philosophical Trans, part 2, 1767. An Account of a New Method of treating Frac- tured Legs. Pott's Remarks on Fractures and Dislo- cations. T. Kirkland, Obs. upon Mr. Pott's General Remarks on Fractures, ire. 8vo. Lond. 1770; also, Ap- pendix to the same, 8vo. Lond. 1771. Cases in Sur- gery, by C. White, edit. 1770. /. Aitken, Essays on several Important Subjects in Surgery, chiefly on the Nature of Fractures of the Long Bones of the Extre- mities, particularly those of the Thigh and Leg, Svo. 1771. Boyer, Traiti des Mai. Chir. t. 3, Encyclo- pedic Me.thodique, partie Chir. art. Fracture, Cuisse, Omoplate, Ileum, ire. ire. CEuvres Chir. dt Desault, par Bichat, t. 1. Parts of the Parisian Chirurgical Journal. Sir J. Earle, A Letter, containing some ■Observations on the Fractures ofthe Lower Limbs; to which is added an Account of a Contrivance to ad- minister Cleanliness and Comfort to the Bed-ridden, or Persons confini il to Hi il by Age, Accident, Sickness, or other Infirmity, 8t-o. Lond. 1807. Leveilli, Nouvelle Doctrine Chir. t. 2, 1812. Assalini, Manuale di Chi- rurgia, parte prima, Milano, 1812. Dupuytren, Des Fractures ou (ourbures des Os des Enfans, in Bul- letin dela Furultide Mid. Paris, 1811. Idem, Sur la Fracture de 1'E.rlrimite infirieure duPcrone, les Lux- ations et les Ac.cidi-ns qui en .sont la suite, in An- nuaire Med. chir. de- Pans, ito. Paris, 1819. Roux, Relation d'nn Voyage fait d Lomlres en 1814, ou Pa- rallile de la Chirurgie Angloise avec la Chirurgie Francois,, p. 173, \-c. Paris, 1815. Med. Chir. Trans, vol. 2, p. 47, i-c. ; vol. 5, p. 358, i-c.; vol. 7, p. 103. Sketches of the Medical Schools of Paris, by J. Cross, p. 87, i-c. Sir A. Cooper, A Treatise on Dislo- cations and Fractures of the Joints, 4to. Lond. 1822 ; and Obs. on Fractures of the Neck of the Thigh-Bone, 1823. H. Earle, Practical Observations in Surgery, 8vo. 1823. W. Gibson's Institutes and Practice of Surgery, Svo. vol. 1, Philadelphia, 1824. B. Bell, an the Diseases of the Bones, 12mo. Edin. 1828. J. Amesbury on Fractures of the Upper Third of the Thigh-Bone, and Fractures of long standing, ed. 2, Svo. Lond. 1829. FRANUM LINGILE. In infants, the tongue ia sometimes too closely tied down, by reason of the fra- num being extremely short, or continued too far for- wards. In the latter case, the child will not be able to use its tongue with sufficient ease in the actions of sucking, swallowing, Sec, in consequence of its point being confined at the bottom of the mouth. Though this affection is not unfrequent, it is less common than is generally supposed by parents and nurses. When the child is small and the nurse's nipple large, it is common for her to suppose the child to be tongue-tied, when, to fact, it is only the smallness of the child's tongue that prevents it from surrounding the nipple, so as to enable it to suck with facility. Mothers also commonly suspect the existence of such an erroneous formation, whenever the child is long in beginning to talk. The reality of the case may always be easUy ascer- tained by examining the child's mouth. In the natural state, the point ofthe tongue is always capable of being turned upwards towards the palate, as the fraenum does not reach along above a quarter of an inch ofthe lower part of the tongue from the apex. But in tongue-tied children, by looking upon one side, we may see the fraenum extending from the back part to the very point, so that the whole length of the tongue is tied down and unnaturally confined. The plan of cure is to divide as much ofthe franum as seems proper for setting the tongue at liberty. The incision, however, should not be carried more exten- sively backwards than is necessary, lest the raninal arteries be cut; an accident that has been known to prove fatal. For the same reason, the scissors used for this operation should have no points. I think the fol- lowing piece of advice offered by a modern author may be of service to practitioners, who ever find it necessary to divide the franum linguae: " It is not the relations of the trunk of the lingual artery alone which the stu- dent ought to make hunself acquainted with. He will do weU to study the position of th arteria ranina in respect to the frasnum linguae. This information will teach him the impropriety of pointing the scissors up- wards and backwards, when snipping the fraenum; an operation, by-the-by, oftener performed than needed. 4 He will learn that the ranular artery lies just above the attachment of the fraenum; so that, if he would avoid it, he must turn the points of the scissors rather down- wards ; if he do not, the artery will probably suffer." —(A. Burns, Surgical Anatomy of the Head and Neck, p. 239.) When an infant has the power of sucking, this pro- ceeding should never be resorted to, even though the fraenum may have the appearance of being too short, or extending too far forwards.—(Fab. HUdanus, centur. 3, obs. 28. Petit, Traiti des Mai. Chir. t. 3, p. 265, idit 1774.) Although the operation of dividing the fraenum lingua is for the most part done without any bad consequences, FRA nrgeous should remember well that it is liable to •dangers, especially when performed either unnecessa- rily or unskilfully. Besides the fatal events which have occasionally resulted from wounding the raninal arteries, the records or surgery furnish us with proofs that the mere bleed- ing from the raninal veins, and the small vessels ofthe frinum, may continue so long, in consequence of the infant's incessantly sucking, as to produce death. In such cases, the chUd swallows the blood as fast as it issues from the vessels, so that the cause of death may ever, escape observation. But if the body be opened, the stomach and intestines wUl be found to contain large quantities of blood.—(See Dionis, Conrs d'Opira- tiom de Chirurgie, 7e Demonstration. Petit, Traite des Maladies Chir. t. 3, p. 282, *c.) Another accident, sometimes following an unneces- sary or too extensive a division of the franum, consists in the tongue becoming thrown backwards over the glottis into the pharynx, where it lies fixed, and causes suffocation. The observations of Petit on this subject are highly interesting.—(See Op. cit. t. 3, p. 267, ire.) Lastly, it should be known, that an infant's inability te move its tongue, or suck, is not always owing to a malformation of the framum. Sometimes the tongue is applied and glued, as it were, to the roof of the mouth, by a kind of mucous substance; and in this case, it should be separated with the handle of a spatula. By this means, infants have been saved who were unable to suck during several days, and were in imminent danger of perishing from want of nourishment.—(See Mimoires de l'Acad. de Chir. t. 3, p. 16, id. 4to.) Seo particularly Petit, Traiti des Maladies Chir. t. 3, p. 260, Sec. Dionis, Cours tPOpirations, ~c Dimonstr. Sabatier, Midecine Opiratoire, t. 3, p. 132, Src, Lassus, Pathologic Chir. t. 2, p. 454. Richerand, Nosogr. Chir. t. 3, p. 284, ed. 2. Ricliter, Anfangsgr. der Wundarzn. b.i,kap.2,p 11, ed. 1800. FRAGILITAS OSSIUM. A morbid brittleness of the bones. Although it may take place at different periods of life, it is remarked to be more common in childhood and in persons of advanced age.—(See B. Btll on Diseases of the Bones, p. 74.) Boyer imputes mollities ossium to adeficiency of lime in their structure; fragilitas ossium to a deficiency of tlie soft matter naturally entering into their texture. He states, that a certain degree of fragilitas ossium necessarily occurs in old age, because the proportion of lime to the bones naturally increases as we grow old, while that of the organized part diminishes. Hence, the bones of old persons more easUy break than those of young subjects, and are longer in uniting again As Mr. Wilson observes, however, they never are found so friable and fragile, as to crumble Uke a calcined bone, but, on the -contrary, they contain a large quantity of oil; a fact particularly noticed by SaUlant (see Hist, de la Sociiti de Mid. 1776, p. 316), and when dried after death, they are so greasy as to be unfit to be preserved as preparations. Their organized vascular part is di- minished, but their oily animal matter is increased.— (On the Skeleton and Diseases of Bones, p. 258.) In persons who have been long afflicted with can cereus diseases, tbe bones become sometimes as brittle as if they had been calcined. Saviard and Louis relate cases of this description.—(Obs. Chir. et Journ. des Savans, 1691. Obs. et Remarques sur les Effets du Virus Cancereux, Paris, 1750. Pouteau, (Euvres Posthumes, t. I.) Two remarkable instances of this kind have been published by Mr. Salter, of Poole. In the Bret, the patient, a female, aged 82, felt the right thigh suddenly break as she was standing at her drawers hor several months previous to the accident, she had had constant and very severe pain in the part of the bone which was broken, and she had bees long afflicted with a ranceroua ulceration sf the mamma. After death, the bone was so flexible, that no bony union could have taken place A rg-nlar dissection of the limb was not a lowed. In Mr. Salter's second case, the patient was also a female, 56 years of age, and for five months pre- ceiling the accident had laboured under violent pain of the right thigh, and a thickening of the periosteum a little above ihe patella. As her friends were puttine her Into a cart, the bone snapped about three inches below the trochanter. For several years she had a seirrhus of tbe left breast. This had been removed and the wound healed, but afterward broke out in the form of cancerous ulceration. In this stage the frac- Vol. I.—D d FRA 417 ture took place, and Was followed in about three months by her death. Mr. Salter removed the thigh-bone, and brought it home for examination; but, previously to its removal, the affected limb was observed to be consider- ably shorter than the other, and flexible at its middle, and a good deal deformed by a projection just below the trochanter major. The muscles of tne thigh were pale and shrunk; a bloody fluid escaped firom the capsular ligament of the knee-joint, and two or three clots of pure blood were in the articular cavity. On removing the patella, a smail ulcer was discovered in the upper and external part ofthe articular surface of the bone. Among other particulars, it is stated that the thigh-bone was remarkably soft throughout its whole length, and Ihe knife could be pushed through it at any part; but at its middle it was most conspicuously deficient in earthy matter. At about three inches from either ex- tremity, it could be bent in any direction; and it was on the upper part of this portion that the fracture had taken place, but tbe precise situation of it was not dis- tinctly visible; and Mr. Salter conceives, that there had been no complete separation Uke what occurs to common fractures. The distortion did not arise from any over- lapping, but from a bending of the bone. The muscles about the upper part of the limb were confounded toge- ther into a uniform mass of a pale red colour, firm and cartilaginous, with bony spicule thickly dispersed through them, and puriform matter slightly tinged with blood issuing from the cut surfaces. The integuments had suffered no change. In the situation of the swell' ing noticed above the patella, the tendon ofthe cruraiia was much thickened and altered in texture, and a con- siderable quantity of pus came from under it; the sub- jacent periosteum was also much thickened, and readily detached. The parietes of the bone were here nearly absorbed, and the medullary cavity was filled with a bloody pultaceous substance.—(See Med. Chir. Treat*. vol. 15, p. 186.) It is justly inferred by Mr. Salter, that as these cases corresponded in so many points, the predisposing cause of fracture was probably the same in both. Both the patients laboured under cancer of the breast, and both suffered much from previous pain and lameness. These cases, it is to be remarked, were rather specimens of mollities ossium, or preternatural flexibility of the bones affected, and seem to have dif- fered from some examples of fragiUty on record, not only in their cause, but in the circumstance of no at- tempt at ossification having taken place in the broken or flexible parts. They resemble, in some respects, Mr. Howship's case; yet differ in the affection being re- stricted to one bone, and being the sequel of a cancerous disease of the breast. Louis mentions a nnn who broke her arm by merely leaning on a servant; and in the London Medical Journal an account is given of a person who could not even turn in bed without breaking some of his bones. One of Professor Gibson's patient's, residing near Trenton, in the United States, has a son 19 years of age, who from infancy 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 while walking across the room. Tie clavicles have suffered more than anv other bone, having been fractured eight times. What is remark- able, the hoy has always enjoyed excellent health, and the bones have united without difficulty or much deformity.—(Institutes, i-c. of Surgery, vol. l,p.370.) Similar cases are mentioned by Mr. B. Bell. A child, he observes, fractures a limb. The fracture unites, and is consohdated perhaps in less than the usual pe- riod. Some time afterward, on lifting a moderate weight, or on giving the limb a slight twist, it is again broken, and again unites. Mr. Bell saw this occur three times in different parts of the right humerus of a child five years of age, within the short period of eighteen months. " Several similar cases," he says, " have been under my care; in all of them, the patients seemed to enjoy robust health, were apparently un- tainted by scrofula, and their fragile bones united in a shorter space of time than I have generally observed to be the casein individuals whose bones were tougher." —{On Diseases of Bones, p. 71.) The same author has keen able to discern in only two cases of fragility a pal- pable deviation from the healthy structure of the bones affected. The subject of one case was a gentleman at 418 FUN FUN the middle period of life, who fractured his humerus in unscrewing a music-stool. The fracture was commi- nuted and did not unite. The arm was at length am- putated, by Mr. George Bell, at the shoulder On ex- amining the limb, the muscles around the fractured bone were found in a pulpy state The bone sur- rounded with blood partly fluid and partly coagulated, was almost friable, and its whole surface perforated by innumerable small, irregularly shaped holes, giving it a reticulated appearance.—(Op. cit. p. 72.) In the latter stages of syphtiis, the bones are alleged to be sometimes remarkably brittle.—(Ephem. Nat. Cur. dec. 1, ann. 3, obs. 112. Walther, Museum Anat. t. 2, p. 29.) In bad cases of scurvy, the bones occasionally become so brittle, that they are broken by the slightest cause, and do not grow together again.—(Boettcher von den Krankh. der Knochen, p. 68.) Dr. Good was once present at a church, in which a lady, nearly seventy years old, broke both the thigh- bones in merely kneeling down; and on being taken hold of to be carried away, had an os humeri also broken, without any violence, and with little pain. Hardly any constitutional disturbance ensued, and in a few weeks the bones united.—(Study of Medicine, vol. 6, p. 332, ed. 3.) The fragilitas ossium of old age is incurable; but in children the tendency depends on some other constitu- tional disease, and can only be cured by a removal of the latter.—(See Boyer on Diseases of the * Bones, vol. 3.) This author, in one of his last'works, expresses his opinion that the doctrine of mollities and fragilitas os- sium being distinct and different diseases, is by no means sufficiently proved by a due number of accurate observations.—(Traiti des Mai. Chir. t. 3, p. 607, 608.) Consult Waldschmidt, Dis. tie Fracturd Ossium sine Causa violentd externa, Kilon. 1721. Acrel, Chir. Vorfctlle, b. 2, p. 136. Courtial, Nouvelles Obs. Anat. sur les Os, p. 64, 12/no. Paris, 1705. Marcellus Dona- tus, lib. 5, c. 1, p. 528. Walther, Museum Anat. vol. 2, p. 29. Schmucker, Vermischte Schriften, b. 1, p. 385. Kentish, in Edin. Med. Comment, vol. 1. Hist. de PAcad. des Sciences, 1765, p. 65. Hist, de la Soc Royale de Midecine, 1777 and 1778, p. 224. Journ. de Mid. t. 77, p. 267; U 84, p. 216. Isenflamm, Pract. Bemerk. iiber Knochen, p. 368. 415. 466. Fabricius HUdanus, cent. 2, obs. 66, 67, 68; cent. 5, obs. 89. VAubenton, Description du Cabinet du Roi, t. 3. Ossa Ventre sponte fracta. Meckren, Obs. Med. Chir. p. 341. Amst. 1682. Weidmann de Necrosi Ossium, p. 2. Francofurti, 1793; and the writings of Duverney, Petit, and Pringle. Gooch's Obs. Auoendix. J. Wil- son on tlie Skeleton, ic. p. 258,8vo. Lond. 1820. Gib- ton's Institutes of Surgery, vol. 1, p. 370; and vol. 2, p. 70, Philadelphia, 1825. B. Bell on Diseases of the Bones, p. 71, Edin. 1828. Salter, in Med. Chir. Trans. vol. 15. Howship, in Edin. Med. Chir. Trans, vol. 2. FUNGUS. Any sponge-like excrescence. Granula- tions.are often called fungous when they are too high, large* flabby, and unhealthy. FUNGUS NEMATODES. (From fungus, and alpa, blood.) The Bleeding Fungus. Spongoid In- flammation. Soft Cancer. Carcinome Sanglante. Medullary Sarcoma. , This disease, whioh has been accurately described only of late years, was formerly generally confounded with cancer. Tbe public are indebted to Mr. J. Bums, of Glasgow, for the first good account of it; and the sub- sequent writings of Mr. Hey, of Leeds, Mr. Freer, of Birmingham, Mr. J. Wardrop, Mr. Langstaff, and others, have made us stUl better acquainted with the subject. It is unquestionably one of the most alarming dis- eases incidental to the human body, because we know of no specific remedy for it; and an operation can only be useful at a time when it is very difficult to persuade u patient to submit to it- Indeed, when the diseased part is extirpated at an early period, a recovery hardly ever follows; for ex- perience proves that it is not a disease of a local nature, but almost always extends to a variety of organs and structures at the same time, either to the brain, the liver, or lungs, Sec. It is of the utmost consequence to be aware of this fact, since we should otherwise be in- duced to attempt many hopeless operations, and deliver a prognosis that might c&use disappointment and cen- sure. In a large proportion of patients, afflicted with ftingus hsematodes, the general disorder of the system is indicated by a peculiarly unhealthy aspect; a sallow, greenish-yellow colour of the skin, which is frequently covered with clammy perspiration; constant trouble- some cough; difficulty of breathing, &c. Fungus Hamatodes is the name used by Mr. Hey. Mr. J. Bums has called the disease spongoid inflam- mation, from the spongy elastic feel which peculiarly characterizes it, and which continues even after ulcera- tion takes place. Fung us hematodes has most frequently been seen to attack the eyeball, the upper and lower ex- tremities, the testicle, and the mamma. But the uterus, ovary, liver, spleen, brain, lungs, thyroid gland, hip, and shoulder-joints, have also been the seat of the dis- ease. A distemper which presents itself in so manj parts must be subject to variety to its appearances. FUNGUS H.EMATODES OF THE EVE. 1. When it attacks the eye, the first symptoms are observable in the posterior chamber, an appearance like that of polished iron presenting itself at the bottom of the eye.—(Scarpa, on Diseases of the Eye, p. 505, ed. 2.) The pupil becomes dilated and immoveable, and instead of having its natural deep black colour, it is of a dark amber, and sometimes of a greenish hue. The change of colour becomes gradually more and more remarkable, and at length is discovered to be oc- casioned by a solid substance, which proceeds from the bottom of the eye towards the comea. The surface of this substance is generally rugged and unequal, and ramifications of the central artery of the retina may sometimes be seen running across it. The front sur- face of the new mass at length advances as far for wards as the iris, and the amber or brown appearance of the pupil, has, in this stage, been known to mislead surgeons into the supposition of there being a cataract, and makes them actually attempt couching. The dis- ease continuing to increase, the eyeball loses its natu- ral figure, and assumes an irregular knobby appearance. The sclerotica also loses its white colour, and becomes of a dark blue or livid hue. Sometimes matter now collects between tbe tumour and the cornea. The latter membrane in time ulcerates, and the ftingus shoots out. In a few instances, it makes its way through the scle- rotica, and is then covered by the conjunctiva. The surface of the excrescence is irregular, often covered with coagulated blood, and bleeds profusely from slight causes. When the fungus is very large, the most pro- minent parts slough away, attended with a fetid sani- ous discharge. In the course of the disease, Ihe absorb- ent glands, under the jaw, and about the parotid gland become contaftiinated. On dissection, a diseased mass is found extending forwards from the entrance of the optic nerve, the vitreous, crystalline, and aqueous hu- mours being absorbed. The retina is annihilated, and the choroid coat propelled forwards, or quite de- stroyed. The tumour seems to consist of a sort of medullary matter, resembling brain. The optic nerve is thicker and harder than natural, of a brownish ash- colour, and destitute of its usual tubular appear ance. In other cases, the nerve is split into two or more pieces, the interspaces being filled up with the morbid growth.—(Wardrop.) Nay, as Mr. Travers has stated, the optic ganglion, tractus opticus, and thalamus have been repeatedly found diseased, and the surround- ing adipose substance in the orbit affected to a consi- derable extent in places also where there was no direct communication with the diseased contents of the globe. —(Synopsis of the Diseases ofthe Eye, p. 221.) Even the brain has been observed to share in the disease, sometimes dark red spots appearing on the dura mater; sometimes small spots, containing a fluid Uke cream, being found between the pia mater and tunica arach- noides. Mr. Travers has a preparation, exhibiting a genuine example of the disease affecting the anterior right lobe of the cerebrum, and protruding the eye from its socket, while the eye itself was perfectly free from disease.—(Op. cit. p. 223.) When the lymphatic glands at the angle of the jaw are enlarged, an they frequently are, they are also found converted into a kind of medul- lary matter, similar to that which composes tlie dis- eased mass in the eyeball. When the skin bursts over a diseased absorbent gland, a sloughy ulcer is produced; but no fungus is emitted, unless the affection of the gland with fungus hsematodes be primary, fungus haematodee of the eye has been erroneously regarded FUNGUti. 419 *» eanrer by tho best writers. We learn from Bichat, Mint more than one-third of the patients on whom De- sault operated for supposed carcinoma of the eye were Under twelve years of age. Twenty out of twenty-four cases of fungus haematodes of the eye, with which Mr. VV.irdrop has been acquainted, happened to children under twelve years of age. Now, as cancer is rather a disease of aged than young persons, and we find from Mr. Wardrop, that fungus hsematodes of the eye mostly affects persons under twelve years of age, it is tolerably certain that most of Desault's cases, reported to be can- eers of the eye, were in fact the equally terrible disease now engaging our consideration. According to Mr. Travers, the only parts of the eye and its appendages subject to be primarily attacked by cancer are the la- chrymal gland, conjunctiva, and eyelids; while the evi- dence of many cases has assured him, that ftingus htematodes may originate in any texture of the eye, with the exception of the lens and comea.—(Synopsis of the Diseases ofthe Eye,p. 216. 222. and 421.) This account, however, differs from that delivered by.Mr. Wardrop and Professor Scarpa, who describe the dis- ease as first commencing in the retina, and particularly at the point where the optic nerve enters the eye. " For (says the latter author), on the first appearance of the yellowish or greenish spot, the retina, on examination, is found to be entirely deficient, or, in other words, to have degenerated into the malignant fungus. It is also found, that the choroid membrane, while the fungus haematodes is in its incipient state, does not appear to have suffered any remarkable alteration in its texture, and that it is only at a more advanced period of the dis- ease that this membrane becomes thickened and se- parated from its connexion with the sclerotica. The choroid membrane, even in the most advanced stage of the disorder, preserves, more than aU others, its natu- ral texture."—(On the Principal Diseases of the Eye, p. 507, ed. 2.) In cases of fungus haematodes, the sight of young subjects is generally destroyed before the attention of parents is excited to the distemper. Frequently, however, a blow, followed by ophthalmy, precedes the growth of the diseased mass. When no external violence has occurred, the first symptom is a trivial fulness of the vessels of the conjunctiva, the iris becoming, at the same tune, extremely vascular, and altered in colour, aud the pupil dUated and immoveable. There is seldom much complaint made of pain; but the child is sometimes observed to be languid and fe- verish. In adults, ftingus haematodes of the eye ge- nerally comes on without any apparent cause, though sometimes in consequence of a blow. At first, the tu- nica conjunctiva is slightly reddened, and vision indis- tinct. The redness and obscurity of sight increases ■lowly, and an agonizing nocturnal headache is ex- perienced ; the eye bursts, and the humours are dis- charged. With regard to the cure of the fungus haematodes of the eye, the only chance of effecting this desirable ob- ject depends upon the early extirpation of the diseased organ. It must be acknowledged, however, that most of the operations, in which the morbid eye has been re- moved, have hitherto proved unsuccessful, owing to a recurrence of the disease. The reason of such Ul suc- cess may be imputed to the optic nerve and other parts being almost always in a morbid state, before an at- tempt is made to remove the eye. One case, however, described by Mr. Travers. as having its seat in the cel- lular texture connecting the conjunctiva to tbe cornea, was operated upon, and no recurrence of the disease had occurred a twelvemonth afterward. No other tex- ture was affected more than the contiguity and extent ofthe disease explained.—(Synopsis ofthe Diseases of the Eye, p. 413.) The most successful extirpation of an eye in an advanced stage of this disease, and, perhaps, tiie only satisfactory one at present on record, is that which was performed by Mr. Wishart, the cure conti- nuing complete eighteen months after the operation.— tsen Edin. Med. Journ. vol. 19, p. 51.) The operation has nearly always been found to fltil when the disease s advanced so far that the posterior chamber is filled jy the fungous mass. With the very few exceptions which there are to this statement, it may be correctly said, that, as no internal medicines nor external appli- cations afford the least hope of checking any form of the fungus hajmatodes, it is manifest, that when the distcmi>cr of the eye exceeds certain bounds, the mise- rable patient is placed beyond the reach of any effectual aid from surgery. In a case which I saw in April, 1821, in the London Eye Infirmary, the disease formed a diseased mass as large as an orange, accompanied with enlarged lymphatic glands over the parotid. The patient was an infont. In this instance, Mr. Lawrence used, as a local application, the Uquor opu sedativus, prepared by Mr. Battley, which was found to lessen considerably the child's sufferings.—(See particularly Wardrop's Obs. on Fungus Hamatodes. Scarpa, On the Principal Diseases of the Eye, chap. 21. Some Cases in Saunders's Treatise on Diseases of tlie Eye; and B. Travers's Synopsis of the Diseases of ihe Eye, Svo. Lond. 1820.) FUNGUS BJEMATODES OF THE LIMBS. 2. In the extremities, the disease begins with a small colourless tumour, which is soft and elastic, if there be no thick covering over it, such as a fascia; but other- wise it is tense. At first, it is free from uneasiness; but by degrees a severe acute pain darts occasionally through it more and more frequently, and at length be- comes incessant. For a considerable the tumour is smooth and even; but afterward it projects irregularly at one or more points ;• and the skin at these places be- comes of a livid red colour, and feels thinner. In this situation it easily yields to pressure, but instantly bounds up again. Small openings now form in these projections, through which is discharged a thin bloody matter. Almost immediately after these tumours burst, a small fungus protrudes like a papilla, and this rapidly increases both to breadth and height, and has exactly the appearance of a carcinomatous ftingus, and frequently bleeds profusely. The matter is thin, and exceedingly fetid, and the pain becomes of the smarting kind. The integuments, for a little way round these ulcers, are red and tender. After ulceration takes place, the neigbouring glands swell, and assume exactly the spongy qualities of the primary tumour. If the patient still survive the disease in its present advanced pro- gress, similar tumours form in other parts of the body, and the patient dies hectic. After death or amputation the tumour is found to consist of a soft substance, somewhat like the brain, of a grayish colour, and greasy appearance, with thin membrane-like divisions running through it, and ceUs or abscesses in different places, containing a thin bloody matter, occasionally in very considerable quan- tity. There does not seem uniformly to be any entire cyst surrounding the tumour; for it very.frequently dives down between the muscles, or down to the bone, to which it often appears to adhere. The neighbouring muscles are of a pale colour, and lose their fibrous ap- pearance, becoming more like liver than muscle. The bones are always carious in the vicinity of the disease. The distemper is sometimes caused by external vio- lence, though in general there is no evident cause whatever.—(Dissertations on Inflammation, by J. Burns, vol. 2.) Mr. Hey has given several cases of the fungus hae- matodes. If I notice the most particular circumstances relative to one of these, it will suffice to inform the reader of the form in. which this terrible affliction has presented itself in this gentleman's practice. A young man, aged twenty-one, two years before ap- plying to Mr. Hey, perceived a small swelling on the inside of the right knee, not far from the patella. This tumour was moveable, and did not impede the motion of the joint: it was not discoloured, but was painftil when moved or pressed upon. It continued to this state half a year, and then, the man having hurt his knee against a stone, it gradually increased in bulk, but did not exceed the size of an egg. The skin was now discoloured with blue specks, which were taken to be veins. He could sttil walk with ease, and follow his business. Two months before his admission into the Leeds In- firmary he met with a fall, and violently bent his knee, but did not strike it against any thing. Tlie tumour began immediately to enlarge ; and, within a few hours, it extended half way up the inside of the thigh. About a fortnight after this accident the skin burst at the lowest part of the tumour, and discharged some blood. A dark-coloured ftingus, about the size of a pigeon's egg, here made its appearance, and a few weeks after- ward the skin burst at another part of the large tumour, and some blood was again discharged. From the fis- sure arose another fungus, which had increased in the 420 FUNGUS. course of the last week to the size of a small melon, and now measured eight inches from one side of its base to the other. Tbe base of the ftingus frequently bled especially when the man allowed his Umb to hang down.' The whole tumour was now of an enormous size, being nineteen inches across, when the measure was carried over the last-mentioned ftingus. From its high- est part to the thigh to the lowKt part, just below the kuee, it measured seventeen inches, without including the fungus. The base tt the tumour at the knee, ex- clusive of that part which ran up the thigh, measured twenty-four iiiches in circumference. The tumour was situated on the inner side of the limb, and was dis- tinctly defined. The skin covering the disease was in some places livid, and had several fissures and smaU ulcerations upon it; but had not burst asunder, except in the two places above described. The tumour was soft, and gave a sensation of some contained fluid, when gently pressed with the hands alternately in opposite directions. The patient said he had walked without pain in his knee a week before his admission into the Infirmary; and he had lost very little blood in his journey to Leeds. He complained of tho greatest uneasiness to the highest part of the tumour. It had become hot and painful in the night-time for some days past. His poise was 114 to a minute, his tongue was clean, and his appetite had been good till the last few days. He kad never felt any pulsation in the tumour. In a consultation it was determined, that the tumour should be laid open, by cutting off a portion of the dis- tended integuments; and that, after removing the con- tents, if the sac should be found in a sound state, the disease should be treated as a simple wound; but if to a morbid state, amputation ofthe limb should be imme- diately performed. A large oval piece of.the integuments being removed, Ihe ;tumour was found to contain a very large quantity of a substance not much unlike coagulated blood; but more nearly resembting the medullary part of the brain in its consistence and oily nature. It was of a varie- gated reddish colour, in some parts approaching to white, and, as blood issued from it, Mr. Hey conceived it was organized. This mass was partly diffused through the circumjacent parts to innumerable pouches, to which it adhered, and was partly contained in a large sac of an aponeurotic texture, which was coifhected with the capsule of the knee-joint. There was a great and universal effusion of blood from the internal sur- face of the sac, and from the pouches containing this morbid mass. Amputation of the Umb was immediately performed, on finding such to be the nature of the case. Mr. Hey unfortunately, however, left a portion of the diseased surface behind on the inner part of the thigh, and hoping ihat a small narrow portion of the upper part of the Bac would soon become a clean sore, and not impede the cure, he made the circular incision two inches be- low its higher part. On examining the amputated limb, the vastus inter- nus was found to be brown, and much softer than the other muscles, which were healthy. There were many Bmall portions of blood extravasated in the substance of this muscle. The sac was formed on the aponeu- rotic covering of the muscle, and ended below where this aponeurosis begins to cover the capsular ligament •f the knee. The two fungous substances above de- scribed appeared to have been only extensions of the morbid mass, where this had made its way through the sac and the integuments. The joint of the knee and muscles of the leg were perfectly sound. I need not detail all the particulars after the opera- tion. Suffice il to say, the man suffered a good deal of constitutional disorder. After a few weeks, the granu- lations upon the stump became good, and the cicatriza- tion was nearly completed at the end of the sixth week after the amputation. At this period, the small and su- perficial portion of the upper part of the great sac, which Mr. Hey had unfortunately left, was now healed; but a tumour now about four inches in length, and be- twet n two and three in breadth, had graduaUy risen at the lower and under part of the thigh beneath the cica- trix This contained a soft substance, exactly similar, : far as the touch could discover, to that which had fi'ded the large sac. This tumour became painful, and sometimes discharged a bloody sertm, sometime* dark- co'oured blood, through four or live small openings in the cicatrix. Mr. Hey laid open Ihe tumour, and removed its con« tents; but no advantage was gained by this proceeding. The interior surface was found to be too much diseased to produce good granulations. Blood continued to ooze out of the wound for a few days. Then the inner sur- face became covered with a blackish substance, which gradually extended itself, and formed a new ftingus. A variety of escharotics were applied to destroy the fan- gous and morbid surface of the wound, but to no pur- pose; the growth of the fungus always exceeded the quantity destroyed. Undiluted oU of vitriol appUed freely had very little effect. An attempt was once more made to cut away the dis- ease; but on examining the wound carefully, after the contained substance was removed, the muscular sub- stance was found degenerated into a hard mass, which fell somewhat Uke cartilage. The adipose membrane was also diseased, and formed into large cells, which had contained the fungous substance. Hence, another amputation seemed the only resource. Af\er this operation, the whole surface of the stump seemed sound, except the principal artery, which was filled with a somewhat stiff matter, resembUng coagu- lated blood, which prevented its bleeding. The inside of tbe vessel, ou being touched with the scalpel, fell hard, and communicated a sensation like that of scrap- ing bone. The man was sent home as soon as his state would admit of it; but he died consumptive about six months afterward. Besides this instance in tbe thigh, Mr. Hey relates cases of fungus hsematodes situated in Ihe fe- male breast, in the leg, in the neck (extending from the jaw to the clavicle, and producing suffocation), on the back part of the neck, on the back part of tbe shoulder, and at the extremity of the forearm, near the wrist. " If I do not mistake (says Mr. Hey), this disease not unfrequently affects the globe of the eye, causing an enlargement of it, with the destruction of its inter- nal organization. If the eye is not extirpated, the scle- rotis bursts at tbe last, a bloody sanious matter is dis- charged, and the patient sinks under the complaint."— (P. 283.) Besides some cases in similar situations to those mentioned by Mr. Hey, one is related by Mr. Burns, in which the hip-joint was the seal of this terrible affec- tion. After detailing the progress of the case to the poor man's death, tlus author states, that he found, on dissection, tbe hip-joint completely surrounded with a soft matter, resembUng the brain, enclosed in thin cells, and here and there cells full of thin bloody wa- ter : the head of the thigh-bone was quite carious, aa was also the acetabulum. The muscles were very pale, and almost like boiled liver, having completely lost their fibrous appearance and muscular properties. The same sort of morbid mischief was also found within the pelvis, most of the inside of the bones on the affected side being carious. An attempt had been made, before the patient died, to tap the bladder; bat the trocar had only entered a cell filled with bloody wa- ter, and situated in a mass of the soft brain-tike sub- stance. I have already said enough to render the description of the dreadful nature of the ftingus nematodes tole- rably complete. Little can be said of the treatment; for we know not of one medicine that seems to have tbe least power of putting a stop to the disease, and, with the exception of a case under Mr. Cline, where the breast healed op after the diseased mass had been thrown off by sloughing (Lancet, vol. 2, p. 401), we have no reason to believe that there is ever the small- est chance of any spontaneous amendment, much less of such a cure. Also, in the case just now cited, it is not known whether any relapse followed. We have seen that:when the chief part of a fungus haeqiatodes is cut away, and only a small portion of its cyst left behind, the fungus is reproduced from ibis part, and soon becomes as formidable, nay, more for- midable than it was before, and this notwithstanding the application of the most powerful escharotics. Nei- ther the hydrargyrus nit rat us ruber, the hydrargyria muriatus, the antimonium muriatum, nor the undi- luted vitriolic acid, has always been able to repress the growth of such fungus.—(Hey.) No known remedy has the power of checking or re- moving the complaint. Friction, with anodyne bal- sams, sometimes gives relief in the early stages; but it does not retard the progress of tin disease. FUNGUS. 421 In short, the only chance of cure consists in extirpa- ting the whole of the distempered parts, removing not only the soft, brain-like, fungous substance, but every part of the cysts, sacs, or pouches to which it may be contained. An operation or this kind, however, is only advisable in the early stages, while the disease is en- tirely locaL if it ever be so, a circumstance much to be doubted; for, after the neighbouring glands have be- come affected, the chance of recovery is almost de- stroyed. It is sometimes difficult, however, to per- suade patients at an early period to submit to amputa- tion or extirpation, because the pain and inconveni- ences are inconsiderable; but the operation should be urged with all the force which a conviction of its ab- solute necessity and the fatal perU of delay ought to inspire. The attempts to cure the disease by cutting it away, have been attended writh such Ul success that some sur- geons deem it advisable not to follow this method, but amputate the limb at once. The annexed views ofthe matter appear to me to be most judicious and rational. First, that if an attempt be made to cut away the tu- mour and save the limb, the surgeon must be careful to remove at the same time a considerable quantity of the soft parts in the circumference of the swelling. Secondly, that the earlier this is done the more likely is it to succeed. Thirdly, that after the tumour is taken out, an attentive examination of the surface of the wound should be made, and every suspicious part or fibre be cut away. Fourthly, that should the disease still recur, amputation ought to be instantly performed. Fifthly, that caustics should never be applied to this disease. Sixthly, that even when one of these opera- tions effectually extirpates the distemper of the limb, the patient's entire recovery is always rendered exceed- ingly uncertain by reason of the viscera and other in- visible parts being frequently affected, at the time of the operation, with the same sort of disease. FUNGUS HAMATODES Of THE TESTICLE. 3. Fungus haematodes of-the testicle sometimes be- gins in its glandular part, sometimes in the epididymis. Its progress is slow, and the pain generally not se- vere. Nor is there at first any inequality or hardness of the diseased part, nor change in the scrotum. When the testicle has become exceedingly large, it feels re- markably soft and elastic, as if it contained a fluid. Hence, the case has often been mistaken for a hydro- cele, and punctured with a trocar.—(Wardrop; Earle, in Med. Chir. Trans, vol. 3, p. 60.) Occasionally, when the tumour is large, it is in some places hard, in others soft. The hydrocele may be known by the wa- ter beginning to collect at the bottom of the scrotum, and then ascending towards the spermatic cord, and by the swelling being circumscribed towards the abdo- minal ring; whereas, the ftingus haematodes begins with a gradual enlargement of the testicle itself, fol- lowed by a fulness which extends up the spermatic cord. It is not in the slightest degree diaphanous, and is much heavier than a simUar bulk of water.—(Earle, op. cit.) As the disease advances, abscesses form, and the scrotum ulcerates, but no ftingus shoots out. When the inguinal glands become contaminated, they often ac- quire an immense size; and as soon as the skin over them bursts, large portions of them slougb away. I Fungus nematodes of the testicle is said to afflict young I more frequently than old subjects. On dissection, the substance of the diseased testicle is found to present a medullary or pulpy appearance, generally of a pale brownish colour, though sometimes red. In most cases the tunica vaginalis and tunica albuginea are adherent together; occasionally there is fluid between them. In an example dissected by Mr. Lawrence, the swell- ing of the testicle consisted of cellular septa filled with pulpy matter. Numerous tubercles of the disease were found in the omentum, and about the pelvis, in- termixed writh recently effused coagula. A mass of soft matter, equal in size to a man's head, lay on the spine behind the aorta and vena cava, which last ves- sel was closed for some extent. The spermatic vessels could not be found.—(Sea Med. Chir. Trans, vol. 8 part 1, art. 13.) The only chance of a cure must be derived flrom a very early performance of castration, before the dis- ease has extended to the inguinal glands, or for up the spermatic cord Indeed, very Uttle hope should be placed to the removal ofthe testicle; for fungus haema- todes appears to be rather a constitutional than a local disease. Nearly every case on record has terminated fatally, and upon dissection either the liver, the lungs, the brain, the mesenteric glands, or other internal parts, have been found affected with the same disease. In one case dissected by Mr. Lawrence, tubercles of a similar structure to the disease in the axilla were found to the lungs, heart, and, in short, in nearly all the tho- racic and abdominal viscera, though the conteuts ofthe skull were free from disease.—(See Cases recorded by Wardrop, Earle, Lawrence, and Langstaff', in Med. Chir. Trans, vol. 3 and 8.) Whe shall quit this subject with stating some of the principal differences between two diseases which have been commonly confounded. A scirrhous tumour is, from its commencement, hard, firm, and incompressi- ble, and is composed of two substances; one hard- ened and fibrous, the other soft and inorganic. The fibrous matter is the most abundant, consisting of septa, which are paler than the soft substance between them. A scirrhous tumour, situated in the gland i's not capable of being separated from the latter part, so much are the two structures blended. A seirrhus in another situation sometimes condenses the surrounding cellu- lar substance, so as to form a kind of capsule, and as- sume a circumscribed appearance. When a scirrhous swelling ulcerates, a thin ichor is discharged, and a good deal of the hard fibrous substance is destroyed by the ulceration; other parts become affected, and the patient dies from the increased ravages of the disease, and its irritation on the constitution. Sometimes, though not always, after a seirrhus has ulcerated, it emits a ftingus of a very hard texture. Such excres-- ■cence, however, is at last destroyed by the ulceration. Cancerous sores, also, frequently put on for a short time, in some places, an appearance of cicatrization. On the other hand, the fungus haematodes, while of moderate size, is a soft elastic swelling, with an equal surface, and a deceitful feel of fluctuation. It is in ge- neral quite circumscribed, being included within a capsule. The substance of the tumour, instead of be- ing for the most part hard, consists of a soft, pulpy, medullary matter, which readily mixes with water. When ulceration occurs, the tumour is not lessened by this process, as in seirrhus; but a fungus is emit- ted, and the whole swelling grows with increased ra- pidity. Cancerous diseases are mostly met with in persons of advanced age, while fungus haematodes generally afflicts young subjects.—(Wardrop.) Many dissections have now proved, that the substance of fungus haematodes may contain cellular septa, which include the pulpy medullar)- matter. Fungus haematodes, to its early stage, is generally attended with less acute pain than what is experienced in cases of seirrhus. The tumour also has a less de- finite boundary than a seirrhus, and it is more diffi- cult to say where the diseased structure terminates, and where the healthy commences. When the disease is in the breast, there is less tendency than to scirrhous cases to disease in the axUlary glands, which may re- main sound though the disorder to the breast may have advanced to suppuration and ulceration. In the breast the disease is also much quicker in its progress than seirrhus.—(A. Cooper, Lancet, vol. 2, p. 399.) In cases of external cancer, the viscera are not in ge- neral affected at the same time with cancerous disease; but in the majority of examples of fungus haematodes, this distemper is found affecting in the same subject a variety of parts. In addition to the outward tumour, we find swellings of a similar nature, perhaps, in the liver, the lungs, the mesenteric glands, or even in the brain. Yet M. Roux wtil have it, that cancer and ftin- gus haematodes are the same disease; or at least that the latter is only a species of the former, and that to both cases the same peculiar diathesis prevails.—(Roux, Parallile de la Chirurgie Angloise avec la Chirurgie Francoise, p. 216, 217.) See Dissertations on Inflammation, by J. Burns, vol. 2. Hey's Practical Observations in Surgery, ed. 3. Freer on Aneurism. Observations on Fungus Hama- todes, or Soft Cancer, by James Wardrop, Svo. Edin. 1809. ThisJ-ast publication is highly deserving of the attention of the surgical practitioner, the disease t» different organs being well described, and its character discriminated from that of cancer. A case of this disease is related in vol. 5 ofthe Lou- 422 GAN don Medical Journal. It was the consequence of an attempt to cure a ganglion by means of a seton, and it proved fatal A case is also related by Mr. Abernethy, m Surgical Observations, 1804, p. 99. See also a Case of Diseased Testicle, accompanied with Disease ofthe Lungs and- Brain, by H, Earle, in Medico-Chirurg Trans, vol. 3, p. 59, i-c. in which vol. four other cases are recorded by Mr. Lawrence, p. 71, et seq., and one by Mr. Langstaff, p. 277; which last I remember to have visited in company with this gentleman and Mr. Lawrence, a short time before the patient died. See also Langstaffs Cases and Observations in the Sth and 9th vols, of the same work. Voyage fait a Lon- dres en. 1814; ou ParalUU.de la Chirurgie Angloise avec la Chirurgie Francoise, p. 211, i-c. On Fungus Hamatodes of tlie Eye there are some valuable obser- vations in the last edition of Scarpa's Treatise on -the Diseases of that organ. See also Saunders on Dis- eases of the Eye, and B. Traver^s Synopsis of Dis- eases of the Eye, 8vo. Land. 1820. G. Frick on Dis- eases of the Eye, p. 287, ed. by Welbank, 8vo. Lond. 1836. Respecting medullary sarcoma, which is generally considered as the same affection as ftingus hsematodes, some farther observations will be delivered in the arti- ele Tumours. FURUNCULUS. (From furo, to rage.) A bile, so named from the violence of the heat and inflammation attending it. A bile is a circumscribed, very prominent, hard, deep- red, inflammatory swelling, which is exceedingly pain- ful, and commonly terminates in a slow and imperfect suppuration. The figure of the tumour is generaUy that of a cone, the base of which is considerably below the surface. Upon the most elevated point of the bile there is usually a whitish or livid pustule, which is exquisitely sensible, and immediately beneath this is the seat of the abscess. The matter is mostly slow in forming, is seldom very abundant, and never healthy at first, being always blended with blood. The com- plaint is seldom attended with fever, except when the tumour is very large, situated on a sensible part, or when several of these swellings occur at the same time in different places. In the last circumstance they often occasion in children, and even in irritable adults, restlessness, loss of appetite, spasms, &c. They rarely exceed a pigeon's egg in size, and they may originate on any part of the body. Biles commonly arise from constitutional causes. Young persons, and especially subjects of foil plethoric habits, are most subject to them. The disease is also observed to occur writh most frequency in the spring.— (Lassus, Pathologie Chir. t. 1, p. 16.) According to Richerand, the origin of biles depends upon a disordered state of the gastric organs.—(Nosographie Chir. t. 1, p. 124, idit. 2.) Frequently they arise without any evident cause, and apparently in healthy constitutions At other times they follow eruptive diseases and typhus. —(W. Gibson, Institutes, i-c. of Surgery, p. 48, vol. 1.) The suppuration attending a bUe is never perfect, and the matter which forms is not only tinged with blood, but surrounded with a sloughy substanoe, which must generally be discharged before the part affected will suppurate kindly, and the disease end. Richter compares the slough to a kind of bag or cyst, and the whole bile to an inflamed encysted tumour. The best plan is mostly to endeavour to make bUes suppurate as freely as possible by applying external emollient remedies. This seems to be the natural course of the disease in its progress to a cure, and, in- deed, all endeavours to disperse furunculous tumours GAN commonly fail, or succeed very imperfectly ; only r«- inoviug the inflammation, and leaving behind an indo- lent hardness; which occasions various inconveniences, according to its situation, every now and then inflames anew, and never entirely disappears until a free suppu- ration has been established. In a very few cases, perhaps, it may be proper to try to resolve biles. For this purpose, besides bleeding, gentle evacuations, and a low diet, which are requisite in this as well as other local inflammations, some prescribe as external appUcations honey strongly aci- dulated with sulphuric acid, alcohol, or camphorated oil. But in the generality of instances suppuration must be promoted by the use of emollient poultices. Tlie tumour, when allowed to burst, generally does so at its apex. However, as the opening is generally long in forming, and too small to allow the sloughy cellular substance to be discharged, it is always best, as soon as matter is known to exist to the tumour, to make a free opening with a lancet, and immediately afterward to press out as much of the matter and sloughs as can be prudently done. This having been accomplished, and the rest of the sloughs pressed out as soon as it is practicable, healthy pus will be secreted, and the part will granulate and heal. Until the suppuration becomes of the healthy kind, and the sloughy substances are en- tirely discharged, an emollient Unseed poultice is the best application; and when granulations begin to fill up the cavity, plain lint and a simple pledget are tho only dressings necessary. For the purpose of stimulating the cavity, and caus- ing it to fill up, Professor Gibson, of PhUadelphia, has sofnetimes employed with success an injection of the nitrate of silver. Where there is reason to suppose the gastric organs to be to a disordered state, an emetic should be given in the early part of the treatment, and afterward small repeated doses of any ofthe mild purguig salts. When an indolent hardness continues after the in- flammatory and suppurative state of biles has been re- moved, the part should be rubbed with camphorated mercurial ointment. Besides the above acute bile, authors describe a chro- nic one, which is said frequently to occur to subjects who have suffered severely from the small-pox, measles, lues venerea, scrofula, and in constitutions which have been injured by the use of mercury. The chronic bile is commonly situated upon the ex- tremities, is of the same size as the acute one, has a hard base, is not attended with much pain, nor any con- siderable discoloration of the skin, until suppuration is far advanced, and the matter is seldom quite formed before the end of three or four weeks. This, like the former, sometimes appears in a considerable number at a time. The discharge is always thinner than good pus, and when the bile is large, and has been long in suppurating, a great deal of sloughy cellular membrane must be cast off before the sore will heal. The principal thing requisite in the local treatment of all furunculous and carbuncular tumours is to make an early free opening into them, and to press out the matter and sloughs, employing emollient poultices tUl all the mortified parts are detached and removed, and afterward simple dressings.—(See Pearson's Principles of Sur- gery. Richter, Anfangsgrunde der Wundarzn. b. 1. Lassus, Pathologie Chir. t. \,p. 15. Richerand,Noso- graphie Chir. t. 1, p. 123, idit. 2. W. Gibson's Insti- tutes of Surgery, vol. 1, Philadelphia, 1824. C. J. M. Langenbeck, Nosologic, S-c. ft. 1, p. 357, GBtt. 1828. 31. J. Chelius, Handb. der Chir. b.l,p. 74, Heidelb. 1826.) ■G GANGLION. (rayyX'ov.) In surgery, a tumour on a tendon or aponeurosis. A ganglion is an encysted, circumscribed, moveable Dwelling, commonly free from pain, causing no altera- tion in the colour of the skin, and formed upon tendons in different parts ofthe body, but most frequently upon the back of the hand and over the wrist. A French gentleman consulted me, who had one upon the upper part of his foot, which created a great sensation of weakness in the motion of the foot; and I have taken notice that ganglions occur particularly often just be- low the knee-pan in housemaids who are in the habit of kneeling a great deal in order to scour rooms. A cu- rious example is recorded, in which a ganglion, situated exactly over the arteria radialis and the arteria super ficialis volae, was at first supposed to be an aneuri/sm —(See Edin. Med. and Surg. Journ. for April, 1821.) These tumours, when compressed, seem to possest GAN GAS 423 considerable elasticity. They often occur unpreceded by any accident; frequently, they are the consequence of bruises and violent sprains. They seldom attain a considerable size, and ordinarily are not painful, though every now and then there are instances to the contrary. When opened, they are found to be filled with a viscid, transparent fluid, resembling white of egg. If they do not disappear of themselves, or are not cured while re- cent by surgical means, they, in some cases, become bo large that they cause great inconvenience, by ob- structing tbe motion of the part and rendering it painful. Discutient applications sometimes succeed in curing gangUons, and in this country friction with the oleum origani is a very common method. I have often seen such tumours very much lessened by this plan of treat- ment, but seldom cured ; for no sooner has the friction discontinued than the fluid in the cyst in general accu- mulates again. . Compression is usually more effectual than discutient liniments. Persons with ganglions have been recom- mended to rub them strongly with their thumb several times a day. After this has been repeated very often the tumour has sometimes disappeared. But the best method is to make continual pressure on ganglions by means of a piece of sheet-lead bound upon the part with a bandage. There is no objection, however, to using once or twice a day, in conjunction with this treatment, frictions with the oleum origani or campho- rated mercurial ointment, provided these measures to- gether do not seem likely to make the tumour inflame, au event which should always be carefully avoided. Ganglions, when irritated too much, have been known to become most malignant fungous diseases. Setons have been recommended to be introduced through ganglions with a view of curing them. This method, however, is not an eligible one; for it is by no means free from danger, as the records of surgery fully prove. Cancerous diseases, and even a malignant fatal fungus (Med. Journ. vol. 5), have arisen from the irri- tation of a seton passed through a ganglion. Frequently,, when a ganglion inflames and ulcerates, the cyst throws out a ftingus which is of a very ma- lignant nature. Hence, the practitioner should avoid making an opening into the swelling, or doing any thing which is likely to occasion sloughing or ulcera- tion of the disease. Ganglions may be cured by pres- sure sufficient to rupture the cyst, and some authors have recommended putting the hand affected upon a table, and then striking the ganglion several times with the flst or a mallet. The cyst of a recent ganglion may also be burst by compressing it strongly with the thumbs with or without the intervention of a piece of money ; the fluid is effused into the adjacent cellular membrane; and pressure being now employed, the opposite sides of the cavity become united by the adhesive inflamma- tion, and the recurrence of the disease is prevented. On this principle Sir Astley Cooper cures the disease. —-(See L'Encyclopidie Mithodique, partie Chir. art. Ganglion; Lassus, Pathologie Chir. t.\, p. 400, tf-c; Leveilli, Nouvellt Doctrine Chir. t. 3, p. 7.) In almost every instance, a ganglion may be cured by pressure and friction; and if not actually cured, the disease may be rendered so bearable by these means, that few patients would choose to have the tumour cut out. Under this plan, the swelling becomes very much diminished, and should it enlarge again, the mode of' relief is so simple, and the case so little troublesome, that patients generally content themselves with occa- sionally wearing a piece of lead on the part. But when ganglions resist all attempts to disperse or palliate them; when they become extremely inconve- nient, either by obstructing the functions of the joint or causing pain, they should be carefully dissected out by first making a longitudinal incision to the skin cover- ing them, then separating the cyst on every side from the contiguous parts, and lastly cutting every particle of it off the subjacent tendon or fascia. The greatest care must be taken not to make any opening to the cyst, so as to let out its contents, and make it collapse; a circumstance which would render the dissection of it entirely out much more difficult. The operation being accomplished, the skin is to be brought together with sticking plaster, and a compress placed over the situation of the tumour, with a view of healing the wound and the cavity by adhesion. When the ganglion has burst, or is ulcerated, it is best to remove the diseased skin together with the cyst, and of course the incision must be oval or circular, as may seem most convenient. The grand object is, not to allow any particle ofthe cyst to remain behind, as it would be very likely to throw out a ftingus, and prevent a cure. In Warner's Cases of Surgery is an account of two considerable ganglions which this gentleman, to imitation of Celsus and Paulus .figineta, thought it right to extirpate. These had become adherent to the tendons of the fingers. In the operation he was ob- liged to cut the transverse ligament of the -wrist; and the patients, who before could not shut then-hands, nor close their fingers, perfectly regained the use of these parts. Mr. Gooch relates a case of the same kind, which had been occasioned by a violent bruise three or four years before. The tumour reached from the wrist to the middle of the hand, and created a great deal of pain. Mr. Gooch extirpated it, and then restored the position of the hand and free motion of the joint by the use of emollient applications and suitable pressure, made with a machine constructed for the purpose. Other cases, confirming the safety of cutting out gan glions, are recorded in the London Medical Journal for 1787, p.,154; by Eller, in Mem. de PAead. des Sciences de Berlin, t. 2, ann. 1746; Schmucker, in Chir. Wahrnehmungen, b. 1, p. 332; Girard, Lupio- logie. The ganglions which occur just below the knee I have seen cured by a little bUster applied over them, and kept open by the savin cerate. Camphorated blisters, indeed, have been proposed as a means of dispersing other ganglions.—(Jaeger, Chir. Cautelen, b. 2.) For information relative to ganglions, consult War- ner's Cases in Surgery. Chirurgical Works of B. Gooch, vol. 2, p. 376. Heister's Surgery. B. BelPs Surgery. Latta's System of Surgery. LEncylopidie Mithodique, partie Chir. art. Ganglion. Richter, An fangsgr. der Wundarzn. b. 1. Lassus, Pathologie Chir. t.l,p. 399. Did. des Sciences Mid. t. 17,p. 311. GANGRENE. (From ypaivoi, to feed upon.) An in- cipient mortification, so named from its eating away the flesh. Authors have generally distinguished mortification into two stages: the first, or incipient one, they name gangrene, which is attended with a sudden diminution of pain to the place affected; a livid discoloration ofthe part, which, after being yeUowish, becomes of a green- ish hue; a detachment of the cuticle, under which a turbid fluid is effused; lastly, the swelling, tension, and hardness of the previous inflammation subside, and on touching the part a crepitus is perceptible, owing to the generation of air in the gangrenous parts. When the part has become quite cold, black, fibrous, incapable of moving, and destitute of aU feeling, circu- lation, and life, this is the second stage of mortification, termed sphacelus. Gangrene, however, is frequently used synonymously with the word mortification.—(See Mortification.) GASTROCELE. (From yaar^p, the stomach, and Krj\n, a tumour.) A hernia of the stomach. GASTRORAPHIA, or gastroraphe. (From yao- rr)p, the belly, and patpi), a suture.) A suture of the belly, and some of its contents. Although the term gastroraphe, in strictness of ety mology, signifies the sewing up of any wound of the beliy, yet Mr. S. Sharp informs us that to his timp the word implied, that the wound of the abdomen was com- plicated with another ofthe bowels. The moderns, I think, seem to limit the meaning of the word to the operation of sewing up a wound to the pa- rietes of the abdomen. What was formerly meant by gastroraphe could scarcely ever be practised, because the symptoms laid down for distinguishing when an intestine is wounded do not with any certainty determine in what particular part it is wounded; which want of information makes it absurd to open the abdomen in order to get at it. Hence the operation of stitching the bowels can only take place when they foil out of the abdomen, and when we can see where the wound is situated. And, indeed, even in these circumstances, the employment of sutures is a practice the propriety of which is questionable, as will be farther considered to the article Wounds. The circumstances making the practice of sewing up a wounded intestine proper are so rare, that Duverney who was the most eminent surgeon to the French army a great many years, and at a period when duels were particularly frequent, and his country at war, declared 424 GLA GLA Ihat he had never had a single opportunity of practising gastroraphe, according to the former acceptation of that word. , . „ ^ Gastroraphe, or merely sewing up a wound of the pa- rietes of the abdomen, may be done, as Mr. Sharp ex- plains, with common interrupted suture (see Suture), or with the quilled one, which is better, as follows : A ligature, capable of splitting into two, has a needle attached to each end of it. The lip of the wound is to be pierced, from within outwards, about an inch from its edge. The other needle is to be passed in the same way through the opposite lip. Then the two needles are to be cut off. As many such sutures must be made as the extent ofthe wound may require. The sides of the wound are next to be brought toge- ther, and the ligatures tied, not in a bow, in the way of tbe interrupted suture, because the continual action of the abdominal muscles might make the Ugatures cut then- way through the parts. On the contrary, it is bet- ter to divide each end ofthe Ugatures into two portions, and to tie these over a piece of bougie laid along the line at which the ligatures emerge from the flesh. This is to be done to all the ligatures on one side first. Then the wound being closed, another piece of bdtigie is to be placed along the other lip of the wound, and the oppo- site ligatures tied over it with sufficient tightness to keep the sides ofthe wound in contact. This suture is ewtainly preferable to the interrupted one, because a great deal of its pressure is made on the two pieces of bougie, and of course it is less likely to cut its way out. Its operation is to be assisted with compresses laid over each side of the wound, and the uniting bandage. In four or five days the sutures may generally be re- moved, and sticking plaster alone employed.—(See Wounds ofthe Abdomen.) It is generally allowed that sutures are violent means, to which we should only resort when it is impossible to keep the lips of a wound in contact by the observance of a proper posture and the aid of a methodical bandage. M. Pibrac believes such circumstances exceedingly nucommon, and in his excellent production in the third volume of the Memoirs of the Royal Academy of Sur- gery, relative to the abuse of sutures, cases are related which fully prove that wounds of the belly readUy unite by means of a suitable posture and a proper bandage, without the practice of gastroraphe. These cases, how- ever, are less decisive and convincing (if possible to be so) than the relations ofthe Caesarean operation, the ex- tensive wound of which has often been healed by aim- pie means, after the faUure of sutures. In fact, it is not only possible to dispense with gastroraphe, it is even mostly advisable to do so; for experience has proved that this operation has sometimes occasioned very bad symptoms. # • Under certain circumstances, however, it may be es- sentially necessary to practise gastroraphe. For in- stance, were a large wound to be made across the parie- tes ofthe abdomen, a suture might become indispensably requisite to prevent the protrusion of the bowels. Yet even in this case the sutures should be as feWin num- ber as possible. In a longitudinal wound of the abdo- men, a bandage of the eighteen-tailed kind might prove very useful, and do away all occasion for gastroraphe. —{See Sutures.) I shall conclude this article with a fact, perhaps more curious than instructive, related by M. Bordier, of Pon- dioherry, in the Journal de Midecine, vol. 26, p. 538. An Indian soldier, angry with his wife, ktiled her, and attempted to destroy himself by giving himself a wound with a broad kind of dagger in the abdomen, so as to eause a protrusion of the bowels. A doctor of the country being sent for, dissected between the muscles and skin, and introduced a thin piece of lead, which kept up the bowels. The wound soon healed up, the lead having produced no inconvenience. The man was afterward hanged, and M. Bordier, when the body was opened, assured himself more particularly of the fact. Indeed, numerous cases prove that lead may lodge to the living body without occasioning the inconvenience which results from the presence of many other kinds of extraneous bodies. See Le Dran, Operationes de Chirurgie. Sharp?! Treatise on the Operations of Surgery. L'Encyclopi- die Mithodique, partie Chirurgicale, art. Gastroraphe. i Sabatier, Midicine Operatoire, t.l. j GLAUCOMA (from yXai'Kij, bluish green) is now de- fined by modern surgeons to be a greenish or gray opa-1 city of the vitreous humour, attended with the loss n a considerable impairment of sight.—( Wilier on Disease* of the Eye, transl. by Monttith, vol. 2, p. 27.) In tho words of Mr. Guthrie, the disease essentially consists in an alteration ofthe component parts ofthe vitreous hu- mour, accompanied with derangement of the structure of the hyaloid membrane, retina, and tunica choroidea, the vessels of which are always more or less varicose. —(Operative Surgery of the Eye, p 214.) Professor Beer considers the subjects of glaucoma and the cata- racta viridis or glaucomatosa together in the same chapter. He observes that these diseases occur ratlw-r frequently, not only as true effects of inflamma- tion of the eye, but sometimes quite unpreceded by this affection. Although glaucoma may continue for a long time as the only disorder, without the crystalline lens being changed in the slightest degree, yet Beer has never seen the case reversed, and the lens become al- tered as it does in glaucoma*; first, and tbe vitreous hu- mour afterward. In what this author describes as gouty ophthalmy, glaucoma is said to come on with tho following symptoms. The iris is not observed to ex- pand, but rather to become contracted; the pupil is not equally dilated, bat extends more towards the canthi, the iris at length becoming scarcely perceptible towards each angle ofthe eye, especially the outer one, and the pupil of course assuming something of the appearance which is seen in the eye of a ruminating animal. In a case,, however, which I once saw in the London Eye Infirmary under Mr. Lawrence, it was particularly re- marked, that the diameter of the pupil was not greatest to the transverse direction; a circumstance which Beer's account would lead us to expect was constant. And it particularly merits notice, that as the iris shrinks to- wards the margin of the comea, its pupillary edge is in- verted towards the lens, so that its smaller circle com- pletely disappears. In this very dilated state of the pu- pil, a gray, greenish opacity is perceived, seeming to be very deep, and arising from a real loss of transparency in the vitreous humour. At this period the lens evidently becomes opaque, acquiring a sea-green hue, and the ca- taracta viridis, or glaucomatosa, now swells and ap- pears to project forwards into the anterior chamber. The pain then becomes more incessant and violent; the varicose affection ofthe eyeball seriously increases; and the eyesight, which began hourly to diminish from the moment when tbe pupil was first observed to be in any degree expanded and opaque, and the iris motion- less, is now so entirely destroyed, that not the slightest perception of external light remains, though the patient may vainly congratulate himself on discerning lumi- nous appearances produced within the eye itself, in the form of a fiery, shining circle, especially when tlie or- gan is gently pressed upon. An eye in this condition (says Beer) has really a look- as if it were dead, the comea being as flaccid and void of lustre as in a corpse. Finally, when these symptoms have attained then* utmost pitch, an atrophy of the eyeball follows, and the painful sensations about the organ cease. In corpulent individuals, however, they still continue with greater violence. Sooner or later the other eye is also either attacked with arthritic iritis, or ophthalmy, or becomes affected with glaucoma, which is ushered in by violent and incessant headache.—(Beer, Lehre von dm Augenkrankheiten, b. 1, p. 581, i-c. Svo. Wien, 1813.) According to this author, glaucoma and the green cata- ract are never the consequences of any description of ophthalmy, but what he terms arthritic.~(B. 2, p. 255. Wien, 1817.) I believe, however, with Mr. Guthrie, that the inflammation is really an unhealthy disorgan izing inflammation, not necessarily dependent upon nor connected with goat-(Operative Surgery of the Eye, p 216), of the effects of whicf disorder the German prac- titioners entertain the most vague notions. Both these affections, after they are conjoined with a general vari- cose disease ofthe eyeball, are set down by Beer as ge- nerally incurable. According to Weller, when the vi- treous humour first begins to be muddy, the disease may sometimes be checked.—(On Diseases of the Eye, vol. 2, p. 29.) The means of relief depended upon in Germany are, frictions on the eyebrow with tinct. opii croc, or liniment, ammon.; tbe avoidance of cold; camphorated bags of aromatic herbs applied over the eye, but the effect of which must be rather insignifi- cant ; issues; setons; rubbing the antimonial ointment over the spine, or behind the ears, &c—(Vol. cit. p. 228.) Other authors recommend applying blisters, and GLE GON 425 giving internally the extract of cicuta, calomel, and soap. —{Encyclopidie Hethodique, partie Chir.) The to- pical use of ether might be tried; but from the history of the disease, the chances of cure must evidently be nearly hopeless.—(See also Tr. G. Benedict de Morbis Humoris Vitrei, 4to. Lips. 1809.) GLEET. By the term gleet is commonly understood a continued running or discharge, after the inflamma- tory symptoms of a clap have for some time ceased, un- attended with pain, scalding in making water, Sec Mr. Hunter remarks, that it differs from a gonorrhoea to be- ing uninfectious, and in the discharge consisting of glo- bular bodies, contained in a slimy mucus instead of se- rum. He says, that a gleet seems to take its rise from a habit of action which the parts have contracted. The disease, however, sometimes stops of iteelf, even after every method has been ineffectually tried. This proba- bly depends upon accidental changes in the constitution, and not at aU upon the nature of the disease itself. Mr. Hunter had a suspicion that some gleets were connected with scrofula. Certain it is, the sea-bath cures more gleets than the common cold bath, or any other mode of bathing; and a cure may sometimes, but not always be accomplished by an injection of diluted sea-water. Gleets are often attended with a relaxed constitution. They also sometimes arise from other affections of the urethra, besides gonorrhoea. A stricture is almost al- ways accompanied with a gleet; and so sometimes is disease of the prostate gland. It is remarked by Mr. Hunter, that if a gleet does not arise from any evident cause, and cannot be sup- posed to be a return of a former gleet, to consequence of a gonorrhoea, either a stricture or diseased prostate gland is to be suspected : an inquiry should be made whether the stream of urine is smaller than common, whether there is any difficulty in voiding it, and whe- ther the calls to make it are frequent. If there should be such symptom, a bougie, rather under the common size, should be introduced; and if it passes into the bladder with tolerable ease, the disease is probably in the prostate gland, which should next be examined.— (See Urethra, Strictures of; and Prostate Gland.) Balsams, turpentines, and the tincture canth., given internally, are of service, especially in slight cases; and when they are useful they prove so almost imme- diately. Hence, if they had neither lessened nor re- moved the gleet in five or six days, Mr. Hunter never continued them longer. The same observation applies to cubebs, so celebrated of late as a remedy for gonor- rhoea and gleet, and the common dose of which is 3 ij. in any convenient fluid three times a day. As the dis- charge when removed is also apt to recur, such medi- cines should be continued for some time after the symp- toms have disappeared. When the whole constitution is weak, the cold bath, sea-bath, bark, and steel may be given. The astrin- gent gums and salt of steel, given as internal astrin- gents, have Uttle power. With regard to local applications, the astringents commonly used are, the decoction of bark, sulphate of ainc, alum, and preparations of lead. The aqua vitrio- lica caerulea, of the old London Dispensatory, dtiuted with eight timts its quantity of water, makes a very good injection. Irritating applications consist either of injections or bougies, simple or medicated with irritating medicines. Violent exercise may be considered as having the same effect. Such applications should never be used till the other methods have been fully tried and found unsuc- cessful. They at first increase the discharge, and on this account are sometimes abandoned too early. Two grains ofthe oxymuriate of mercury, dissolved in eight ounces of distilled water, make a very good irritating injection. In irritable habits such an application may do great harm, and therefore, if possible, the capability of the parts to bear its employment should first be made out. Bougies sometimes act violently, but Mr. Hunter thought them more efficacious than injections. A sim- ple unmedicated one is generally sufficient, and must be used a month or six weeks before the cure can be depended upon. Bougies medicated with camphor or turpentine were formerly employed for the cure of gleet: they did not require so long a trial as common bougies : at present, I believe, they are not used at all by any surgeon of eminence. Whatever bougies are employed should be under ihe common size. Mr. Hunter knew a gleet disappear on the breaking out of two chancres on the glans. Gleets have also been cured by a blister on the under side of the ure- thra, and by electricity. In every plan of treatment, rest or quietness is gene- rally of great consequence ; but, after the failure ofthe usual modes, riding on horseback wUl sometimes im- mediately effect a cure. Regularity and moderation in diet are to be observed. Intercourse with women often causes a return or in- crease of gleet; and in such cases, it gives suspicion of a fresh infection ; but the difference between this and a fresh infection is, that here the return is almost immediately after the connexion. Gleets in women are cured nearly in the same man- ner as those of men. Turpentines, however, have no specific effect on the vagina; and the astringent injec- tions used may also be stronger (ban those intended for male patients. [The tincture of cantharides, pretty freely adminis- tered, and for some time, is a powerful means of re- storing the tone of the genital organs, and of curing gleet. Its use, however, must be persisted in for some time. In that condition of the system to which a gleety discharge depends upon a diseased state of the prostate gland, Dr. Francis, of New-York, has given tbe muriated tincture of gold with reUef, to cases where the muriated tincture of iron proved irritating, and seemed to augment existing evUs. Our Ameri- can remedy, the pyrola, ought not in instances of this sort to be overlooked. While it invigorates the tone of the digestive organs, it is valuable to various affec- tions of the urinary organs.—Reese.] See A Treatise on the Venereal Disease, by John Hunter, ed. 2. Also, Swediaur's Practical Observa- tions on Venereal Complaints. GLOSSOCATOCHUS. (From y\u>ooa, the tongue, and Karixwt to depress.) The ancient glossocatochus was a sort of forceps, one of the blades of which served to depress the tongue, while the other was ap- pUed under the chin. GOITRE. See Bronchocele. GONORRH03A. (From yovi), the semen, and }im, to flow.) Etymologically, an involuntary discharge of the semen • out always, according to modem surgery, a discnarge of purulent infectious matter, from the ure- thra to the male, and from the vagina and surfaces of the labia, nymphae, clitoris, &c, to the female subject. Dr. Swediaur, after censuring the etymological im- port as conveying an erroneous idea, says, if a Greek name is to be retained, he would call it blennorrhagia, from [fkiwa, mucus, and him, to flow. However, as most ofthe modems consider the discharge as pus, not mucus, the etymological import of blenorrhoea is an objectionable as that of gonorrhoea. Mr. Howship has repeatedly examined the discharge with a microscope, but without perceiving any essential difference between such discharge and the pus effused from an ulcer.-^ (On Complaints affecting the Secretion and Excretion of the Urine, p. 260.) In English, the disease is commonly called a clap, from the old French word clapises, which were pubUc shops, kept and inhabited by stogie prosti- tutes, and generally confined to a particular quarter of the town, as is even now the case in several of the great towns to Italy. In German, the disorder is named) a tripper, firom dripping; and in French, a chaudepisse, from the heat and scalding in making v/&teT.-(Swediaur.) We shall first present the reader with some of Mr. Hunter's opinions concerning the nature of gonorrhoea, its symptoms, and treatment; and, lastly, take notice of the observations of some other writers. When an irritating matter of any kind is applied to a secreting surface it increases that secretion, and changes it from its natural state to some other. In the present instance, it is changed from mucus to pus, Till about the year 1753, it was generally supposed, that the matter from the urethra in cases of gonorrhoea arose from ulcers in the passage; but about that time .it was ascertained that pus might be secreted without a breach of substance. It was first accidentally proved by dissection, that pus might be formed to the bag of the pleura without ulceration; and Mr. Hunter after- ward examined the urethra of malefactors and others, who were executed or died whUe known to be affected with gonorrhoea, and demonstrated that the canal was entirely free from every appearance of ulcer. The time when a gonorrhoea first appears after tolas- 426 GONORRHOEA. tion, is extremely various. Tt generally comes on sooner than a chancre. Mr. Hunter had reason to be- lieve that in some instances the disease began in a few hours ; while in others, six weeks previously elapsed ■ but he had known it begin at all the intermediate pe- riods. However, it was his opinion, that about six, eight, ten, or twelve days after infection is the most common period. The surface of the urethra is subject to inflamma- tion and suppuration from various other causes besides the venereal poison; and sometimes discharges hap- pen spontaneously, when no immediate cause can be assigned. Such may be called simple gonorrhoea, hav- ing nothing of the venereal infection in them. Mr. Hunter knew of cases in which the urethra sympathized with the cutting of a tooth, and all the symptoms of a gonorrhoea were produced. This hap- pened several times* to the same patient. The urethra is known to be sometimes the seat of the gout; and Mr. Hunter was acquainted with instances of its being the seat of rheumatism. When a secreting surface has once received the inflam- matory action, its secretions are increased and visibly altered. Also, when irritation has produced inflamma- tion and an ulcer in the solid parts, a secretion of mat- ter takes place, the intention of which, in both, seems to be to wash away the irritating matter. But in in- flammations arising from specific or morbid poisons, the irritation cannot be thus got rid of; for although the first irritating matter be washed away, yet the new matter has the same quality as the original had; and therefore, upon the same principle, it would pro- duce a perpetual source of irritations, even if the ve- nereal inflammation, like many other specific diseases, were not, what it really is, kept up by the specific quality of the inflammation itself. This inflammation seems, however, to be only capable of lasting a limited time, the symptoms peculiar to it vanishing of them- selves, by the parts becoming less and less susceptible of irritation; and the subsequent venereal matter can have no power of continuing the original irritation, for otherwise there would be no end to the disease. The time which the susceptibility of the irritation lasts must depend upon the difference in the constitution, and not upon any difference in the poison itself. Mr. Hunter believed that the venereal disease only ceased spontaneously when it attacked a secreting sur- face, and produced a mere secretion of pus without ul- ceration. Such were some of the sentiments of this great man, who was a firm believer in the identity of the poisons of syphilis and gonorrhoea; but this idea, and the hypothesis about the impossibUity of any spon- taneous cure of venereal sores, are now very generally relinquished. The first symptom of gonorrhoea is generally an itching at the orifice of the urethra, sometimes extend- ing over the whole glans. A little fulness of the lips of the urethra, the effect of inflammation, is next ob servable, and soon afterward a running appears. The itching changes into pain, more particularly at the time of voiding the urine. There is often no pain till some time after the appearance of the discharge and other symptoms; and in many gonorrhoeas there Is hardly any pain at all even when the discharge is very considerable. At other times, a great degree of soreness occurs long before any discharge appears. There is generally a particular fulness in the penis, and more especially in the glans. The glans has also a kind of transparency, especially near the beginning ofthe urethra, where the skin, being distended, smooth, and red, resembles a ripe cherry. The mouth of the urethra is, in many instances, evidently excoriated. The surface of the glans itself is often in a half-exco- riated state, consequently very tender; and it secretes a sort of discharge. The canal of the urethra becomes narrower, which is known by the stream of urine be- in-' smaller than common. This proceeds from the fulness of the penis in general, and either from the lining of the urethra being swollen or m a spasmodic state The fear of the patient whUe voiding his unne, also disposes the urethra to contract; and the stream of urine is generally much scattered and broken as ZoTaa it leaves the passage. There is frequently some degree of hemorrhage from the urethra, perhaps from the distention of the vessels, more es]*ciarwhen there is a chordee, or a tendency to it. Small sweU- togs often occur along the lower snrfacs of the penis, In the course of the urethra. These Mr. Hunter sus- pected to be enlarged glands of the passage. They oc- casionally suppurate and burst outwardly, but now and then in the urethra itself. Mr. Hunter has also suspected such tumours to be ducts, or lacuna* of the glands of the urethra distended with mucus, in conse- quence of the mouth of the duct being closed, in a manner similar to what happens to the duct leading from the lachrymal sac to the nose, and so as to induce inflammation, suppuration, and ulceration. Hardness and swelling may also occur in the situation of Cow- per's glands, and end to considerable abscesses in the perinaeum. The latter tumours break either internally or externally, and sometimes to both ways, so as to produce fistula; in perinaeo. A soreness is often felt all along the under side of the penis, frequently extending as far as tbe anus. The pain is particularly great in erections; but the case differs from chordee by the penis remaining straight. In most cases of gonorrhoea, erections are frequent, and even sometimes threaten to bring on mortification; as opium is of great service, Mr. Hunter thought that there was reason to suppose them of a spasmodic nature. The natural slimy discharge from the glands of the urethra is first changed from a fine, transparent, ropy secretion to a watery, whitish fluid; and the lubricating fluid which the passage naturally exhales becomes less transparent; both these secretions becoming gra- dually thicker, assume more and more the qualities of common pus. The matter of gonorrhoea often changes its colour and consistence, sometimes from a white to a yellow, and often to a greenish colour. These changes depend on the increase and decrease ofthe inflammation, and not on the poisonous quality of the matter itself; for an irritation of these parts, equal to that produced in a gonorrhoea, wiU produce the same appearances. The discharge is produced from the membrane lining the urethra, and from the lacuna;, but in general only for about two or three inches from the external orifice. Mr. Hunter says, seldom farther than an inch and a half, ortwo inches at most. This he terms the specific extent of the inflammation. Whenever he had an op- portunity of examining the urethra affected with gonor- rhoea, he always found the lacunae loaded with matter, and more visible than in the natural state. Before the time'of this celebrated man, it was commonly supposed that the discbarge arose from the whole surface ofthe urethra, and even from Cowper's glands, the prostate and vesicula; seminales. . But if the matter were secreted from all these parts, the pus would collect in the bulb, as the semen does, and thence be emitted in jerks; for nothing can be in the bulbous part of the urethra without stimulating it to action, especiaUy when in a state of irritation and inflammation. When the inflammation is violent, some of the. .ves- sels of the urethra often burst, and a discharge of blood ensues. Sometimes such blood is only just enough to give the matter a tinge. In other instances, erections cause an extravasation by stretching the part. When the inflammation goes more deeply than the membranous lining, and affects the reticular membrane of the urethra, it produces in it an extravasation of coagulable lymph, the consequence of which is a chordee.—(See Chordee.) Mr. Hunter suspected that the disease is communi- cated or creeps along from the glans to the urethra, or, at least, from the lips ofthe urethra to its inner surface, as it is impossible that the infectious matter can, during coition, get as far as the disease extends. He mentions an instance, in which a gentleman, who had not co- habited with any woman for many weeks, to all ap- pearance caught a gonorrhoea from a piece of plaster, which had adhered to his glans penis in a necessary abroad. The infection is accounted for, by supposing that some person with a clap had previously been to this place, and had left behind some ofthe discharge, and ihat the above gentleman had allowed his penis to remain in contact with the matter till it had dried. Many symptoms depending on the sympathy of other parts with the urethra sometimes accompany a gonor- rhoea. An uneasiness, partaking of soreness and pain, and a kind of weariness, are felt about every part ofthe pelvis. The scrotum, testicles, perinaeum, amis, and hips become disagreeably sensible, and the testicles often require to be suspended. So irritable, indeed, are GONORRH(EA. 427 they in such cases, that the least accident, or even ex- ercise, which would have no effect of this kind at an- other time, will make them swell. The glands of the groin are often affected sympathetically, and even sweU a little, but they do not suppurate, as they generallydo when they inflame from the absorption of matter. Mr. Hunter has seen the irritation of a gonorrhoea so exten- sive as to affect with real pain the thighs, buttocks, and abdominal muscles. He knew one gentleman who never had a gonorrhoea without being immediately seized with universal rheumatic pains. When tbe disorder, exclusive of the affections from sympathy, is not more violent than has been described, Mr. Hunter termed it a common or simple venereal gonorrhoea; but if the patient is very susceptible of such irritation, or of any other mode of action which may accompany the venereal, then the symptoms are in proportion more violent. In such circumstances, we sometimes find the irritation and inflammation exceed the specific distance, and extend through the whole urethra. There is often a considerable degree of pain in the perinaeum; and a frequent, though not a constant, symptom is a spasmodic contraction of the accelera- tores urinae and erectores muscles. In these cases, the inflammation is sometimes considerable, and goes deeply into the cellular membrane, but without pro- ducing any effect except swelling. L; other instances, it goes on to suppuration, often becoming one of the causes of fistula; in perinaeo. Thus, Cowrper's glands may suppurate, and the irritation often extends even to Ihe bladder itself. When the bladder is affected, it becomes more sus- ceptible of every kind of irritation. It will not bear the usual distention, and therefore the patient cannot retain bis water the ordinary time; and the moment the desire of making water takes place, he is obliged instantly to make it, with violent pain in the bladder, and still more in the glans penis, exactly similar to what happens in a fit of the stone. If the bladder be not allowed to dis- charge its contents immediately, the pain becomes almost intolerable; and even when the water is evacu- ated, there remains for some time a considerable pain both in the bladder and glans. Sometimes, though rarely, when the bladder is much affected, the ureters, and even the kidneys sympathize; and Mr. Hunter had reason to suspect that the irrita- tion might be communicated to the peritoneum by means of the vas deferens. Mr. Hunter mentions a case, in which, while the in- flammatory symptoms of a gonorrhoea were abating, an incontinence of urine came on ; but to time got spon- taneously well. A very common symptom attending a gonorrhoea is a swelling of the testicle.—(See Hernia Humoralis.) Another occasional consequence is a sympathetic swelling of the inguinal glands.—(See Bubo.) A hard cord is sometimes observed, leading from the prepuce along the back of the penis, and often di- recting its course to one ofthe groins, and affecting the glands. At the part of the prepuce where the cord takes its rise, there is most commonly a swelling. This sometimes happens when an excoriation and a discharge from the prepuce or glans penis exist. In one case, Mr. Howship thought the large vein on the dorsum of the penis was inflamed and thickened.—(On Complaints affecting the Secretion and Excretion of tlie Urine, i-c. p. 266.) From tbe above account, the symptoms of gonorrhoea in different cases seem to be subject to infinite variety. The discharge often appears without any pain, and the coming on ofthe pain is not at any stated time after the appearance of the discharge. There is often no pain at all, although the discharge is in considerable quan- tity, and of a bad appearance. The pain often goes off while the discharge continues, and will return again. In some cases, an itching is felt for a considerable time, which is sometimes succeeded by pain; though in many cases it continues till the end of the disease. On tho other hand, the pain is often troublesome and con- siderable, even when there is little or no discharge. The neighbouring parts sympathize, as the glands of tho groin, the testicle, the loins and pubes, the upper parts of the thighs, and the abdominal muscles. Some- times the disease appears a few hours after the applica- tion of the poison ; sometimes not till six weeks have elapsed. Lastly, it is often toipossible to determine whether thf case is a yenereal discbarge, or rather one produced by the application of infectious matter, or only an accidental discharge, arising from some un- known cause. GONORRHOEA IN WOMEN. The disorder is not so easily ascertained in them as in men, because they are subject to a disorder called fluor albus, which resembles gonorrhoea. A mere dis- charge to women is less a proof of the existence of a gonorrhoea than even a discharge without pain in men. The kind of matter does not enable us to distinguish a gonorrhoea from a fluor albus; for in the latter affec- tion, the discharge often puts on all the appearance of venereal matter. Pain is not necessarily present, and therefore forms no line of distinction. The appearance of the parts often gives us but little information; " for (says Mr. Hunter) I have frequently examined the parts of those who confessed all the symptoms, such as in- crease of discharge, pain in making water, soreness in walking, or when the parts were touched, yet I could see no difference between these and sound parts. I know of no other way of judging, in cases where there are no symptoms sensible to the person herself, or where the patient has a mind to deny any uncommon symp- toms, but from the circumstances preceding the dis- charge ; such as her having been connected with men supposed to be unsound, or her being able to give the disorder to others; which last circumstance, being de- rived from the testimony of another person, is not always to be trusted to, for obvious reasons." But though there may sometimes be great difficulty to form- ing a judgment of some of these cases, the surgeon may frequently come to a right conclusion, by recol- lecting, as Mr. Dunn has reminded me, that, besides the difference depending on the suddenly severe symp- toms of gonorrhtea, fluor albus may be known by the great debility; the sinking of the stomach; the weari- ness of the limbs; the pain of the back, always in- creased by the erect posture; the severe headaches; the painful menstruation, together with the very gradual increase of the disease. From the manner in which the disease is contracted, it must principally attack the vagina, a part not en- dowed with much sensation. In many cases, however, it produces a considerable soreness on the inside ofthe labia, nymphae, clitoris, caruncula; myrtiformes, and meatus urinarius. In certain cases, these parts are so sore, that they will not bear to be touched; the person can hardly walk; the urine gives pain in its passage through the urethra, and when it comes into contact with the above-mentioned parts. The' bladder, and even the kidneys, occasionally sympathize. The mucous glands on the inside of the labia often swell, and sometimes suppurate, forming smaU abscesses, which open near the orifice of the vagina. According to Mr. Hunter, the venereal matter from the vagina sometimes runs down the perinseum to the anus, and produces a gonorrhcEa or chancre in that situation. The disease in women may probably wear itself out, as in men; but it may exist in the vagina for years, if the testimony of patients can be reUed on. TREATMENT OF GONORRHOEA. As every form ofthe venereal disease is supposed to arise from the same cause, and as we have a specific for some forms, we might expect that this would be a certain cure for every one; and therefore, that it must be no difficult task to cure the disease, when in the form of inflammation and suppuration in the urethra. Experience teaches us, however, that the gonorrhoea is the most variable in its symptoms, wltile under a cure; and the most uncertain, with respect to its cure, of any forms of the venereal disease (if it ever be a form of this disease at all), many cases terminating in a week, while others continue for months under the same treatment. The only curative object is, to destroy the disposition and specific mode of action in the sotids of the parts, and as they become changed, the poisonous quality of the matter produced will also be destroyed. This effects the cure ofthe disease, but does not always remove the consequence. Gonorrhoea is incapable of being continued beyond a certain time in any constitution; and when it is vio- lent, or of long duration, it is owing to the part being 1 very susceptible of such irritation, and readily retain- 428 GONORRHCEA. tag it. As no specific remedy for gonorrhoea is known, it is fortunate that time alone will effect a cure. It is worthy of consideration, however, whether medicine can be of any service. Mr. Hunter is inclined to think it not of the least use in nine cases out often. But even this would be of some consequence, if the cases capable of being benefited could be distinguished. The means of cure generally adopted are of two kinds, internal remedies and local appUcations; but whatever plan is pursued, we are always to attend more to the nature of the constitution, or to any accom- panying disease to the parts themselves, or parts con- nected with them, than to the gonorrhtea itself. When the symptoms are violent, but of the common inflammatory kind, known by the extent of the inflam- mation not exceeding the specific distance, the local treatment may be either irritating or soothing. According to Mr. Hunter, irritating appUcations are Jess dangerous to these cases, than when irritable in- flammation is present, and they may alter the specific action; but to produce this effect their irritation must be greater than that of the original injury. The parts wiU afterward recover of themselves, as from any .other common inflammation. Mr. Hunter believes, however, that in the beginning the soothing plan is the best. If the inflammation be great, and of the irritable kind, no violence is to be used, for it would only increase the symptoms; and nothing should be done that can tend to stop the dis- charge, as it would not put a stop to the inflammation. The constitution is to be altered, if possible, by reme- dies adapted to each disposition, and reducing the dis- ease to its simple form. If the constitution cannot be altered, nothing is to be done, and the action is to be allowed to wear itself out. When the inflammation has abated, the cure may be attempted by internal remedies or local applications which do not operate violently, whereby the irritation might be reproduced. Gentle astringents may be ap- plied. But if the disease has begun mildly, an irritating in- jection may be used, in order quickly to get rid of the specific mode of action. This application wtil increase the symptoms for a time; but when it is left off they will often abate or wholly disappear; and after such abatement astringents may be used, the discharge be- ing the only thing to be removed. When itching, pain, and other uncommon sensations are felt for some time before the discharge appears, Mr. Hunter diffidently expresses his inclination to recom- jnend the soothing plan, instead of the irritating one, to order to bring on the discharge, which is a step to- wards the resolution ofthe irritation ; and he adds, that to use astringents would be bad practice, as by retard- ing the discharge they would only protract the cure. When there are strictures or swelled testicles, astrin- gents should not be used; for whUe there is a dis- charge such complaints are relieved. Mr. Hunter thus expresses himself in regard to the effect of mercury in gonorrhoea: " I doubt very much 4)f mercury having any specific virtue in this species of the disease; for I find that it is as soon cured without mercury as with it, f mercury sufficient for the cure of a chancre. Men have also been known to contract a gonorrhoea when loaded with mercury for the cure of a lues venerea: the gonorrhoea, nevertheless, has been as difficult of cure as in ordinary cases." Mr. Hunter does not say much in favour of evacu- ants, diuretics, and astringents given internally. He allows, however, that astringents, which act specifi- cally on the parts, as the balsams conjotoed with any I other medicine which may be thought right, may help to lessen the discharge, in proportion as the inflamma- tion abates. Local applications may be either internal to the ure- thra, external to the penis, or both. Those which are applied to the urethra seem to promise most efficacy, because they come into immediate contact with the diseased parts. They may be either in a solid or fluid form. A fluid is only a very temporary application. The solid ones, or bougies, may remain a long while; but in general irritate immediately, firom then- soUdity alone; and Mr. Hunter says, the less bougies are used when the parts are in an inflamed state th "*rw" eonveved to the hospital for the wounded in that town, wtoch was superintended by M. Boy Several day were suffered to elapse before amputation was per- formed , not one of the patients escaped. At Mentz, after the retreat from ^ankfort several of the wounded, who had had Umbs shot off did not have amputation done till some time afterward, and not one of them recovered. At Nice, after the taking of Saourgio, two *»niP«ta- lions were practised at the hospital No. 2, one of the forearm, the other of the arm, nine or ten days after the receipt of the injuries: both the paUents died. \t Perpignan, Baron Larrey visited two soldiers, on whom amputation had been done, seven or eight days after the receipt of gun-shot injuries in the action or the 14th of July, 1794. One had had a leg shot off, and the other his right arm. Notwithstanding Larrey's utmost care, he could not save their lives: one died of tetanus; the other of gangrene. In the month of August, 1805, two cannoniers of the guards, in discharging the artillery, had each a hand shot away, and all the fore part of their bodies burnt. These were the two men whose office it was to charge the gun. At the moment when they had just rammed down the wadding on the cartridge, a spark that had been left unextinguished, from the neglect to keep the a member, breaks tbe bone, divides and tears the mus- cles, and destroys the large nerves, without, however, touching the main artery. According to Larrey, Ibis is a fourth case requiring immediate amputation. Mr. Guthrie seems to coincide on this point with Larrey : " If a cannon-shot strike the back part of the thigh, and carry away the muscular part behind, and with it tbe great sciatic nerve, amputation is necessary, even if the bone be untonched, &c. In this case, I would not perform the operation by the circular inci- sion, but would preserve a flap from the fore part or sides, as I could get it, to cover the bone, which should be short."—(Gulltrie, On Gun-shot Wounds of the Ex- tremities, p. 184.) Fifth case. If a spent cannon-shot, or one that has been reflected, should strike a member obtiquely, without producing a solution of continuity in tbe skin, as often happens, the parts which resist its action, such as the bones, muscles, tendons, aponeuroses, and vessels, may be ruptured and lacerated. The extent of the internal disorder is to be examined; and if the bones should feel, through the soft parts, as if they were smashed, and if there should be reason to suspect, from the swelling, and a sort of fluctuation, that the vessels are lacerated, amputation ought to be immediately practised. We learn from Larrey, that this is also the advice of Baron Percy. Sometimes, however, the vessels and bones been left unexiingu.sneQ,.rou. iu-= ,^. £e~mrod escape injury, and the muscles are almost the only %£$&&^*& ZSS^^X^ Parish Jrdered. In this circumstance we are enjoined every thing that was situated in front of the charge. The right hand of one of the cannoniers was com- pletely lom off, between the two phalanges of the car- pus, and thrown more than two hundred paces. The counter-shock even threw the man down into the ditch of the square of the Hdtel des Invalides. The left hand of the other cannonier was torn away, together with the forearm at the elbow-joint, and also forced to a considerable distance. The tendons and muscles sustained vast injury, and the worst symptoms would have occurred, if amputation had not been instantly performed. In one case amputation was done at the wrist; and in the other at the lower third of the arm. The two operations were followed by complete suc- cess, although the burns upon the face and chest, in both the patients, were serious and extensive. Second case. When a body, propelled by gun- their relation to the air through which they have to powder strikes a limb in such a manner as to smash pass; 2dly, the internal disorder observable m the dead the bones, violently contuse, lacerate, and deeply tear bodies of persons whose death is imputed to the mere parts (___ to follow the counsel of De la Marttoiere, who recom- mended making an incision through the skin. By this means, a quantity of thick blackish blood will be dis- charged, and the practitioner must await events. Ac- cording to Larrey, such incision is equally necessary to the preceding case before amputation, in order to as- certain the extent of the mischief which the parts have sustained. It is to such injury done to internal organs, that we must ascribe the death of many individuals, which was for a long while attributed to tbe commotion produced to the air.—(See Ravaton, Traiti des Plaiesd'Armes dfeu.) Although, says Larrey, this opinion has been sanc- tioned by surgeons of high repute, we may easily con- vince ourselves of its falsity, if we carefully consider, 1st, the direction and course of solid hard bodies, and away the soft parts, amputation ought to be immediately performed. If this measure be neglected, all the injured parts will soon be seized with gangrene; and besides, as Larrey has explained, the accidents which the gra- vity ofthe first case produces wiU also here be excited. It is only doing justice to the memory of M. Faure to state, that this second case was one which he also par- ticularly instanced as demanding the immediate per- formance of amputation.—(See Prix de PAcad. Royale de Chirurgie, t. S, p. 23, ed. IZmo.) Third case. If a similar body were to carry away a great mass of the soft parts, and the principal vessels of" a limb (of the thigh, for instance), without frac- turing the bone, the patient would be in a state demand- ing immediate amputation ; for, independently of the accidents which would originate from a considerable loss ef substance, the limb must inevitably mortify. Mr. Guthrie also says," A cannon-shot destroying the artery and vein on the inside (ofthe thigh), without Injuring the bone, requires amputation."—(P. 185.) •When, however, the femoral artery or vein is injured by a musket-ball, or small canister-shot, this gentleman re- commends tying the vessel above and below the wound in it, if the nature of the ease be evinced by hemorrhage. But he believes, that when both vein and artery are injured, amputation is necessary.—(P. 186.) With re- spect to bleeding from the femoral vein, as it may easily be stopped by moderate pressure, the propriety of using - pj\y ligature at all is questionable. " An injury' of the femoral artery (observes Mr. Guthrie) requiring an operation, accompanied with fracture of the bone of the most simple kind, is a proper case for immediate amputation; for, although many patients would recover from either accident alone, none would, I believe, surmount the two united; and the higher the accident is in the thigh, the more imperious is the necessity for amputation."—(Guthrie, On Gun- shot Wounds, p. 187.) Fourth oase. A grape-shot strikes Ihe thick part of impression off he air agitated by the ball; 3dly, the properties of the elastic substances, such as the integu- ments, cellular substance, &c, struck by tbe shot. It is universally agreed among philosophers, that a solid body, moving in a fluid, only acts upon a column of this fluid, the base of which column is nearly equal to the surface which the solid body presents.—(See Le Vacher sur quelques Particularitis concernant les Plaies faites par Armes d feu, in Mem. de PAcad. de Chirurgie, 1.11, p. 34, ed. 12mo.) Thus, a cannon-ball, to traversing a space equal to its diameter, can only displace a portion of air, in the relation of three to two, compared with the size of the shot. This fluid, to consequence of its divisibility and homogenealness with the ambient air, is dispersed in all directions, and confounded with the total mass of the atmosphere. The effects of this aeriform substance amount to nothing, and not a doubt can be entertained, that if there is the slightest solution of continuity of any part of the body, it must depend upon the direct action of the baU itself. Besides, if the quickness of the motion of a ball be considered, which quickness is known to diminish in an inverse ratio to the squares of the distance, it wUl be seen that the space through which the shot has passed before striking the object against which it was di- rected, will already have materially lessened the cele- rity of the projectile, while the motion of the column of air must be totally lost. The different movements which the ball describes to its course, and the elasticity of the skin, enable us to ex- plain how internal injuries are produced, without any external solution of continuity, and often even without ecchymoses. The motion communicated to the ball by the power which projects it is, for a given space, recti- linear. If, at this distance, it strikes against the body, it carries the part away to an extent proportioned to the mass with which it touches the part. But the ball, after having traversed a certain distance, undergoes, 444 GUN-SHOT WOUNDS. In consequence of the resistance of the air, and the at- traction of gravity, a change of motion, and now turns on its own axis in the diagonal direction. If the shot should strike any rounded part of the body, towards the end of its course, it wUl run round a great portion of the circumference ofthe part, by the effect of its curvilinear movement. It is also in this manner, observes Larrey, that the wheel of a carriage acts to passing obliquely over the thigh or leg of an individual stretched upon the ground. In this case, the results are the same as those of which we have been speaking. The most elastic parts yield to the im- pulse of the contusing body; while such as offer re- sistance, as, for instance, the bones, tendons, muscles, and aponeuroses, are fractured, ruptured, and lacerated. For the same reason, it sometimes happens that the viscera are similarly injured. At first sight, all the parts appear to be entire; but a careful examination will not let us remain long in doubt about the internal mischief. In this case, an ec- chymosis cannot manifest itself outwardly, because the extravasation of blood naturally takes place in the deep excavations occasioned by the rupture of the muscles and other parts, and because this fluid cannot make its way through the texture of the skin. Such extravasations can only be detected by the touch. The foregoing reasoning is supported by experience. How often, says Larrey, have we not seen the ball carry away pieces of helmets, hats, cartridge-boxes, knapsacks, or other parts of the soldier's dress, with- out doing any other injury 1 The same ball, perhaps, takes off his arm, often at a time when it is closely ap- plied to the body of his comrade, and yet the latter does not receive the slightest harm. The shot may pass between the thighs, and these members hardly exhibit an ecchymosis at the points which are gently grazed; the only example in which ecchymosis does occur. In other instances, the ball severs the arm from the trunk, and the functions of the thoracic vis- cera are not at all injured. Baron Larrey then relates the following case, which is analogous to one which I saw near Antwerp, and have already mentioned in the foregoing columns. M. Meget, a captain, marching in the front of a square of men, in the heat of the battle of Altzey, 30th March, 1793, had his right leg almost entirely carried away by a large cannon-shot, without the contiguous limb of his lieute- nant, who was as close as possible to him, receiving the least injury. The violent general commotion ex- cited, and the extreme severity of the weather, made this officer's condition imminently perilous. The pro- gress of the symptoms, however, was checked by am- putation, which was instantly performed. M. Meget was then conveyed to the hospital at Landau, fifteen leagues from the field of battle, where he got quite well. Larrey declines relating numerous other analogous amputations, which he has been called upon to practise under the same circumstances. M. Buffy, a captain of the artillery of the army of the Rhine, was struck by a howitzer ;his left arm being injured, and his head so nearly grazed that the corner of his hat, which was placed forwards over his face, was shot away as far as the crown. This officer, the skin of whose nose was even torn off, was not deprived of his senses, and he was actually courageous enough to continue for some minutes commanding his company. At length, he was conveyed to Larrey's ambulance, who amputated his arm: in about a month the patient was well. Larrey expresses bis belief, that what have been er- roneously termed wind contusions, if attended with the mischief above specified, require immediate ampu- tation. The least delay makes the patient's preserva- tion extremely doubtful. The internal injury of the member may be ascertained by the touch, by the loss of motion, by the little sensibility retained by the parts, which have been struck: and, lastly, by practising an incision, as already recommended. In order to confirm the principle which he endeavours to establish in opposition to many writers, Larrey in- dulges himself with the following digression. At the siege of Roses, two cannoniers, having nearly similar wounds, were brought from the trenches to the ambulance, which Baron Larrey had posted at the vil- lage of Palau. They had been struck by a large shot, which, towards the termination of its course, had grazed" posteriorly both shoulders. In one, Larrey per- ceived a slight ecchymosis over all the back part of tha trunk without any apparent solution of continuity. Respiration hardly went on, and the man spit up a large quantity of frothy vermilion blood. The pulse was small and intermitting, and the extremities were cold. He died an hour after the accident, as Larrey had prognosticated. This gentleman opened the body to the presence of M.Dubois, inspector of the military hospitals of the army of the eastern Pyrenees. The skin was entire; the muscles, aponeuroses, nerves, and vessels of the shoulders were ruptured and lace- rated, the scapula broken in pieces, the spinous pro- cesses of the corresponding dorsal vertebrse, and the posterior extremity of the adjacent ribs, fractured. The spinal marrow had suffered injury; the neighbour- ing part ofthe lungs was lacerated, and a considerable extravasation had taken place in each cavity of the chest. The second cannonier died of similar symptoms, three-quarters of an hour after his arrival at the hos- pital. On opening the body, the same sort of mischief was discovered, as in the preceding example. In the German campaigns of the French armies, Larrey met with several similar cases, and accurate examination has invariably convinced him of the di- rect action of a spherical body, propelled by means of gunpowder. Sixth case. According to Baron Larrey, when the articular heads are much broken, especially those which form the joints of the foot or knee, and the Uga- ments which strengthen these articulations are bro- ken and lacerated by the fire of a howitzer or a grape- shot, or other kind of ball, immediate amputation is in- dispensable. The same indication would occur, were the ball lodged in the thickness of the articular head of a bone, or were it so engaged in the joint as not to admit of being extracted by simple and ordinary means.—(See also Guthrie on Gun-shot Wounds, p. 197.) Fractures extending into the joints, and accompanied with great laceration of the ligaments,.were cases of gun-shot injuries pointed out by M. Faure as indispen- sably requiring immediate amputation.—(See Prix de l'Acad. de Chir. t. 8.) Thus we see, that this author was not so averse to early amputation as several mo- dern writers b'ave represented. It is only in this manner that the patients can be rescued from the dreadful pain, the spasmodic affec- tions, the violent convulsions, the acute fever, the con- siderable tension, and the general inflammation of the limb, which, Larrey observes, are the invariable con- sequences of bad fractures of the large joints. But, adds this author, if the voice of experience be not lis- tened to, and amputation be deferred, the parts become disorganized, and the patient's life is put into imminent peril. It is evident, says he, that in this case if we wish to prevent the patient from dying of the subsequent symp- toms, amputation should be performed before twelve, or at most twenty-four hours have elapsed: even M. Faure himself professed this opinion in regard to cer- tain descriptions of injury.—(Mim. de Chir. Militaire, t.2.) With respect to wounds of the knee, the sentiments of Mr. Guthrie nearly coincide with those of Larrey. " I most solemnly protest (says Mr. G.), I do ifot re- member a case do well, in which I knew the articulat- ing end of the femur or tibia to be fractured by a ball that passed through the joint, although I have tried great numbers, even to the last battle of Toulouse. I know that persons wounded in this way have lived; for a recovery it cannot be called, where the limb is useless, bent backwards, and a constant source of irri tation and distress, after several months of acute suf- fering, to obtain even this partial security from im- pending death; but if one case of recovery should take place in fifty, is it any sort of equivalent for the sacrifice of the other forty-nine ? Or is the preserving of a limb of this kind an equivalent for the loss of one man ?"—(On Gun-shot Wounds, p. 196.) In the attack of the Village of Merksam, near Ant- werp, early in 1814, a soldier of the 95th regiment was brought to our field-hospital, having received a musket- ball through the knee-joint. The staff-surgeons on duty, and Mr. Curtis, surgeon of the 1st guards, were preparing to amputate the limb, when a surgeon at- tached to the 95th, urgently recommended deferring GUN-SHOT WOUNDS. 445 the operation. Superficial dressings were applied, and the patient sent to the rear. He lived several months after the accident, at times affording hopes of a perfect recovery ; but in the end, he fell a victim to hectic symptoms. Indeed, such is the general unfortunate result of these cases, that Dr. Hennen lays it down as a law of military surgery, that no lacerated joint, particularly the knee, ankle, or elbow, should ever leave the field unamputated where the patient is not obviously sink- ing.—(On Military Surgery, p. 41, ed. 2.) According to Mr. Guthrie, fractures of the patella, without injury of the other bones, admit of delay, pro- vided the bone is not much splintered. Seventh case. Larrey observes, that if a large bis- cayen, a small cannon-shot, or a piece of a bomb-shell, in passing through the substance of a member, should have extensively denuded the bone without breaking il, amputation is equally indicated, although the soft parts may not appear to have particularly suffered. Indeed, the violent concussion produced by the acci- dent has shaken and disorganized all the parts; the medullary substance is injured, the vessels are lace- rated, the nerves immoderately stretched, and thrown into a state of stupor; the muscles are deprived of their tone; and the circulation and sensibility in the limb are obstructed. Before we decide, however, Ba- ron Larrey cautions us to observe attentively the symp- toms which characterize this kind of disorder. The case can be supposed to happen only in the leg where the bone is very superficial, and merely covered at its anterior part with the skin. The following are described as the symptoms: the limb is insensible, the foot cold as ice, the bone partly exposed, and, on careful examination, it wUl be found that the integuments, and even the periosteum, are ex- tensively detached from it. The commotion extends to a considerable distance; the functions of the body are disordered; and all the secretions experience a more or less palpablo disturbance. The intellectual faculties are suspended, and the circulation is retarded. The pulse is small and concentrated; the countenance pale; and the eyes have a dull, moist appearance. The pa- tient feels such anxiety, that he cannot long remain in one posture, and requests that his leg may be quickly taken off, as it incommodes him severely, and he expe- riences very acute pain in the knee. When all these characteristic symptoms are conjoined, says Larrey, we should not hesitate to amputate immediately: for otherwise the leg will be attacked with sphacelus, and the patient certainly perish. Larrey adduces several interesting cases in support of the preceding observations. Eighth case. When a large ginglymoid articulation, such as the elbow, or especally the knee, has been ex- tensively opened with a cutting instrument, and blood is extravasated in the joint, Larrey deems immediate amputation necessary. In these cases, the synovial membranes, the ligaments, and aponeuroses inflame, the part swells, and erethismus rapidly takes place; and acute pains, abscesses, deep sinuses, caries, febrile symptoms, and death are the speedy consequences. Larrey has seen numerous subjects die of such injuries, on account of the operation having been postponed through a hope of saving the limb. In his Memoires it Chirurgie Militairt, torn. 2, some of these are de- tailed. Although a wound may penetrate a joint, yet if it be small, and unattended with extravasation of blood, M. Larrey informs us, it will generally heal, provided too much compression be not employed. This gentleman believes in the common doctrine of the pernicious effect of the air on the cavities of the body; yet in this place a doubt seems to affect him: speaking ofthe less dan- ger of small wounds of joints, he says, " a quoi titnt cette d'ff' rence, puisque Pair penitre dans Varticula- tion dans Pun comme dans I autre cas ?" When two limbs have been at the same time so in- jured as to require amputation, we should not be afraid of amputating them both immediately, without any in- terval. We have, says Larrey, several times performed this double amputation with almost as much success as the amputation of a single member. He has re- corded an excellent case in confirmation of this state- ment.— (Mim. de Chir. Militaire, t. 2, p. 478.) When a limb is differently injured at the same time In two place*, and one of the wounds requires ampu-1 tation (suppose a wound of the leg with a splintered fracture of the bone, and a second of the thigh, done with a ball, but without any fracture ofthe os femoris, or other bad accident), Larrey recommends us first to dress the simple wound of the thigh and amputate the leg immediately afterward, if the knee be free from injury. When it is necessary to amputate above this joint, the less important wound need not be dressed till after the operation, provided it can be comprehended in the section ofthe member, or be so near the place of the incision as to alter the indication. When the wound demanding amputation is the upper one, the operation of course is to be done above it, without paying any regard to the injury situated lower down. Ninth case. To the foregoing species of gun-shot wounds, pointed out by Baron Larrey as urgently re- quiring immediate amputation, my own experience and Ihe observations of Dr. Thomson justify me in adding compound fractures of the thigh from gun-shot violence. I am particularly glad that the latter gentleman has devoted a proper degree of attention to these cases; for the opportunities which I had of judging when abroad, incline me to believe, that military surgeons are hardly yet sufficiently impressed with the propriety of imme- diate amputation in gun-shot fractures of the thigh. There were brought into my hospital at Oudenbosch, in 1814, about eight of such cases, all in the worst state for an operation, because several days had elapsed after the receipt of the injuries. All these patients died, ex- cepting one, whose fracture was not far above the con- dyles, and I do not know, that he ever regained a very useful limb. Another had indeed been rescued by am- putation from the dangers of the injury; but was un- fortunately lost by secondary hemorrhage about three days after the operation. The bleeding was almost instantly suppressed; yet such was the weakness of the patient, that the irritation of securing the vessel, and the loss of blood together, destroyed at once every hope of recovery. Were I to judge, then, from my own personal observations in the army, and from some other cases which I saw under my colleagues, I should without hesitation recommend immediate amputation in all cases of compound fractures of the thigh, caused by grape-shot, musket-balls, s the case may require, for returning the protruded intestine, securing the intestine itself, and promoting the adhesion of the parts, are all that the surgeon has to do in the way of" operation ; and even to this the less he interferes the better. Nature makes wonderful exertions to reUeve every injury inflicted upon her, and they are often surprisingly successful, if not injudiciously inter- fered with. In a penetrating wound of the abdomen, whether by gun-shot or by a cutting instrument, if no protrusion of intestine take place (and this, it must be observed, in musket or pistol wounds rarely occurs), the lancet, with its powerful concomitants, abstinence and rest, particularly in the suptoe posture, are our chief dependence. Great pain and tension, which usually accompany these wounds, must be reUeved by leeches to the abdomen (if they can be procured), by topical applications of fomentations, and the warm bath; and if any internal medicine is given as a purga- tive, it must, for obvious reasons, be of the mildest nature. The removal of the ingesta, as a source of irri- tation, is best effected by frequently repeated oleaginous clysters" (see Hennen's Principles of Military Sur- gery, p. 431, ed. 2); and with respect to dressings, as the same author has observed concerning cases in which a ball has passed directly through the abdomen, the mildest application should be employed, and no plugging with tents, nor introduction of medicated dressings, thought of.—(P. 406.) Iu this publication may be found cases, in which musket-balls were passed by stool (p. 404); in which an artificial anus was formed (p. 407, i-c.); or the kidneys, liver (p. 430—432), dia- phragm (p. 437), and other viscera, injured. The following case, exhibiting the possibility of re- covery, though the small intestine be completely severed with a baU, is interesting, particularly as cases of this kind have been regarded as jiositively fatal. The success was also obtained, notwithstanding the treatment appears to have been rather too officious, es- pecially in regard to four incisions made in the end of the bowel, when one would have removed the constric- tion spoken of. At the assault of Cairo, 1799, M. N. was shot in Ihe abdomen with a ball, which divided the muscular pa- rietes of this cavity on the right side, and a portion of the ileum. Larrey, being upon the field of battle, gave him the first assistance. The two ends of the intestine protruded in a separated and inflated state. The upper end was everted in such a way, that its contracted edge, like the prepuce in a case of paraphymosis, stran- gulated the intestinal tube. The course of the feces was thus obstructed, and the contents of the bowel ac- cumulated above the constriction. Although the patient's recovery was nearly hopeless, both from the nature of the wound and from the de- bility and cholera morbus, which had already seized him in the short period that he remained without succour to one of the intrenchments, Larrey was desirous of trying what could be done for so singular a case. He first made four small cuts through the constricted part of the intestine, with a pair of curved scissors, and put the bowel into its ordinary state. He passed a ligature through the piece of the mesentery, corresponding to the two extremities of the bowel. These he reduced as far as the margin of the opening, which he had taken care to dUate; and the dressings having been applied, he awaited events. The first days were attended with alarming symptoms, wbich, however, afterward sub- sided. Those which depended upon the loss of the ali- mentary matter, successively abated; and after two months, the ends of the Ueum were opposite each other, and disposed to become connected together. Larrey seconded the efforts of nature, and dressed the patient with a tampon or sort of tent, that was occasionally employed, for two months. The patient was then dis- charged from the hospital quite cured. In several instances, says Larrey, the sigmoid flexure of the colon was injured, and yet the wounds were cured without any fecal fistulae. At the siege of Acre, three examples occurred ; and at that of Cairo two. Larrey dilated the entrance and exit of the ball. Clysters, made of the decoction of linseed, and emollient beve- rages, were frequently exhibited; and the patients were kept on low diet, and in the most quiet state. Sword-wounds, and those made with the bayonet or lance, may injure some part of the bladder, or even pass through both sides of this organ. In the latter case, the injury is usually fatal, as the urine escapes from the toner wound into the abdomen, and immediately excites mortal inflammation. Baron Larrey dressed on tbe field of battle several soldiers, whose bladders were thus completely transfixed, and who all perished of in- flammation and gangrene, within the first forty-eight hours. However, he observes, that if the weapon enter the bladder at that part of its fundus which is not co- vered by the peritoneum, the case is curable, unless complicated with too much internal hemorrhage. The surest criterion of these cases is the escape of the urine from the external wound ; and its discharge may either be momentary, occasional, or continual; differences to be accounted for by the situation of the wound, and the changes which happen in the bladder. When the bladder is full, and its upper part is pierced, the urine will issue only just at the moment of the ac- cident, and as soon as it is discharged, the edges of the wound will come together, and permanently close, es- pecially if the urine can pass freely through the natural channel. But when this favourable condition is absent, the bladder becomes enormously distended again, the wound is opened anew, and the urine discharged once more from the external opening. The same things might happen, if one were to withdraw too soon tho GUN-SHOT WOUNDS. 449 •tastic gum catheter, which has been introduced: and by introducing the instrument again, the urine might be diverted from the wound, and its natural course re- established. Lastly, Larrey observes, that when the wound is situated at one of the lowest points of the bladder, the discharge of urine may be incessant, and be of more or less duration. When the track of these punctured wounds is ex- tensive, and not direct, -abscesses form at different points where the urine passes. These abscesses Larrey directs to be immediately opened, and their re- currence prevented by the introduction of an elastic gum catheter through the urethra; one of the chief means of relief in all wounds of the bladder. To- gether with this treatment, he recommends the warm bath, the application of camphorated otiy liniments to the belly, antispasmodic cooling medicines, frequent clysters, and sometimes cupping in the vicinity of the wound, or bleeding.—(See Mim. de Chir. Mil. t. 4, p. 286,287.) On the last two means of relief, it would have been better if Larrey had laid more stress; for, next to Ihe catheter, they are unquestionably the most essential. Baron Larrey informs us, that the gun-shot wounds of the bladder which occurred in Egypt had for the most part a favourable termination. The most re- markable case was that of F. Chaumette, a light-horse- man, who was wounded at the battle of Tabor. The ball passed across the hypogastrium, about one finger- breadth above the pubes, to the point of the left buttock, which corresponds to the ischiatic notch. Thedirection of the wound, and the issue of feces and urine from the two orifices, left no doubt that the bladder and rectum were injured. M. Milioz, who directed Ihe surgical affairs of the division of the army under Kleber, dili- gently pursued the same kind of treatment which he had seen Larrey adopt at the siege of Acre. During Ihe suppurative stage, the patient was affected with fever; and after tbe sloughs were detached, the dis- charge was very copious. A catheter that was passed into tbe bladder prevented an extravasation of the urine, and at the same time promoted the union of the wound of that viscus. This was healed the first, and the patient upon his return to Cairo was quite cured. Larrey has recorded several other interesting cases of wounds, either of the bladder alone, or of it and the rectum together, to which I must content myself with referring.—(See Mim. de Chir. Militaire, t. 2, p. 160. 165; t. 3, p. 340, i-c.; t. 4, p. 296, i-c.) A ball may go through both sides of the bladder, and then either perforate the neighbouring parts and escape externally, or bury itself deeply in the flesh. When it has gone quite through the bladder, and afterward passed out of the body again, urine blended with blood immediately issues from one or both apertures, accord- ing to their situation. The flow of urine through the urethra is either lessened, or completely suppressed; but through this passage the patient generally voids more or less blood. Acute and incessant pain is felt in the course of the wound, together with a frequent painftil desire to make water, nausea, sometimes actual vomiting, and extreme anxiety and restlessness. Either in its passage inwards, or its course outwards, the ball may have injured or perforated the rectum ; in which case, tbe urine passes into this bowel, and, mixing with the feces, is discharged from the anus. When a part of the bladder towards the cavity ofthe abdomen is injured, as, for instance, its posterior sur- face, which is covered by the peritoneum, the urine is generally extravasated within the belly, and inflamma- tion of. the preceding membrane is the immediate con- sequence. This inflammation spreads with rapidity, and attacks all the viscera, producing vast distention of the abdomen, fever, coma, and other bad symptoms, soon terminating in gangrene and death.—(Larrey, Mem. de Chir. Ma. t,4,p. 292, 293.) During the first four-and-twenty hours, very little urine escapes from gun-shot wounds of the bladder, in consequence of the swelling, which almost instantly affects the lips of the wound. When the bladder is fttil this fluid is discharged only at the moment of the acci- dent, and mostly only from the wound, by whieh the ball has made its exit. An extravasation is prevented by the thick slough which fills all the track of the injury and it is not till the deadened parts become loose, that any effusion can happen. Hence, it is of the highest Importance to introduce an elastic gum catheter into Ihe urethra, where it should be kept, and the instrument Vol. L—Ff should be large enough to fill exactly this canal; for, according to Baron Larrey's observations, if, at the pe- riod when the sloughs are detached, the urine has not a ready passage outwards, it passes through the wound, and is extravasated the more readily, inasmuch as the separation ofthe sloughs has occasioned many openings, by which the fluid may insinuate itself into the cellu- lar membrane. Hence gangrenous mischief and death On two points, my own experience would not lead me to join in the sentiments of Larrey: first, to oppo- sition to his statement, I am sure that there is risk of extravasation of urine earlier than the period which he specifies, having known this accident commence, as it were, within a few hours after the receipt of the wound; and, therefore, I should not depend upon the sloughs being always at first a complete barrier to extravasation of urine (indeed, their formation throughout the whole track of a gun-shot wodnd is by no means a regular occurrence), but invariably pass a catheter as soon as possible, for the more certain prevention of this dan- gerous consequence. Secondly, the period of the sepa- ration of sloughs may, indeed, often be contemporary with the first appearance or symptoms of extravasation, particularly in cases where the employment of the ca- theter is for some time deferred, as in Baron Larrey's practice, because then a partial extravasation of the urine, soon after the injury, and previous to the intro- duction of the catheter, will cause rapid sloughing, and actually prevent the adhesive inflammation from closing up the cavities of the cellular membrane to time to prevent a fatal extension of that irritating fluid among the surrounding parts. Were it not for the partial early effusion of urine, no doubt, the adhesive inflammation would, in these cases, soon have the same effect, in obvia- ting the danger of urinary extravasation,which it has after lithotomy, or paracentesis ofthe bladder.—(SeeBladder.) If is the practice of Baron Larrey to dilate the wounds, in order to facilitate the escape of the urine, which might otherwise lodge to the track of the ball ; and perhaps here the method may frequently be right, though I should conceive its propriety must usually depend upon whether the urine has a tendency to continue to flow out through the wounds or not, and upon the pre- sence of obstruction or not. And to confirmation of this opinion, I may cite Dr. Hennen's declaration, that in these cases, he has very rarely found it necessary to enlarge the wound when the catheter and proper dressings have been employed.—(Ore Military Surgery, p. 421, ed. 2.) And as soon as possible a large elastic gum catheter should be introduced, and left in the ure- thra, taking care to withdraw it, and pass in a clean one every two or three days, so that no incrustations may occur. Sometimes, however, the passage of a ca- theter is very difficult, as is the case when there are splinters of bone in the urethra, or the parts about the neck ofthe bladder are inflamed.—(Mim. de Chir. Mi- litaire, t. 4, p. 294.) Emollient clysters and acidulated demulcent drinks are to be prescribed, and the patient is to be kept upon a very low regimen, and in the most quiet state. The dressings are to be light and simple, and cleanliness observed.—(Op. cit. t. 2, p. 165—170.) Instead of camphorated embrocations to the abdomen, another means commended by Larrey, it appears to me, that this author's directions would have been more complete and judicious, had be advised to these cases bleeding, both topical and general. From the injury of arterial ramifications, or varicose vessels, blood is sometimes extravasated within the wounded bladder, and causes deep-seated irritation. According to Baron Larrey, the case is indicated by the symptoms of retention of urine, and those of inflamma- tion, with a small pulse, pallor ofthe countenance, and dryness ofthe wounds.—(T. 4, p. 295.) A more decided criterion, I should think, would be the partial escape of urine mixed with blood, a symptom which could deceive only where the urethra itself had been injured. Larrey states, that blood extravasated in the bladder rarely co- agulates, because blended with urine; and hence, he ad vises its discbarge to be facilitated by means of a catheter, and tepid, emollient, anodyne, injections— (T. 4, p. 295.) Sometimes balls carry before them into the bladder fragments of bone, small coins, pieces of buttons, &c.; or bits of bullets break off, and lodge to that viscus. When these extraneous bodies are not above a certain size, they are frequently voided through the urethra (see Cases in Dr. Hennen's work, p. 419. 422. 424, ie ed. 2); and their evacuation may be materiaUy fltcili 450 GUN-SHOT WOUNDS. tated by the introduction of an elastic gum catheter, the size of which is to be increased gradually, until the largest can be passed, when the foreign substances will readily enter the tube, or pass out through the dilated urethra. In this way Baron Larrey has saved gravel patients from a vast deal of suffering.—(Mem. de Chir. Mil. t. 4, p. 302.) In such cases, the urethral forceps made by Mr. Weiss might often be used with advantage.—(See Lithotomy.) When the ball is too large to be taken out in this manner, the lateral opera- tion is to be performed, and it ought to be done before the bladder falls into an ulcerated or gangrenous state, from the pressure and irritation of the foreign body. However, as wounds of this organ frequently give rise to dangerous inflammation, Larrey recommends this operation to be done either before its attack or not till after its subsidence.—(Vol. cit. p. 309.) In fact, almost all the operations of this kind on record have been done some considerable time after the receipt of the wound, and to this practice my own judgment would lead me to give a general preference. In one case, however, Larrey operated on the fourth day after the receipt of the wound, and with success. After the battle of Waterloo, I was not a little sur- prised to find, in the St. Elizabeth Hospital at Brussels, a considerable number of cases, in which either the intestines, the stomach, the omentum, or the bladder protruded. I think we had in the division under Mr. Collier and myself not less than three protrusions of the bladder. An order which I received to join the amiy in the field on the 27th of June, deprived me of the opportunity of witnessing the progress and termi- nation of these interesting cases. However, many had ended fatally before my departure from Brussels. GUN-SHOT WOUNDS OF THE THORAX. Wounds of the lungs, abstracted from other mischief, are now well known not -to be always fatal. Balls have been found in the substance of the lungs after having lodged there twenty years, during all which time the patients were healthy, and free from symp- toms indicative of the case.—(Percy, Manuel, ic.p. 2o\) Mr. Hunter had some reason to believe, that wounds of the lungs made with balls were generally less dan- gerous than such as were made with sharp-pointed in- struments ; for he had seen several patients recover af- ter they had been shot through the lungs, while other persons died of very small wounds of those organs, done with swords and bayonets. Perhaps one cause of this fact may be owing to the circumstance of gun- shot wounds generally bleeding less than other wounds, so that there is not so much danger of blood being, ef- fused in the cavity ofthe chest or the cells ofthe lungs. The indisposition of the orifice of a gun-shot wound to heal up too soon, is also another circumstance that must lessen the hazard, as whatever matter happens to be extravasated has thereby an opportunity of escaping. But from what has been stated, it must not be in- ferred that gun-shot wounds of the lungs are not ac- companied with a serious degree of danger. Frequently the patient expires instantly, being suffocated in conse- quence of profuse hemorrhage from those organs; for though it be true that gun-shot wounds generally do not bleed much when the injured vessels are under a certain size, yet the contrary is the case when the wounded vessels are like those situated towards the root of the lungs. Gun-shot wounds of the chest also often prove fatal by the inflammation that is excited within this cavity. Appearances sometimes create a belief, that a ball has passed completely through the chest and lungs, when the fact is otherwise. " Thus (as Dr. Hennen observes), I have traced a ball by dissection, passing into the cavity of the thorax, making the circuit ofthe lungs, penetrating nearly opposite the point of entrance, and giving the appearance ofthe man having been shot fairly across, while bloody sputa seemed to prove the fact, and in reality rendered the same measures, to a certain extent, as necessary as if the case had been what was suspected. The bloody sputa, however, were only secondary, and neither so active and alarming as those which pour out at once from the lungs when wounded."—(Military Surgery, p. 368, ed. 2.) A se- cond cause of deception is the frequent long course of a ball, round the chest under the skin and muscles, previously to its exit, whereby an appearance is pre- sented, as if the patient had been shot through the thorax. And another source of deception, as to lbs actual penetration of balls, is, "where they strike against a handkerchief, linen, cloth, &c, and are drawn out unperceived to their folds, a peculiarity which has not escajied M. Larrey, who gives an interesting notice on it to the Bulletins de la Faculti de Mid. Paris, 181*% No. 2. I have also given an instance in the preceding pages."—(Hennen, loco cit.) In these cases, the ab- sence of bloody expectoration directly after the injury, the undisturbed state of respiration, and the greater freedom from oppression, anxiety, syncope, and other bad symptoms, than in cases where the lungs are hurt, form grounds for a correct opinion on the true na- ture of the accident. It cannot be supposed that adhesions always take place round the opening of a gun-shot wound in the chest, because the lungs must sometimes collapse, and become considerably distant from the pleura, especially when the communication established between the at- mospheric air and the cavity of the thorax is very free and direct. However, as adhesions are extremely com- mon between the outer surface of the lungs, and ihe inner surface of the pleura costalis, they must to many instances exist before the receipt of a wound, and, of course, prevent the usual collapse ofthe lungs. As the general symptoms and treatment of wounds* of the chest are detailed in the article Wounds, I shall not here detain the reader long upon the subject. When a patient has been shot in the chest, the most impor- tant indication is to prevent and subdue inflammation of the lungs and pleura. In few other cases can re- peated and large bleedings be so advantageously prac- tised. Here there will not be so much danger of an extravasation of blood as in stabs; and even if an effti- sion of that fluid were to happen within the cavity of (he pleura, the opening would generally be sufficient for its escape, and it would not be so frequently found necessary to dilate the wound, or make a new opening, as when the injury has been inflicted with a sharp- pointed weapon. In this last kind of case, when attended in the begin- ning with bleeding, Baron Larrey particularly insists upon the advantage of immediately bringing the edges of the wound together with adhesive plaster, instead of leaving it open, as advised by the generality of writers-, and he endeavours to prove, that this immediate clo- sure of the wound has great effect in stopping the he- morrhage from the pulmonary vessels Supposing an extravasation of blood in the chest were to follow, he argues that it would be better to let it out afterward by a suitable incision, than to suffer the patient to perish of hemorrhage at once by not closing the wound.— (Mim de Chir. Mil. t. 4, p. 151, &c.) Dr. Hennen is in favour of the same practice.—(On Military Surgery, p. 373, ed. 2.) In a penetrating gun-shot wound of tho chest, after taking away from thirty to forty ounces of blood, the surgeon should extract all extraneous sub- stances and splinters of bone within reach, and even dilate the external wound for this purpose, if necessary. Light, unirritating dressings are then to be applied. The patient may now be (comparatively speaking) easy, until the spitting of blood, and danger of suffocation from inward hemorrhage come on again, when the- lancet must be again employed; " and if by this ma- nagement, repeated as often as circumstances demand,, the patient survives the first twelve hours, hopes may begin to be entertained of his recovering from the im mediate effects of hemorrhage;" and until this danget is over, as Dr. Hennen truly observes, the lancet is the only thing which can save life. Afterward, when the paroxysms of pain, the sense of suffocation, and the return of hemorrhage have become more moderate, di- gitalis may be prescribed with the most beneficial ef- fect ; and if the cough be very troublesome, no medi- cine is more useful than the spermaceti mixture with opium. With this treatment must be combined the exhibition of saline purgatives, mild laxative clysters, and a strictly low diet, the patient being allowed only slops.—(See Hennen's Military Surgery, p. 373, ed. 2.) When matter forms in the thorax, in consequence of gun-shot wounds, the opening will generaUy suffice for its escape; but should the collection of pus be con- fined, and occasion dangerous symptoms, the external wound must either be enlarged, or a new incision prac- tised, as circumstances may indicate. The mode of making an opening into the chest is considered in the article Paracentesis. GUN When a ball lodges, without falling into the chest, it tnay lie either in the substance of the parietes of this rwvity between the muscles, or in one ofthe intercostal spaces, and continue there a very long time without ruusing much inconvenience, or making its way out- wards. But when it is lodged in the thoracic cavity itself, it descends by its weight, and sometimes excites considerable irritation, suppuration, sinuses, and hectic symptoms; in this case, if its situation can be ascer- tained, Baron Larrey recommends an attempt to ex- tra.-t it. In an early stage of the case, he says that the intercostal space will often be wide enough to let the ball pass through it; but that, at a later period, this space becomes too narrow, and it will be neces- sary to cut away a portion of the tipper edge of tbe rib with a lenticular knife, which is to be preferred to a treptiine or saw. This advice is Supported by some very interesting cases.—(See Mem. de Chir. Mil. t. 4, p. 253.) Frequently the ball fractures the rib, and, with the aid of dilatation, sufficient room for its ex- traction may be made: but the possibility and propriety of removing it through the original opening will, of course, depend upon the situation of the foreign body, and the urgency of the symptoms. A case is recorded in which a ball, weighing three ounces and a half, was thus removed.—(Med. and Surg. Journ. vol. 3, p. 353.) Alphons. Ferrius de Sclopetorum, sive Archibuso- rum Vulneribus, i-c. Svo. Roma, 1552. /. F. Rota de Bellicorum Tormentariorum Vulneribus et Curatione, 4to. Bonon. 1555. Botaltusde Curat. Vulner. 1565. Wm. Clowe's Approved Treatise for all young Chirurgeons concernirig Burnings with Gunpowder, and Wounds made with Gun-shot, i-c.4to. 1591. /. Quercetanus, Sclopetarius, sive de curandis Vulneribus qua Sclo- petorum et similium Tormentorum Idibus acciderunt, Svo. 1591,12mo. Leipz. 1614. Fr. Plazzonus, de Vulne- ribus Sclopetorum, ic 4to. Venet. 1618. /. Woodal, Viaticum,fal. Lond. 1639. H. F. Le Dran, Traite, ou R flexions tiries de la Pratique sur les Plaies d'Armes dfeu, 2de id. \2mo. Paris, 1740. Desport, Traite des Plaies d'Armes A feu, 12mo. Paris, 1749. Ran- by's Method of treating Gun-sltol Wounds, 12mo. Lon- don, 1781. Observations sur les Plaies d'Armes dfeu, compliquies de Fracture aux Articulations des Extre- mitis, ou au Voisinage de ces Articulations, par M. Boucher, in Mim. de PAcad. de Chirurgie, t. 5, p. 279, idit. in 12mo. Observations sur des Plaies d'Armes d feu, compliquies sur tout de Fracas des Os, par M, Boucher, in opere cit. t. 6, p. 109, i-c. idit. in 12mo. Observations sur les Plaies d'Armes dfeu: 1. Sur un Coup de Fusil, avec Fracas des deux Machoires; par M. Cannae: 2. Sur une Plaie (PArme dfeu t.raversant la Poitrine d'un cdti d Pautre; par M. Gerard: 3. Sur une Plaie tPArme dfeu, p wtrante depuis la Par- tie ant rieure du Pubis jusqu'd POs Sacrum; par M. Andouilli: 4. Sur une Jambe icrasie par un Obus, ou petite Bombe; par M. Cannae: 5. Sur une Plaie d la Partie infirieure et interne de la Jambe, faite par un Eclat de Granade, sans Fracas tPOs; par M. Cannae: 6. Pricis de plusieurs Observations sur les Plaies d'Armes dfeuendifftrentes Parties,parM. Bordenave: —all these papers are inserted in Mim. die PAcad. de Chirurgie, t. 6, in 12mo.; and in t. 11 of the same edi- tion are inserted Memoires sur le Traitement des Plaies d'Armes d feu, par M. de la Martiniire, et Mhnoircs sur quelques Particularit.es concernant les Plaiesfaites par Armes dfeu, par M. Vacher. M. Faure1 s memoirs relative to amputation in cases of gun-shot wounds may be seen in t.8 ofthe Recueil des Piices qui ont concouru pour le Prix de PAcad. de Chirurgie, idit. in 12mo. John Hunter's Treatise on the Blood, Inflam- mation, and Gunrshot Wounds, 1794. Richter, An- fangsgriinde der Wundarzneykunst, b. 1. Schmucker, Vermischte Chir. Schriften, 3 vols. Svo. Berlin, 1776. 1782. Chirurgische Wahrnehmungen, Berlin, 2 vols. Svo. 1,44.1789: works of high value. Discourses on the Nature and Cure of Wounds by John Bell, p. 169, S-c. edit. 3. Richerand, Nosographie Chir. t. I, idit. 4. Chevalier's Treatise on Gun-shot Wounds, edit 3 Li- veUli, Nouvelle Doctrine Chirurgicale, t. 1, chap. 8, p. 436, ire. Encyclopidie Methodique, partie Chir. art Plates the child's agitations and cries would render the operation impracticable, or derange all the proceedings taken to ensure its success. It is plain however, that such reasons are not of great weight. A child, four or five years old, and very often even one eight or ten years of age, is more difficult to manage than an infant only a few months old. Every child of the above age has a thousand times more dread of the pain, than of the deformity or of the inconveniences of the complaint, to which he is habituated ; while an in- fant of tender years fears nothing, and only feels the pain of the moment. A more rational objection is the liability of infants to convulsions after operations, and this has induced many excellent surgeons to postpone the cure of the hare-lip tiU the child is about two years old. This custom is also sanctioned by SU- Astley Cooper, who mentions to his lectures several instances, which have either been communicated to him by others, or have occurred in his own practice, where operations for the cure of hare- lips in very young infants have had a fatal termination, in consequence of an attack of convulsions or diarrhoea. The period when dentition is completed, or the age of two years, he therefore sets down as the most advan- tageous for the operation, and if parents urge its being done earlier, he very properly advises the surgeon to let them be duly apprized of the risk, so that in the event of the child being cut off, he may not incur blame for having operated at a disadvantageous period of life.—(See Lancet, vol. 3, p. 108.) The latter end of 1823,1 met Sir Astley Cooper to consultation in a case where this yery question occurred. The deformity was particularly unsightly, in consequence of the upper jaw-bone being imperfectly ossified in front, and one side of it forming a considerable projection forwards through the fissure which extended into the nostril, at the same time that the nose was seriously distorted to one side of the face. The parents, persons of the first respectability, were therefore uncommonly solicit- ous for an early operation, some instances of the suc- cess of which in very young infants had already been communicated to them by their friends. The projection Of bone, they had also learned, might be cut away, so as to permit the soft parts to meet, which they now would not do. The risk of an operation on the infant in question, then scarcely two months old, was fairly explained to the parents; but I doubt whether they could have been prevailed upon to wait three months longer, had not Sir Astley Cooper represented to them the dis- advantages of cutting away the bony projection, and urged the allowance of a little time to reduce the pro- tuberance by means of pressure. As I had not had any previous conference with Sir Astley on the subject, I was particularly gratified in finding his advice agree precisely with what I had already given, when the case was first shown to me. Exactly when the infant was five months old, a period selected on account of its be- ing the latest previously to the usual time of the com- mencement of the ailments of dentition, I performed the operation in the presence of Messrs. Ives, of Chert- sey, and Mr. Ives, jun., of Chobham. By this time the bone had been so effectually depressed, by means of a kind of spring-truss, constructed by Messrs. Salmon and Ody for the purpose, and worn several hours daily, that the soft parts admitted of being brought over it with tolerable factiity. Union followed very well, and, though it was one of the worst hare-lips ever seen by Mr. Ives, senior, or myself, without an extensive divi- sion of the palate, the disfigurement is now very trivial, and the wrong direction of the nose constantly under- going farther diminution, to proportion as the jaw re- cedes under the pressureof the apparatus, which is sttil employed. This is the youngest infant on which I have operated; but, in October, 1824,1 performed the operation on an infant twelve months old, at Walton on Thames, where I was kindly assisted by Mr. Stillwell, surgeon to that town. Union took place very favourably, without arjy indisposition whatever. Only one pin was used at the lower part of the lip, as I found that the upper part of the division could be perfectly and readUy closed with a strip of adhesive plaster. Mr. Sharp observes, " there are many lips where the loss of substance is so great, that the edges ofthe fissure cannot be brought together, or at best where they can but just touch; in which case it need not be advised to forbear the attempt: it is likewise forbid in young qhil- dren, and with reason, if they suck; but otherwise it may be undertaken with great safety, and even with more probability of success than in others that are older."—(Operations in Surgery, chap. 34.) Le Dran performed the operation on children of all ages, even on those at the breast. B. Bell did it wilh success on an infant only three months old. Muys ad- vises it to be undertaken as soon as the child is six months old. Roonhuysen operated on children ten weeks after their birth, and all his contemporaries have praised his singular dexterity and success. As an es- sential step to the success of the operation, he recom- mended hindering the children from sleeping a certain length of lime before it was undertaken, in order that they might fall asleep immediately afterward; and with the same view opiates have been prescribed. Putting out of consideration the partial success which has attended the use of blistering plaster for making the edges of the fissure raw and capable of union, all practitioners entertain the same sentiment with regard to the object of this operation, which consists in reduc- ing the preternatural solution of continuity to the state of a simple wound, by cutting off the edges of the se- parated parts throughout their length, and then keep- ing these parts in contact untU they have completely grown together. But although such principles have been generally admitted, there was formerly some difference of opinion with respect to the best method to be followed in practice; some operators having pre- ferred sutures for keeping the edges of the wound in contact; while others disapproved of them, believing that a perfect cure might always be accomplished by means of adhesive plaster and a uniting bandage, so as to save the patient from all the pain and annoyance of sutures. M. Louis thought that the use of sutures in the ope- ration for the hare-lip proceeded from a false idea re- specting the nature of the disease; for, the fissure in the lip being wrongly imputed to loss of substance, it was deemed impossible to keep the parts to contact, except by a suture. " The separation of the edges of the fissure in tha lip," says M. Louis, " is only the effect of the retraction of the muscles, and is always proportioned to the ex- tent of the cleft. Persons with hare-lips are capable of bringing the edges of the fissure together by muscu- lar action, by puckering up their mouths. On the other hand, the separation is considerably increased when they laugh, and the breach appears excessively large after superficially paring off its edges on both sides. The interspace in the hare-lip must not, therefore, be mistaken for a loss of substance. This truth is con- firmed by the effects of sticking-plaster, which bas sometimes been applied to the hare-lip, as a preparatory measure before the operation, and wbich materially lessens the separation of the parts. According to the confession of all who have writ- ten in favour of the twisted suture, it seems advisable only on the false idea, that the hare-lip is the effect of a greater or less loss of substance: and they say, posi- tively, that we must not have recourse to it when there is only a simple division to be united. The twisted suture must then be proscribed from the operation for the natural hare-lip, since it is proved that this mal- formation is unattended with loss of substance. At the same time, a loss of substance is but too real, after the extirpation of scirrhous and cancerous tumours, to which tne lips are very subject.' Yet, even in these cases, the extensibility of the lips allows an attempt to be made to reunite the double incision, by which the tumour has been removed, and it succeeds without the smallest deformity, when care is taken to direct each incision obliquely, so that both of them form, where they meet, an acute angle, in the base of which the tu- mour is comprised. Here tbe means of union ought to be the more efficacious, because the difficulty of keeping the edges of the wound approximated is greater. M. Pibrac, to his memoir on the abuse of sutures, when speaking of the hare-lip, has already explained, that they are badly-conceived means, and more hurtful in proportion as there is a greater loss of substance, be- cause the greater the interspace is between the twe parts, the more fear is there of their efforts on tha HARE-LIP. 457 needles or pins left in the wound. Hence, care has al- ways been taken to make tbe dressings aid the opera- tion of the suture. After this consideration, judici- ously made by the partisans of this plan, there was only one more step to be taken, according to M. P">rac, in order to evince the necessity of proscribing it. The cap or copper headpiece described by Verduc and Nuck, for compressing the cheeks; the clasps of Heister; and strips of adhesive plaster; are all only inventions for the support of the parts, and keeping them from be- ing disunited. When the suture failed, it was by these means that the original deformity was corrected, to- gether with that produced by the laceration, which would not have occurred without the suture. As then, the dressings, when methodically applied, are capable of effectually rectifying the mischief of the suture, M. Louis inquires, why should they be considered only as a resource in a mere accidental case? Why should they not be made the chief and primary means of reu- niting the lip, even when there is a loss of substance? Nothing can be opposed to the proofs adduced upon this point. They are even drawn from the practice of those who have employed sutures without success. Such persons have themselves furnished the proofs of the bandage being capable of repairing the mischief resulting from the twisted suture." M. Louis, with a view of perfecting our notions on this matter, lays it down as a fact, that the retraction of the muscles being the cause of the separation of the edges of the fissure, it is not to these edges we are to apply the force which is to unite them; but that it should be applied farther to the very parts, whose ac- tion (the cause of the separation) is to be impeded, and whose contraction is thus to be prevented. A great many means for supporting the wound, only irritate the muscles and excite them to action, and it is this ac- tion which we should endeavour to overcome. The means for promoting union can only be methodical, when directly employed to prevent such action, by an immediate application on the point where it is to be re- sisted. The facility with which the parts may be brought forwards, so as to bring the two commissures of the lips into contact by the mere pressure of the hands, shows what may be expected from a very sim- ple apparatus, which will execute the same office with- out any effort, in a firm and permanent manner, and which will render sutures unnecessary, the inconve- niences of which are too well known. M. Louis, after having explained the reasons of the theory on which he founded his method, relates seve- ral cases, taken either from his own practice or that of others, to illustrate its advantages. He details the his- tory of twenty cases in which his plan perfectly suc- ceeded, both in accidental hare-lips, with considerable loss of substance, and in natural ones. In most of these instances, however, it was thought proper to as- sist the bandage with one stitch at the extremity ofthe fissure, close to the vermilion border of the lip, for the purpose of keeping the parts securely on a level. Notwithstanding the operation as performed with the twisted suture is opposed by an authority of such weight as that of M. Louis, stUl it is the method most commonly practised. No modem surgeons doubt that a hare-lip may be cured by means of adhesive piaster and uniting bandages, quite as perfectly as with a su- ture ; and all readily allow, that the first of these me- thods, as being more simple and less painful, would be preferable to the latter one, if it were equally sure of succeeding. But it is considered far more uncertain in its effect. To accomplish a complete cure, the parts to be united must be maintained in perfect contact, until they have contracted the necessary adhesion; and how can we always depend upon a bandage for keeping them from being displaced? What other means, be- sides a suture affords to this respect perfect security ? I shall first describe the operation as usually done teE^ f -he:presem **with the w^ **™™ The first thing is to examine whether there is any ad- hesion of the hp to the gum; and if there be, to divide it with a knife. Some authors (Sharp) recommend the frenulum, which attaches the lip Z\he^run, al ways to be divided: but when the hare-lip is at some distance from ihis part, it will not be in the way ofthe operation, and need not be cut. On the other hand when the fnenulum is situated in the centre of the di' vision, it is clear ihat in operating, we must necessa- rily include it to the incision, and it should therefore be divided beforehand, taking care not to encroach too much upon the gum, lest the alveolary process be laid bare; nor too much upon the lip, because making it thinner would be unfavourable to its union. When one of the incisor teeth opposite the fissure pro- jects forwards, it must be drawn, iest it distend and irri- tate the parts after they have been brought into con- tact. Sometimes, but particularly in cases in which there is a cleft in the bony part of the palate, a portion of the os maxillare superius forms such a projection just in the situation of the fissure in the lip, that it would render the union very difficult, if not impracticable. In this circumstance, the common plan has been to cut off the projecting angles of bone with a strong pair of bone- nippers. The part was then healed, and the operation for the hare-lip performed. Instead of cutting off the projection of bone, which is always a painftil measure, Desault used to emplcy simple compression, by which means the prominence was usually reduced in a few weeks, and the opportunity afforded of operating for the cure of the hare-lip.—((Euvres Chir. par Bichat, t. 2, p. 207.) Of course, the actual necessity of using bone-nippers, or even of having recourse to compres- sion of the bony projection, wiU depend upon circum- stances ; for if the prominence of bone be sharp and irregular, no surgeon, I conceive, would hesitate about the removal of such inequalities in preference to the trial of pressure. Mr. Dunn, of Scarborough, has ex- pressed to me his doubts whether cutting off the pro- jections of the alveolary process be ever necessary, as the pressure of the entire lip gradually diminishes the deformity. " I had (says he) two very unseemly cases, with an immense division of the palate, together with a projection of the alveolary process, which, with the incisor teeth, resembled the talons of a bird. A tuber- cular appendage of skin hung upon the base of the nose. By drawing the teeth in the first case very deli- cately, I avoided fracturing the bony projection. I then cut off* one edge of the nasal appendage, and of the lip on the same side, and attached them together with two needles. The wound was sufficiently united in a week or ten days to allow the same operation on the other side. In less than three weeks the boy was sent home quite well, to the astonishment of the neigh- bourhood, where his frightful appearance had made him an object of disgust and ridicule. I succeeded in tbe other case even without the extraction of the teeth. Both the patients can now articulate labial sounds, re- tain their saliva, and are gradually losing the inconve- nience of the passage of the mucus from the nose into the mouth, as the fissure is more contracted, and the projection by no means so disagreeable." These facts should lessen the haste with which certain operators proceed to cut off every projection of the alveolary process; for a moderate prominence of bone without any sharp, irritating edges or angles, will not hinder the success of the operation ; and even the propriety of removing teeth must entirely depend upon their be- ing likely, by their direction, to irritate the lip, and dis- turb the union of the fissure. One serious objection to cutting away the projection ►of the jaw is the deformity afterward likely to conti- nue during life from the deficiency of the incisores teeth; and another is, the subsequent overlapping of the lower jaw, and its projection beyond Ihe upper one; communicating to the mouth an appearance seen to very old subjects. These were the considerations which induced me, in the case above mentioned, to em- ploy pressure, which is much more conveniently ap- plied by means of a kind of spring-truss, adapted to the child's head, than with bandages, which would be seriously annoying, and the right action of which could not be regulated without the utmost difficulty. When also some of the bone must be cut away on account of its roughness and angular prominences, I advise the practitioner to remove only the irritating points, and afterward have recourse to pressure. In the operation, the grand object is to make as smooth and even a cut as possible, in order that it may more certainly unite by the first intention, and of such a shape that the cicatrix may form only one nar- row line. The edges of the fissure should, therefore, never be cut off with scissors, which constantly bruise the fibres which they divide, and a sharp knife is al- ways to be preferred. The best plan is, either toplaca any flat instrument, such as a piece of horn, wood, or 458 HARE-LIP. pasteboard, underneath one portion of the lip, and then holding the part stretched and supported on it, to cut away the whole of the callous edge ; or else to hold the part with a pair of forceps, the under blade of which is much broader than the upper one: the first serves to support the lip, the other contributes also to this effect, and, at the same time, serves as a sort of ruler for guiding the knife in an accurately straight line. When the forceps are preferred, the surgeon must of course leave on the side of the upper blade just as much of the edge of the fissure as is to be re- moved, so that it can be cut off with one sweep of the knife. This is to be done on each side of the cleft, observing the. rule, to make the new A wound in straight lines, because the sides of it can never be made to correspond without this caution. For instance, if the hare-lip had this shape, the incision ofthe edges must be continued in straight lines tUl they meet in the manner here represented. A In short, the two incisions are to be per- fectly straight, and are to meet at an angle above, in order that the whole track of the wound may be brought together, and united by the first intention. Two silver pins, made with steel points, are next to be introduced through the edges of the wound, so as to keep them accurately in contact; the lowest pin being introduced first, near the inferior termination of the wound, and the upper pin afterward, about a quarter of an inch higher up. A piece of thread is then to be repeatedly wound round the ends of the pins, from one side of the division to the other, first transversely, then obliquely, from the right or left end of one pin above, to the opposite end of the lower one, Sec Thus the thread is made to cross as many points of the wound as possible, which greatly contributes to maintaining its edges in even apposition. Any portion of the wound above the pins not closed by the preceding means may now have its edges brought together with a strip of ad- hesive plaster. Lastly, the ends of the pins are to be supported by small dossils of lint, placed between them and the flesh; a minute but essential circumstance, which, as my friend Mr. Dunn, of Scarborough, re- minds me, I forgot to mention in a former edition of this work. It is obvious that a great deal of exactness is requisite in introducing the pins, in order that the edges of the incision may afterward be precisely ap- plied to each other. For this purpose, some surgeons previously place the sides of the wound in the best po- sition, and mark with a pen the points at which the pins should enter and come out again; a method which, as far as my observations extend, merits imita- tion. The pins ought never to extend more deeply than about two-thirds through the substance of the lip, and it would be a great improvement always to have them of a flat, instead of a round shape, and a little curved, as this is the course which they naturally ought to take when introduced. The steel points should also admit of being easily taken off, whenthe pins have been applied; and, perhaps, having them to screw off and on is the best mode, as removing them in this way is not so likely to be attended with any sudden jerk which might be injurious to the wound, as if they were made to pull off. In general, the pins may be safely removed in abqut four days, when the support of sticking plaster will be quite sufficient. After the operation, the surgeon should never omit the use of compresses and a bandage for keeping for- ward the cheeks, so rhat the risk of the pins making their way out by ulceration, arising from the dragging of the soft parts on them, may be prevented. With this view, a close, strong nightcap, with a piece of broad tape attached to the back part of it, and with two ends of sufficient and equal length, is to be put on; a com- nress is then to be laid over one cheek, and fixed by bringing one portion of the tape forwards over it, which is to be fastened to the capon the opposite side of the head. The other compress is then to be applied, and fixed in a similar manner. Lastly, a bandage is to be put under the chin, and brought over each compress up to the top of the head, where the ends of it are to be fastened to the cap. During all these proceedings, until the compresses are well secured, the assistant must support them steadily with his hands. Lastly, the bandage, compresses, and cap ahould all be securely stitched together. The process just described is what is well known by the name of the twisted suture, which is applicable to other surgical cases, in which the grand object is to heal some fistula or opening by the first intention. Mr. Sharp says, it is of great service in fistula? of the ure- thra, remaining after the operation for the stone, in which case the callous edges may be cut off, and the lips ofthe wound held together by the above method. Although the generality of surgeons used the twisted suture, I ought to notice that Sir A. Cooper gives the preference to the common interrupted suture, on account of the difficulty sometimes experienced in withdrawing the pins, and the liability of the new adhesions to be broken on the occasion; whereas the threads of a com- mon suture may be cut and taken out with the greatest facility.—(See Lancet, vol. 3, p. 107.) However, as most children cry on the removal ofthe suture, .whether one kind or the other be employed, the only safe plan is not to withdraw the pins or ligatures till four complete days have elapsed from the time of the operation, when the adhesions will be tolerably strong; and the cheeks should always be held forwards by a skilful assistant during the period of changing the dressings, and until the compresses on the cheeks have been again duly se- cured with a bandage. [When pins are used in this operation, they ought to be made of gold, which is not liable to become oxi- dized. Instead, however, of these pins, which are ordi- narily made with steel points, Dr. Barton, of Philadel- phia, prefers to use a piece of iron wire, with a point made by simply cutting it with a pair of scissors; thus avoiding the risk ofthe steel point slipping off the pin, an accident which has often happened, and left the point within the lip. So many failures have occurred from the pins being torn out by the child, or catching in the nurse's clothes, that if there were no other objection to the use of pins, they ought to be abandoned. Many surgeons in this country (and among these Dr. Mott) have adopted the interrupted suture in cases of hare-lip, and with the most satisfactory results; and it is confidently believed that the twisted suture ought to be abandoned, on ac- count of the obvious objections which attach to every modification ofthe shape, configuration, and materials I ofthe pins. It will be seen that Sir A. Cooper has laid j it aside altogether.—Reese.] What has hitherto been stated refers to the most simple form of the hare-lip, viz. to that which presents only one fissure. When there are two clefts, the cure is accomplished on the same principle, but it is rather more difficult of execution; so that the old surgeons, until the time of Heister, almost all regarded the opera- tion for the double hare-lip as impracticable. Only a few described it, with the direction to operate on each fissure, just as if it were single. M. de la Faye even operated in this way with success.—(Mem. de PAcad. de Chir. t. 4, ito.) M. Louis was of opinion, that all difficulties Would be obviated by doing the operation at two different times, and awaiting the perfect cure of one ofthe fissures before that of the other was under- taken. Heitster had similar ideas, but he never put the scheme to practice, nor did he even positively ad- vise it. After all, however, experience proves that it is not essential to perform two operations for the cure of the double hare-lip. Desault found that when the edges of the two fissures were pared off, and care taken to let one ofthe pins pass across the central piece of the lip, the practice answered extremely well.—(See (Euvres Chir. t. 2, p. 201.) In cutting off the edges of the fissure, the incision must be carried to the upper part of the lip; and even when the fissure does not reach wholly up the lip, the same thing should be done; for in this manner the sides ofthe wound will admit of being applied together more uniformly, and the cicatrix will have a better ap- pearance. We should also not be too sparing of the edges, which are to be cut off. Practitioners, says M. Louis, persuaded that the hare-lip was a .division with loss of substance, have invariably advised the removal ofthe callous edges. But in the natural bare-lip, there is no callosity; the margins of the fissure are composed, like those of the lip itself, of a pulpy, fresh-coloured, vermilion flesh, covered with an exceedingly delicate cuticle. The whole of ihe part having this appearance must be taken away, together with a little of the trus skin. At the lower part of the fissure, towards the HARE-LIP. 4o9 nearest commissure, a rounded red substance is com- monly situated, which it is absolutely necessary to Include in the incision. Were this neglected, the union below would be unequal, and, through an injudicious economy, a degree of deformity would remain. The grand object, however, is to make the two incisions diverge at an acute angle, so that the edge- may be put into reciprocal contact their whole length, without the least inequality. . M. Louis used to operate as follows: the patient being seated in a good light, his head is to be supported on an assistant's breast, who with the fingers of both hands pushes the cheeks forwards, in order to bring the edges of the fissure near to each other. These are to be laid on a piece of pasteboard, which is co be put between the jaw and lip, and be an inch and a half long, from twelve to fifteen lines broad, and at most one line thick. The upper end should be rounded by flattening the comers. In order to facilitate the incision, the Up is to be stretched over the pasteboard, the operator holding one portion over the right with the thumb and index finger of the left hand, while the assistant does the same thing on the left side. Things being thus disposed, the edges of the hare-lip are to be cut off with two sweeps of the bistoury, in two oblique lines, forming an acute angle above the fissure. For the removal of the edges of the hare-lip, scissors have sometimes been preferred to a knife; but notwith- standing Desault's partiality to them, as most conve- nient (see (Euvres Chir. t. 2, p. 179), they ire now very generally disused. The pinching and braising which result from the action ofthe two blades are cir- cumstances which cannot be favourable to the union of the wound ; and though they may not commonly be serious enough to prevent union by the first intention, they might occasionally tend, with any other untoward occurrence, to hinder this desirable event. Let not practitioners here be led by Mr. B. Bell's statement, that in one instance he cut off one side of the fissure with a knife, and the other with scissors; that the latter cut produced least pain, and that on this side there was no more swelling nor inflammation than on the opposite one. The pins should be introduced at least two-thirds of the way through the substance of the lip, lest a furrow should remain on the inside of the part, which might prove troublesome by allowing pieces of food to lodge in it. There is, however, a Stronger reason for attend- ing to this circumstance, viz. the hemorrhage which may take place when it is neglected. As soon as the edges of the wound have been brought together by means ofthe suture, and the pins are properly placed, Ihe bleeding almost always ceases; but when the pins have not been introduced deeply enough, and the poste- rior surfaces of the incisions are not applied to each other, the blood may continue to run into the mouth, and give the surgeon an immense deal of trouble. In the memoir written by Louis, there is a case in which the patient died in consequence of such an accident. Persons who had undergone the operation were always advised to swallow their spittle, even though mixed with blood, in order to avoid disturbing the wound by getting rid of it otherwise. In the case alluded to, the patient, who had been operated upon for a cancerous affection of the lip, swallowed the/blood as he had been directed to do, and he bled so profusely that he died. On tha examination of the body, the stomach and small intestines were found full of blood. " This deplorable case," says the illustrious author who relates it," de- serves to be recorded for public instruction, for the purpose of keeping alive the attention of surgeons on all occasions, where, in consequence of any operation whatsoever, there is reason to apprehend bleeding in the cavity ofthe mouth. Platner is the only writer who as far as I know, foresaw this kind of danger. The bleed- ing from the edges of ihe wound stops of itself (says he) as soon as they have been brought into contact and stitched together; but care must be taken that the Da- tient does not swallow the blood, which mi»ht make him vomit, or else suffocate him. Hence his head should be elevated that the blood may escape 'externally a precaution more particularly necessary in young chil- drcu" Having described the mode of operating for the hare- ^p as approved of by the generality of practitioners and detaUed every thing which seemed material, I have'now onlv to explain the method adopted by M. Lquw *jja I sentiments respecting several particular points of the operation have been already stated; and an account of the means which he employed in lieu of the twisted suture, for uniting the edges of the wound, is aU that remains to be noticed. Several bandages for supporting the two portions of the divided lip, and lessening tbe pressure which they make against the pins, have been mentioned by authors. Franco and Quesnay, in particular, describe two kinds. These means were not only employed as auxtiiary, but even sometimes as curative ones, when it was impossible to use needles. To such bandages, too complicated and too uncertain in their effect, M. Louis prefers a simple linen roller, one inch wide, three ells long, and rolled up into two unequal heads. He begins with applying the body of this bandage to the middle ofthe forehead; he unrolls the two heads from before backwards, above the ears, between the upper part of the cartUage and the cranium, in order to let them cross on the nape of the neck, and then pass forwards agbto. The assistant who supports the head, and pushes forwards the cheeks, must lift up the ends of his fingers, in the place of which, on each side, a thick compress is to be put. This being covered, and pushed from behind forwards by the roller, will constantly perform the office of the assist- ant's fingers, who is to continue to support the appara- tus, until it is all completely applied. The longest of the two heads of the roller being slit in two places near the lip, presents two parallel openings; the remnant of the shortest one is divided into two parts, as far as its end. The two little narrow bands in which it termi- nates must then pass through the openings of the former, and cross upon the middle of the lip. The ends of the roller being carried from before backwards, are then to be made to cross again on the nape of the neck, where the shortest is to end. The remainder ofthe long one is to be employed in making turns round the head. This bandage may be still more securely fixed by means of a piece of rape, which is to pass the forehead over the sagittal suture, and be pinned at each end to the circumvolutions ofthe roller; while a second piece of tape is to cross the first one at the top of the head, and also to be attached at its extremities to the uniting bandage, and the compresses placed under the zygo- matic arches, for the purpose of pushing forwards the cheeks. This bandage is extremely simple, and would answer well as an auxiliary to the twisted suture. I think this last means will always be the favourite of the practical surgeon, because the desired effect can be produced by it with much less trouble than must be taken with the bandage, in order to render the operation of the latter sufficiently certain. Besides, as I have noticed, M. Louis himself mostly made one stitch near the red part of the Up, so that he cannot be said to have trusted altogether to the bandage. What has been said concerning the operation for the hare-lip, is equally applicable, not only to the- treat- ment of cancer of the lip, but also to that of accidental cuts or lacerations of this part, from any cause what- soever. We shall only remark, that in a recent wound, all the surgeon has to do, is to apply the twisted suture and adhesive plaster without delay. When there is a fissure in the bones forming the roof of the mouth, it usually diminishes, and gradually closes, after the hare-lip is cured. But this does not always happen, and when the parts remain so crtnsi- derably separated as to obstruct speech and deglutition, or cause any other inconvenience, a plate of gold or silver, exactly adapted to the arch of the palate, and steadied by means of a piece of sponge fixed to its con- vex side and introduced into the cleft, may sometimes be usefully employed. When the sponge is of suita- ble size and very dry before being used, the moisture of the adjacent parts will make it swell, and in many cases be sufficient to keep it in its situation, so as greatly to facilitate speaking and swallowing. Some- times, however, the fissure is so shaped that the sponge cannot be fixed in it: this principally happens when the opening widens very much towards the front of the jaw. In such cases, it has been proposed to fix a plate of gold by means of springs covered with the same metal. Platina, which is cheaper, might be used for the same purpose. The subject, however, of arti- | ficial palates is one on which much mechanical inge- nuity may yet be usefutiy exerted, and it can hardly be i expected that I should here do more than give refer- 460 HEA HEA ences to works in which the reader may find informa- tion upon it.—(See Fauchard, Le Chirurgien-Dentiste, 2 torn. l2mo. Paris, 1728. Camper, Vermischte Schrif- ten, No. 13. Loder's Journ. b. 2, p. 25, p. 185. i-c. Von Steveling iiber eine merkwurdige kunstliche Er- fetzung mehrerer, sowohl zur Sprache, als zum Schlucken nothwendiger, zerstorter Werkzeuge; Svo. Heidelb. 1793. Siebold, Chir. Tagebuch, No. 20. J. H. F. Autenrieth, Supplementa ad Hist. Embryonis Humani, quibus accedunt Observata quadam circa Pa- latum fissum, verosimillimamque illi medendi Metho- dum, ito. Tubing. 1797. Cullerion, in Journ. Gin. i-c. t. 19. Recueil Period, i-c. t. 11, p. 22. Did. des Sciences Med. t. 37, art. Obturateur. C. Graefe et Ph. von Walther, Journ. der Chir. b. 1, p. 1, 8vo. Berlin, 1820; in this work Graefe lias described a method of curing fissures in the soft palate by means of a parti- cular kind of suture, with the various instruments necessary in the operation.) [The operation of staphyloraphy, or palate suture was first performed in 1816, by Professor Graefe, of Berlin, and soon afterward repeated in Paris by M. Roux. Professor Warren, of Harvard University, was the first to perform it to this country, and Professor Ste- vens, of New-York, has since repeated it on a young man, set. 25, for a frightful congenital division of the pa- late, with very satisfactory success. This latter case is reported at length in the New-York Medical and Surgical Journal, for April, 1827.—Reese.] For information, relative to the hare-lip, see B. Bell's Surgery, vol. 4. Heister's Surgery. Le Dran's Opera- tions. Sluarp's Operations. F. D. Herissant, Mim. de PAcad. des Sciences, annie 1743, p. 86: a very curious case, complicatedwith a fissure in the palate, and two ob- long apertures at tlu sides of this cleft. In play, the child would sometimes fill his mouth with water, and through those apertures let it spout out at the nostrils, in imitation of what takes place in whales. G. D. La Faye, Mim. de PAcad. Roy ale de Chir. t.l,p. 605, annie 1743. E. Sandifort, Obs. Anat. Pathol. 4to. et Mu- seum Anat. p. 110. 164, Lugd. Bat. 1777. Flajani, Collezione d'Oss., i-c. t. 8, Svo. Roma. Lotto's Sur- gery, vol. 2. Louis, in Mim. de l'Acad. de Chir. t. 4, p. 385, 4to. annie 1768, t. 5, p. 292, annie 1774. De la Midecine Opiratoire, par Sabatier, t. 3, p. 272, Svo. Pa- ris, 1810. (Euvres Chir. de Desault, par Bichat, t. 2, p. 173. Traiti des Operations de Chirurgie, par A. Bertrandi, chap. 19. P. N. Haguette, Sur le Bec-de- liivre naturel, 4to. Paris, 1804. /. Kirby, Cases, i-c. Svo. Lond. 1819: forceps recommended for holding the lip in the operation. Richter, Anfangsgr. der Wun- darzn. b. 2, kap. 7. Locher de Operationelabii leporini, Jena, 1792. Fretur de Labio leporino, Hala, 1793. Rieg. van. der Hasencharte, Frankf. 1803. M. J. Che- lius, Handb. der Chir. b. 1, p. 425, Heidelb. 1826. Sprengel, Gesehichte der Chir. Operationen, b. l,p. 155. Graefe, Angiedasie, v. Langenbeck Bibl. b. 2, p. 359. Eckoldt, Ueber erne sehr complicirte Hasenscharte; Leipz. 1804, fol. HEAD, injuries of the. From the variety of parts of which the scalp is composed, from their structure, connexions, and uses, injuries done to it by external violence become of much more consequence than the same kind of ills can prove, when inflicted on the com- mon integuments of the rest of the body. One princi- pal reason of the danger in these cases depends upon Ihe free communication between the vessels of the pe- ricranium and those of the dura mater, through the diploe of the skull; for when inflammation is kindled in the former membrane, it may extend itself to the latter. According to Sir Astley Cooper, there are three modes in which wounds of the scalp may induce fatal consequences. 1st, by producing what is called au erysipelatous inflammation on the head; 2dly, by producing extensive suppuration under the tendon of the occipito-frontalis muscle; 3dly, by rendering a simple fracture compound, so as to cause more exten- sive inflammation of the dura mater.—(Lectures, vol. 1, p. 350.) The latter observation, as far as my inform- ation reaches, is new, and deserves the serious con- sideration of the practitioner; for to the great hospital where I was educated, and to all the practice which I have seen in the army and elsewhere, no analogy of this kind was ever suspected between ordinary com- pound fractures and those of the cranium. If the doc- trine be correct, it forms another weighty argument J against the method of cutting down to a fracture of the skull without urgent motives. Incised wounds of the scalp are, indeed, less liable than contused or lacerated ones to produce bad conse- quences ; but they ere not entirely devoid of danger; in proof of which, Sir Astley Cooper mentions the case of a lady of rank in the country who died from the re- moval of an encysted tumour ofthe scalp.—(Lectures, vol. \,p. 349.) Passing over these cases, however, which generally heal as weU the generality of cuts in the skin of other parts of the body, and require no particu- larity of treatment, Mr. Pott proceeds immediately to lacerated and punctured wounds. " The former may be reduced to two kinds: viz. those in which the scalp, though torn or unequally divided, still keeps its natu- ral situation, and is not stripped nor separated from the cranium to any considerable distance beyond the breadth of the wound; and those in which it is consi- derably detached from the parts it ought to cover. The first of these, if simple, and not combined with the symptoms or appearances of any other mischief, does not require any particular or different treatment from what the same kind of wounds require on all other parts;" but with respect to those in which the scalp is separated and detached from the parts it ought to co- ver, Mr. Pott makes no scruple of declaring it as his opinion, that its preservation ought always to be at- tempted, unless it be so torn as to be absolutely spoiled, or there are manifest present symptoms of other mis- chief. In former days, the excision of the lacerated and detached scalp was the general practice; but Mr. Pott had so often made the experiment of endeavour- ing to preserve the torn piece, and so often succeeded, that he recommended it as a thing always to be at- tempted, even though a part of the cranium were per- fectly bare. Here I may remark that all practitioners now inva- riably avoid cutting away the scalp, even in the cir- cumstances in which such practice was allowed by Pott. By spoiled, this eminent writer must mean so injured as necessarily to slough afterward. However, as no harm results from taking the chance of its not sloughing, which never can be with certainty foretold; and as the excision of the part is painful and pro- ductive of no benefit, even if sloughing must follow: such operation is, in every point of view, hurtful and wrong. With respect to other mischief, as a reason, the examination of the cranium, and even the applica- tion of the trephine, never, require any of the scalp to be cut away.—(See Trephine.) Let the surgeon, therefore, free the torn piece from all dirt or foreign.bodies, and restore it as quickly and as perfectly as hejfcan to its natural situation. Notwithstanding Mr. Pott assents to the employment of sutures for uniting certain lacerated wounds of the scalp, the best practitioners of the present day gene- rally employ only sticking plaster. Sometimes the loosened scalp will unite with the parts from which it is torn and separated, and there will be no other sore than what arises from the impracticability of bringing the lips of the wound into smooth and immediate con- tact, the scar of which sore must be small in propor- tion. Sometimes such perfect reunion is not to be ob- tained ; to which case, matter will be formed and col- lected in those places where the parts do not coalesce: but this does not necessarily make any difference ei- ther in the general intention or in the event; this mat- ter may easily be discharged by one or two small open- ings made with a lancet; the head will still preserve its natural covering; and the cure will be very little retarded by a few small abscesses. In some cases (as Pott proceeds to describe), th« whole separated piece will unite perfectly, and give little or no trouble, especially in young and healthy per- sons. In some, the union will take place in certain parts and not in others (also Brodie, in Med. Chir. Trans, vol. 14, p. 408); and consequently matter will be formed, and require to be discharged, perhaps at se- veral different points; and in some particular cases, circumstasces, and habits, there will be no union at all,. the torn cellular membrane or the naked aponeurosis wtil inflame and become sloughy, a considerable quan- tity of matter will be collected, and, perhaps, the cra- nium will be denuded. But even in this state of things, which does not very often happen, where care has been taken, and is almost the worst which can happen in the case of mere simple laceration and detachment, HEAD. 461 ff the surgeon will not be too soon or too much alarmed, nor in a hurry to cut, he will often find the cure much more feasible than he may at first imagine : let him take care to keep the inflammation under by proper means, let him have patience till the matter is fairly and fully formed, and the sloughs perfectly separated, and when this is accomplished, let him make a proper number of dependent openings for the discharge ol them, and let him by bandage and other proper ma- nagement keep the parts in constant contact with each other, and he will often And, that although he was foiled in his first intention of procuring immediate union, yet he will frequently succeed in this his se- cond ; he will yet save the scalp, shorten the cure, and prevent the great deformity arising (particularly to wo- men) not only from the scar, but from the total loss of hair. This union may often be procured, even though the cranium should have been perfectly denuded by the accident; and it is true, not only though it should have been stripped of its pericranium at first (see Aberne- thy on the Injuries of the Head, case 6), but even if that pericranium should have become sloughy and cast off, as Mr. Pott has often seen. " Exfoliation from a cranium laid bare by external violence, and to which no other injury has been done than merely stripping it of its covering, is a circum- stance (says Pott) which would not so often happen if it was not taken for granted that it must be, and the bone treated according to such expectation. The soft open texture of the bones of children and young people will frequently furnish an incarnation, which will cover their surface, and render exfoliation qitite unnecessary (see also Brodie, in Med. Chir. Trans, vol. 14, p. 409): and even in those of mature age, and in whom the bones are still harder, exfoliation is full as often tbe effect of art as the intention of nature, and produced by a method of dressing calculated to accomplish such end, under a supposition of its being necessary. Some- times, indeed, it happens that a small scale will neces- sarily separate, and the sore cannot be perfectly healed till such separation has been made; but this kind of exfoliation will be very small and thin in proportion to Ihat produced by art, that is, that produced by dressing the surface of Ihe bare bone with spirituous tinc- tures, Sec Small wounds, that is, such as are made by instru- ments or bodies which pierce or puncture rather than cut, are in general more apt to become inflamed and to give trouble than those which are larger; and, to this part particularly, aie sometimes attended with so high inflammation, and with such symptoms, as alarm both patient and surgeon. If the wound affects the cellular membrane only, and has not reached the aponeurosis or pericranium, the inflammation and tumour affect the whole head and face, the skin of which wears a yellowish cast, and is sometimes thick set with small bUsters, contain- ing the same coloured serum: it receives the impres- sion ofthe fingers, and becomes pale for a moment, but returns immediately to its inflamed colour; it is not very painful to tbe touch, and the eyelids and ears are always comprehended to the tumefaction, the former of which are sometimes so distended as to be closed; a feverish heat and thirst generally accompany it; the patient is restless, has a quick pulse, and most com- monly a nausea and inclination to vomit. This accident generally happens to persons of bilious habit, and is indeed an inflammation of the erysipela- tous kind: it is somewhat alarming to look at, but is not often attended with danger. The wound does to- deed neither look well, nor yield a kindly discharge, while ihe fever continues, but still it has nothing threatening in its appearance, none of that look which bespeaks internal mischief; the scalp continues to ad- here firmly to the skull, and the patient does not com- plain of that tensive pain, nor is he afflicted with that fatiguing restlessness which generaUy attends mis- chief underneath the cranium. Phlebotomy, lenient purges, and the use of the common febrifuge medicines, particularly those of the neutral kind, generally remove it in a short time When tlie inflammation is gone off, it leaves on the skm for a little whUe a yellowish tint and a dry scurf and, upon the disappearance of the disease, the wound immediately recovers a healthy aspect, and soon heals wii.iout any farther trouble. I do not believe that the exhibition of bark, to this form of erysipelas, is ever productive of any decided benefit. Wounds and contusions of the head, which affect the brain and its membranes, are also subject to an erysipelatous kind of swelling and inflammation; but it is very different both in its character and conse- quences from the preceding. In this (which is one of the effects of inflammation of the meninges), the febrile symptoms are much higher, the pulse harder and more frequent, the anxiety and restlessness extremely fatiguing, the pain in the bead intense; and as this kind of appearance is, in these circumstances, most frequently the immediate precursor of matter forming between the skull and dura mater, it is generally attended with irregular shi- verings, which are not followed by a critical sweat, nor afford any relief to the patient. To which it may be added, that in the former case the erysipelas generally appears within the first three or four days; whereas, in the latter, it seldom comes on till several days after the accident, when the symptomatic fever is got to some height. In the simple erysipelas, although the wound be crude and undigested, yet it has no other mark of mischief; the pericranium adheres firmly to the skull, and upon the cessation of the fever, all ap- pearances become immediately favourable. In that which accompanies injury done to the parts under- neath, the wound not only has a spongy, glassy, un- healthy aspect, but the pericranium in its neighbour- hood separates spontaneously from the bone, and quits all cohesion with it. In short, one is an accident pro- ceeding from a bUious habit, and not indicating any mischief beyond itself; the other is a symptom or a part of a disease, which is occasioned by injury done to the membranes of the brain : one portends little or no ill to the patient, and almost always ends well; the other implies great hazard, and most commonly ends fatally. It is therefore hardly necessary to say, that.it behooves every practitioner to be careful in distinguish- ing them from each other. If the wound be a small one, and has passed through the cellular membrane to the aponeurosis and pericra- nium, it is sometimes attended with very disagreeable, and even very alarming symptoms, but wbich arise from a different cause, and are very distinguishable from what has been yet mentioned. In this, the inflamed scalp does not rise into that de- gree of tumefaction as in the erysipelas, neither does it pit,Ar retain the impression of the fingers of an ex- aminer. It is of a deep red colour, unmixed with the yellow tint of the erysipelas; it appears tense, and is extremely painful to the touch: as it is not an affec- tion of the cellular membrane, and as the ears and the eyelids are not covered by the parts in which the wound is inflicted, they are seldom if ever compre- hended in the tumour, though they may partake of the general inflammation of the skin; it is generally at- tended with acute pain in the head, and such a degree of fever as prevents sleep, and sometimes brings on a delirium. A patient in these circumstances will admit more free evacuations by phlebotomy than one labouring under an erysipelas: the use of warm fomentation is required in both, in order to keep the skin clean and perspirable, but an emollient cataplasm, which is gene- rally forbid in the former, may to ihis latter case be used with great advantage. When the symptoms are not very pressing, nor the habit very inflammable, this method will prove suffi- cient; but it sometimes happens that the scalp is so tense, the pain so great, and the symptomatic fever so high, that by waiting for the slow effect of such means, the batient runs a risk from the continuance of the fever, or else the injured aponeurosis and pericranium, becoming sloughy, produce an abscess, and render the case both tedious and troublesome. A division of the wounded part by a simple incision down to the bone, about half an inch or an inch to length, wUl most commonly remove all the bad symptoms, and, if it be done in time, will render every thing else unne«e*' sary.*' We here perceive that, to this form of infls"1' mation. the practice of making an incision lu"1Jm- sanction of Pott; but the extent of the wound hre,j,oa mended is moderate, and very different from "*/H,*as of (been recently proposed for phlegmonous erJJL"of bocU the limbs. With respect to the good ef2itiy exag- an incision Desault considers the'" ^^ ' 462 HEAD. gerated by authors; and while he admits that they are useful when the inflammation extends under the apo- neurosis, he is not inclined to sanction it as a right proceeding in other instances.—(See (Euvres Chir. var Bichat, t. 2, p. 8.) Thus Mr. Pott was of opinion, that the differences of the symptoms in the foregoing cases depended upon whether the wound only affected the skin and cellular membrane or reached more deeply to the aponeurosis and pericranium; a doctrine which has been justly re- garded as questionable. With respect to the observa- tion that in a puncture of the aponeurosis the swell- ing is confined within the limits of this fascia, and does not extend to the ears and eyetids, it is a senti- ment which Desault thought arose rather from ana- tomical speculations than the observation of nature. The doctrine, indeed, must appear doubtful, when it is recollected, 1st, That the aponeurosis and pericranium are parts of scarcely any sensibility. 2dly, That the Opinion had its origin at a period when these parts were imagined to be highly sensible. 3dly, That in other parts of the body, a wound in which a fascia or the periosteum is concerned is rarely attended with the above-described severe symptoms. 4thly, That here the wounds often affect only ihe skin and cellular membrane, and yet these symptoms occur even with a phlegmonous character. 5tly, On the contrary, in other instances, in which the aponeurosis and pericra- nium are undoubtedly wounded, no bad symptoms at all take place. 6thly, These symptoms may almost always be removed by the exhibition of tartarized an- timony.—(CKuvres Chir. de Desault, t. 2, p. S.) In the case often named inflammation of the fascia, after bleeding, it is not the fascia itself, which is the real and chief seat of the pain, inflammation, &c, but the sub- jacent cellular membrane and muscles. The theory of Desault is, that the erysipelatous affections of the scalp, so frequent after injuries of the head, are con- nected With disorder of the functions of the liver, pro- duced by such accidents. Yet it is difficult to under- stand why a mere puncture of the scalp should cause this disorder of the liver more commonly than the same kind of wound of any other superficial part of the body. The injuries to which the scalp is liable from contu- sion, or appearances produced in it by such general causes may be divided into those in which the mischief is confined merely to the scalp, and those in which other parts are interested. The former, which only come under our present con- sideration, are not indeed of importance, considered abstractedly. The tumour is either very readily dissi- pated, or the extravasated blood causing it is easily got rid of by a small opentog. J. L. Petit first, and after- ward Pott, particularly noticed this case, on account of an accidental circumstance which sometimes at- tends it, and renders it liable to be very much mis- taken. " When the scalp receives a very smart blow, it often happens that a quantity of extravasated blood immediately forms a tumour, easily distinguishable from all others, and generally very easily cured. But it also sometimes happens, that this kind of tumour produces to the fingers of an unadvised or inattentive examiner a sensation so like to that of a fracture, with depression of the cranium, as may be easily mis- taken." Now if, upon such supposition, a surgeon immediately makes an incision into the tumid scalp, be may give his patient a great deal of unnecessary pain, and for that reason run some risk of his own character. " The touch is in this case so liable to deception, that recourse should always be had to other circumstances and symptoms, before an opinion be given. If a person with such tumour, occasioned by a blow, and attended with such appearances and feel, has any complaint which seems to be the effect of pressure made on the brain and nerves, or of any mischief done to the parts within the cranium, the division of the scalp, in order to inquire into the state of the skull, is right'and necessary; but if there are no such general symptoms, and the patient is in every respect perfectly well, the mere feel of something like a fracture will not authorize or vindicate such operation, since it will often be found that such sensation is a deception, and that, when the extravasated fluid is removed, or dis- sipated, the cranium is perfectly sound and uninjured." -{Pott.) With the exception of instances in which the dura" mater suppurates from a blow on the head, and the symptoms are such as to require the trephine, or other examples in which an abscess forms under the scalp, or a large quantity of blood is effused in the same situ- ation, none of the cases which have here been con- sidered can justify making incisions in the scalp. When blood is extravasated under the scalp, the sui- geon need not be too officious with his knife, merely because there is a tumour containing blood. The fa- cility with which an effusion of blood under the scalp is dispersed is well illustrated in a case mentioned by Mr. Brodie. He was consulted about a young gentle- man, under whose scalp an effusion of blood extended from the superciliary ridges to the nape of the neck, and from ear to ear. The blood appeared to be in a fluid state, and was so copious, that no part of the cranium could be felt. In a few weeks, and with Ihe aid of a cold lotion, the whole tumour was dispersed, Mr. Brodie observes, that whatever might be the ves- sel ruptured, it must have continued to bleed a con- siderable time, in order to produce so large an extravasa- tion. I have seen Jhree or fbur cases nearly as remark- able as the preceding, and having a similar favourable termination under the use of simple discutient lotions and occasional purgatives. In one instance, attended by Mr. Brodie, he succeeded in preventing the effusion from attaining the extent described in his other case, by means of pressure applied to the point where the blow had been received, and a vessel ruptured.—(See Med. Chir. Trans, vol. 15, p. 406.) The utility of an incision in what was supposed by Pott to be an inflammation of the aponeurosis is al least questionable, as far as it is done under the idea of merely obviating tension, without there being any matter to be discharged. Incisions, expressly for the purpose of exposing the bone, are only right as a pre- paratory step to trephining, when the necessity for this operation is indicated by decided and urgent symptoms of pressure on the brain. Now such pressure, in any of the examples above treated of, can only arise from a suppuration under the skull, a subject which will presently be considered. Dr. Hennen, in his truly practical work, has very properly advised surgeons not to be content with clip- ping away a little of the hair'around the injury, but al- ways to have the head shaved toaproperextent. This pro- ceeding, which is perfectly harmless in itself, is more ge- nerally right than the custom of cutting the scalp, which has been too frequently employed without any rational aim. The free removal of the hair directly aftert he acci- dent often brings into view marks indicative of other parts ofthe head having been struck besides that which is at first noticed, and thus the practitioner Will have a more correct notion of the serious nature of the acci- dent than he might otherwise have conceived, and be more strict in his mode of treatment. Nay, fractures and depression of the skull, sometimes not denoted by any disturbance of the functions of the brain, arid liable to escape observation while concealed under the hair, are frequently detected after its removal, and the sur- geon being now aware of the extent and situation of the mischief, must of course be better qualified to con- duct the treatment. In short, as Dr. Hennen has ob- served, " independent of the more accurate view (thus procured), we facilitate the application of leeches, if they may be found necessary, and of a most excellent adjuvant on all occasions, viz., cold applications." It affords me particular pleasure to be able to num- ber so good a surgeon as Dr. Hennen among the ad- vocates of Schrnucker's plan -'' having the head well shaved and covered with cloths wet with a very cold lotion ; a practice which the latter eminent surgeon al- ways adopted, whether a sabre-cut or gun-shot injury of this part had the appearance of being serious or not. " As soon as the patient was brought to the hospital with a wound of the head, whether the injury looked important or not (says Schmucker), I directed the hair to be immediately removed, and after the necessary di- latation applied dressings. Sixteen ounces of blood werenext taken away, and the evacuation, in less quan- tity, repeated, according to circumstances, three or four times within the space of twenty-four hours. The pulse now generally became softer, and the determina- tion of blood to the head lessened. Over the dressings and the whole of the head, thick cloths, dipped in iho cold mixture hereafter specified, were laid, and renewed HEAD. 463 overy hour. These cloths were kept in their place with the bandage called the grand couvre-chef.—(See Band- age.) As internal medicines, the nitrate ol potassa, neutial salts, and emollient and stimulating clysters, and gentle aperients were given. These means were employed, both in slight injuries and in these where the bones were depressed, and the fissures and fractures were accompanied with violent convulsive twitchings, coma, paralysis, and other bad symptoms ; and even in cases where the use ofthe trephine was indispensable, the practice was continued until the cure was complete." Schmucker assures us, that under such treatment, fewer patients with wounds ofthe head were lost than used previously to happen, especially of those whose injuries at first had the appearance of being but slight. —(See Chir. Wahrnehmungen, b. 1, p. 154.) Schmucker was led to try this practice by the great benefit which he had seen afforded by the application of cold water to the head in cases of mania, attended with great determination of blood to the brain. And in order to increase the efficacy of the water, he added to every five gallons of it two quarts of vinegar, six- teen ounces of nitre, and eight of the muriate of am- monia. This mixture was then preserved for use in a cold place.—(Vol. cit. p. 153.) Or, in order to avail ourselves fully of the frigorific effects of this mixture, it should be prepared, as Dr. Hennen observes, in small quantities, and used immediately before its tempera- ture has risen; or "snow, or pounded ice, or ice-water applied to the parts in a half filled bladder, or cloths simply dipped in cold water, will often answer every purpose.—(On Military Surgery, p. 279, ed. 2.) Dr. Hennen mentions one important fact, in recommenda- tion of cold applications, antimonials, and saline pur- gatives, preceded by the common blue pill, and assisted with quiet and abstinence, viz. by such means, " those troublesome puffy enlargements and erysipelatous af- fections of the scalp, which so often succeed to bruises, are prevented, and where the evacuant plan is duly ob- served, the extensive and formidable erysipelatous af- fections, so common formerly, are rare and mild at pre- sent in military hospitals." 2. Effects of Contusion on the Dura Mater and Parts within the Skull. In consequence of blows, falls, and other shocks, either blood may be effused under the cranium, or in- flammation and suppuration of the dura mater may arise. The best description of the latter case is that delivered by Mr. Pott. Smart and severe strokes on the middle part of the bones, at a distance from the sutures, he says, are most frequently followed by this kind of mischief: the coats of the small vessels, which sustain the injury, inflame and become sloughy, and in consequence of such alter- ation in them, the pericranium separates from the out- side of that part of the bone which received the blow, and the dura mater from the inside, the latter of which membranes, soon after such inflammation, becomes sloughy also, and furnishes matter, which matter being collected between the said membrane and the cranium, and having no natural outlet, whereby to escape or be discharged, brings on a train of very terrible symptoms, and is a very frequent cause of destruction. The effect of this kind of violence is frequently confined to the vessels connecting the dura mater to the cranium, to which case the matter is external to the said membrane; but sometimes the matter formed in consequence of such violence is found on the surface of the brain, or between the pia and dura mater, as well as on the sur- face of the latter; or, perhaps, in all these three situa- tions at the same time. The difference of this kind of disease from either an extravasation of blood or a concussion of the brain is great and obvious. "All the complaints produced by extravasation are such as proceed from pressure made on the brain and nerves, and obstruction to the circula- tion of the blood through the former; stupidity loss of sense and voluntary motion, laborious and obstructed pulse and respiration. Ac, and (which is of importance to remark), i/ the effusion bt at all considerable these symptoms appear immediately or very soon after the accident. The symptoms attending an inflamed or sloughy state of the membranes, in consequence of external vio- lence, are very different; they are all of the febrile kind and never at first imply any unnatural pressure • such are pain in the head, restlessness, want of sleep, fre- quent and hard pulse, hot and dry skin, flushed counte- nance, inflamed eyes, nausea, vomiting, rigor; and, to- wards the end, convulsion and delirium. And none of these appear at first, that is, immediately after the ac- cident ; seldom until some days are passed.'' This last observation, made by Pott, is one that is well worthy of the practitioner's constant recollection, lest he wrongly fancy his patient secure too soon, and neglect the early use of the only means by which a re-^ covery can be effected. Thus, as Sir Astley Cooper notices, the time when inflammation of the brain (and, it may be added, of its membranes) follows the violence is generally about a week ; rarely sooner. Frequently it does not come on IU1 a fortnight or three weeks after the injury; and even more time must elapse before the patient is quite safe, or ought to deviate from a strict and temperate regimen. In confirmation of this re- mark, a case is mentioned, where the neglect to keep the bowels regular brought on a fatal attack of inflam- mation of the brain, as late as four months after the receipt of a blow on the head.—(Lectures, ire. p. 339.> One set or class of symptoms is produced by an ex- travasated fluid making pressure on the brain and ori- gin of the nerves, so as to impair or abolish voluntary motion and the senses; the other is caused by the in- flamed or putrid state of the membranes covering the brain, and seldom affects the organs of sense, until the latter end of the disease, that is, until a considerable quantity of matter is formed, which matter must press like any other fluid. "If there be neither fissure nor fracture of the skull, nor extravasation nor commotion underneath it, and the scalp be neither considerably braised nor wounded, the mischief is seldom discovered or attended to for some few days. The first attack is generally by pain in the part which received the blow. This pain, though beginning in that point, is soon extended all over the head, and is attended with a languor, or dejection of strength and spirits, which are soon followed by a nau- sea and inclination to vomit, a vertigo or giddiness, a quick and hard pulse, and an incapacity of sleeping, at least quietly. A day or two after this attack, if no means preventive of inflammation are used, the part stricken generally swells, and becomes puffy and ten- der, but not painful; neither does the tumour arise to any considerable height, nor spread to any great ex- tent : if this tumid part of the scalp be now divided, the pericranium wUl be found of a darkish hue; and either quite detached or very easily separable from the skull, between which and it will be found a small quan- tity of dark-coloured ichor. If tbe disorder has made such progress that the peri- cranium is quite separated and detached from the skull, the latter will even now be found to be somewhat al- tered in colour from a sound, healthy bone. From this tune the symptoms generally advance more hastily and more apparently; the fever increases, the skin becomes hotter, the pulse quicker and harder, the sleep more disturbed, the anxiety and restlessness more fatiguing; and to these are generally added irregular rigors, which are not followed by any critical sweat, and which, instead of relieving the patient, add consi- derably to his sufferings. If the scalp has not been di- vided or removed, until the symptoms are thus far ad- vanced, the alteration of the colour of the bone will be found to be more remarkable; it will be found to be whiter and more dry than a healthy one; or, as Fallo- pius has very justly observed, it wUl be found to be more like a dead boue: the sanies or fluid between it and the pericranium will also, in this state, be found to- be more in quantity, and the said membrane will have a more livid, diseased aspect. In this state of matters, if the dura mater be denuded it will be found to be detached from the inside of the cranium, to have lost its bright silver hue, and to be, as it were, smeared over with a kind of mucus, or with matter, but not with blood. Every hour after this pe- riod, all the symptoms are exasperated, and advance with hasty strides: the headache and thirst become more intense, the strength decreases, the rigors are more frequent, and at last convulsive motions, attended in some with delirium, in others with paralysis or co- matose stupidity, finish the tragedy. If the scalp has not been divided till this point of time, and it be done now, a very offensive discoloured kind of fluid will be found lying on the bare cranium, HEAD. whose appearance will be stiU more unlike to the healthy natural one; if the bone be now perforated, matter will be found between it and the dura mater, generaUy in considerable quantity, but different in different cases and circumstances. Sometimes it wUl be in great abundance, and diffused over a very large part of the membrane; and sometimes the quantity will be less, and consequently the space which it occupies smaller. Sometimes it lies only on the exterior surface of the dura mater; and sometimes it is between it and the pia mater, or also even on the surface of the brain, or within the substance of it, &c. As the inflammation and separation of the dura ma- ter is not an immediate consequence of the violence, so neither are the symptoms immediate, seldom until some days have passed; the fever at first is slight, but in- creases gradually; as the membrane becomes more and more diseased, all the febrile symptoms are heightened; the formation of matter occasions rigors, frequent and irregular, until such a quantity is collected as brings on delirium, spasm, and death." When the scalp has been wounded, Mr. Pott ob- serves, the wound will for some little time have the same appearance as a mere simple wound of this part, unattended with other mischief, would have; it will, like that, at first discharge a thin sanies or gleet, and then begin to suppurate; it will digest, begin to incarn, and look perfectly well; but after a few days, all these favourable appearances will vanish; the sore will lose its florid complexion and granulated surface; will be- come pale, glassy, and flabby; instead of good matter, it will discharge only a thin discoloured sanies; the lint with which it is dressed, instead of coining off ea- sUy (as in a kindly suppurating sore), will stick to all parts of it; and the pericranium, instead of adhering firmly to the bone, will separate from it all round to some distance from the edges. " This alteration in the face and circumstances ofthe sore is produced merely by the diseased state of the parts underneath the skull; which is a circumstance of great importance in support of the doctrine advanced; and is demonstrably proved, by observing that this diseased aspect of the sore and this spontaneous sepa- ration of the pericranium are always confined to that part which covers the altered or injured portion ofthe dura mater, and do not at all affect the rest of the scalp: nay, if it has by accident been wounded^to any other part, or a portion has been removed from any part where no injury has been done to the dura mater, no such sepa- ration will happen, the detachment above will always correspond to that below, and be found no where else. The first appearance of alteration in the wound im- mediately succeeds the febrile attack; and as the febrile symptoms increase, the sore becomes worse and worse; Ihat is, degenerates more and more from a healthy, kindly aspect. Through the whole time from the first attack of the fever to the last and fatal period, an attentive observer will remark the gradual alteration of the colour of the bone, if it be bare. At first, it will be found to be whiter and more dry than the natural one; and as the symptoms increase, and either matter is collected or the dura mater becomes sloughy, the bone inclines more and more to a kind of purulent hue or whitish yellow: and it may also be worth while in this place to remark, that if the blow was on or very near to a suture, and the subject young, the said suture will often separate in such a manner as to let through it a loose, painful, ill-natured fungus; at which time, also, it is not uncommon for the patient's head and face to be attacked with an erysipelas. In those cases in which the scalp is very Uttle in- jured by the bruise, and in which there is no wound nor any immediate alarming symptoms or appearances, the patient feels little or no inconvenience, and seldom makes any complaint, until some few days are past. At the end of this uncertain time, he is generally at- tacked by the symptoms already recited; these are not pressing at first, but they soon increase to such a de- gree, as to baffle all our art: from whence it will ap- iiear, that when this is the case, the patient frequently suffers from what seemaat first to indicate his safety, and prevents such attempts being made, and such care from being taken of him, as might prove preventive of mischief. But if the integuments are so injured as to excite or claim our early regard, very useful information may iruui thence be collected; for whether the scalp be con- siderably bruised, or whether it be found neccssar to divide it for the discharge of extravasated blood, or on account of worse appearances or more urgent symp- toms, the state of the pericranium may be thereby sooner and more certainly known: if in the place of such bruise, the pericranium be found spontaneously de- tached from the skull, having a quantity of discoloured sanies between them under the tumid part, to the man- ner already mentioned, it may be regarded as a pretty certain indication, either that the dura mater is begin- ning to separate in the same manner, or that, if some preventive means be not immediately used, it will soon suffer; that is, it wtil inflame, separate from the skull, and give room for a collection of matter between them. And with regard to the wound itself, whether it was made at the time of the accident, or afterward artifi- cially, it is the same thing; if the alteration of its ap- pearance be as related, if the edges of it spontaneously quit their adhesion to the bone, and the febrile symp- toms are at the same time making their attack, these circumstances will serve to convey the same inform- ation, and to prove the same thing. The particular effect of contusion is frequently found to attend on fissures, and undepressed fractures of the cranium, as well as on extravasations of fluid, in cases where the bone is entire; and, on the other hand, all these do often happen without the concurrence of this individual mischief. All this is matter of accident: but let the other circumstances be what they may, the spontaneous separation of the altered pericranium, in consequence of a severe blow, is almost always fol- lowed by a suppuration between the cranium and dura mater; a circumstance extremely well worth attending to in fissures and undepressed fractures of the skull, because it is from this circumstance principally that the bad symptoms and the hazard in such cases arise. It is no very uncommon thing for a smart blow on the head to produce some immediate bad symptoms, which after a short space of time disappear and leave the patient perfectly well. A slight pain in the head, a little acceleration of pulse, a vertigo and sickness, sometimes immediately follow such accident, but do not continue many hours, especially if any evacuation has been used. These are not improbably owing to a Ught commotion of the brain, which having suffered no material injury thereby, soon cease. But if, after an interval of some time, the same symptoms are re- newed; if the patient, having been well, becomes again feverish and restless, and that without any new cause; if he complains of being languid and uneasy, sleeps disturbedly, loses his appettie, bas a hot skin, a hard, quick pulse, and a flushed, heated countenance; and neither irregularity 'of diet nor accidental cold has been productive of these; the mischief is most certainly impending, and that most probably under the skull. If the symptoms of pressure, such as stupidity, losa of sense, voluntary motion, &c, appear some few days after the head has suffered injury from external mis chief, they dp most probably imply an effusion of a fluid somewhere; this effusion may be in the sub- stance of the brain, in its ventricles, between its mem- branes, or on the surface ofthe dura mater; and which of these is the real situation of such extravasation is a matter of great uncertainty, none of them being at- tended with any peculiar mark or sign that can be de- pended upon as pointing it out precisely; but the in- flammation of the dura mater, and the formation of matter between it and the skull, in consequence of contusion, is generally indicated and preceded by one ■ which Mr. Pott has hardly ever known to fail; a puffy, circumscribed, indolent tumour of the scalp, and a spontaneous separation of the pericranium from tlie skull under such tumour. These appearances, therefore, following a smart blow on the head, and attended with languor, pain, restlessness, watching, quick pulse, headache, and slight, irregular shiverings, do almost infallibly indi- cate an inflamed dura mater, and pus either forming or formed between it and the cranium." By detachment of the pericranium is not meant every separation of it from the bone which it should cover. It may be, and often is, cut, torn, or scraped off, without any such consequence; but these sepa- rations are violent; whereas that which Mr. Pott means is spontaneous, and is produced by the destruction of those vessels by which it was connected with the skull, and by which the coiamuuication between it and HEAD. 465 the internal parts was carried on; and therefore it is to be observed, that it in not the mere removal of that membrane which causes the bad symptoms, but it is the inflammation of the dura mater; of which inflam- mation this spontaneous secession of the pericranium is an almost certain indication. Sometimes the scalp is so wounded at the time of the accident, or so torn away, as to leave the bone per- fectly bare; and yet the violence has not been such as to produce the evil just now spoken of. In this case, if the pericranium be only turned back along with the detached portion of scalp, there may be probability of its reunion; and it should therefore be immediately made clean and replaced, for the purpose of such expe- riment; which, if it succeeds, will save time and pre- vent considerable deformity. Should the attempt fail, it can only be in consequence of the detached part sloughing. Hence, removing it with a knife, though allowed by Pott, is now never practised. Frequently, when the scalp does not adhere at once, it becomes at- tached to the cranium afterward by a granulating process. When the detached piece sloughs, the worst that can happen is an exfoliation from the bare skull. sometimes the force which detaches or removes the scalp also occasions the mischief in question; but, the integuments being wounded or removed, we cannot have the criterion of the tumour of the scalp for the di- rect ion of our judgment. Our whole attention must be directed to the wound and general symptoms. The edges of the former will digest as well, and look as kindly for a few days, as if no mischief was done un- derneath. But after some little space of time, when the patient begins to be restless and hot, and to com- plain of pain in the head, these edges will lose their vermilion hue, and become pale and flabby. Instead of matter, they will discharge a thin gleet, and the pe- ricranium will loosen from the skull to some distance from the said edges. Immediately after this, all ihe general symptoms are increased and exasperated; and as the inflammation of the membrane is heightened or extended, they become daily worse and worse, until a quantity of matter is formed and collected, and brings ,wi that fatal period, which, though uncertain as to date, very seldom fails to arrive. " The method of attempting the relief of this kind of injury consists in two points: viz. to endeavour to pre- vent the inflammation of the dura mater; or, that being neglected or found impracticable, to give discharge to the fluid collected within the cranium, in consequence of such inflammation. Of all the remedies in the power of art, for inflam- mations of membranous parts, there is none equal to phlebotomy. To this truth many diseases bear testi- mony ; pleurisies, ophthalmies, strangulated hernias, Sec; and if any thing can particularly contribute to the prevention of the ills likely to follow severe con- tusions of the head, it is this kind of evacuation; but then it must be made use of in such a manner as to be- come truly a preventive; that is, it must be made use of immediately and freely." Acceleration or hardness of pulse, restlessness, anx- iety, and any degree of fever, after a smart blow on the head, are always to be suspected and attended to. Im- mediate, plentiful, and repeated evacuations by bleed- ing have in many instances removed * these in per- sons to whom Mr. Pott firmly believes very terrible mischief would have happened, had not such precau- tion been used. In this, as well as some other parts of practice, we neither have nor can have any other method of judging, than by comparing together cases apparently similar. Mr. Pott had more than once or twice seen that increased velocity and hardness of pulse, and that oppressive languor, which most fre- quently precede mischief under the bone, removed by free and related bloodletting; and had often, much too often, seen cases end fatally, whose beginnings were fully as slight, but in which such evacuation had been either neglected or not complied with. This ju- dicious writer, " would by no means he thought to in- fer from hence, that early bleeding will always prove a certain preservative; and that thev onlv die to whom it has not been applied: this, like all other hu- man means, is fallible; and perhaps there are more cases out of its reach than within it, but where pre- ventive means can take place, this is eertainly the best and the most frequently successful. The second intention, viz. the discharge of matter Vol. I —G g collected under the cranium, can be answered only by the perforation of it. When from the symptoms and appearances already described, there is just reasan for supposing matter to be formed under the skull, the operation of perforation cannot be performed too soon : it seldom happens that it is done soon enough." In short, whenever the dura mater, after the head has received external violence, separates or is detached spontaneously from the bone underneath it, and such separation is attended with the collection of a small quantity of thin brown ichor, an alteration of colour in the separated pericranium, unnatural dryness ofthe bone, chilliness, horripilatio, languor, and some degree of fever, Mr. Pott considers the operation indispensably necessary to save the patient's life. When the skull has been once perforated, and the dura mater thereby laid bare, the state of the matter must principally determine the surgeon's future conduct. In some cases, one opening will prove sufficient for all necessary purposes; in others, several may be necessary. Notwithstanding the operation of perforation be abso- lutely and unavoidably necessary, as Mr. Pott remarks, " the repetition of bloodletting or cooling laxative me- dicines, the use of antiphlogistic remedies, and a most strict observance of a low diet and regimen, are as in- dispensably requisite after such operation as before: the perforation sets the membrane free from pressure, and gives vent to collected matter, but nothing more; the inflamed state ofthe parts under the skull, and all the necessary consequences of such inflammation, call for all our attention, full as much afterward as before; and although the patient must have perished without the use of the trephine, yet the merely having used it will not preserve him without every other caution and care."— (Pott.) In relation to this subject, a remark made by Sir Ast- ley Cooper merits notice : when pus lies between the dura mater and skull, the application of the trephine, he acknowledges, is a successful practice; but, accord- ing to his experience, this situation of the purulent matter is comparatively rare, as it generally collects between the pia mater and surface of the brain, for which case an operation will be useless.—(Lectures, i-c. vol. 1, p. 325.) It is stated by Mr. Brodie, that in hospital practice, suppuration between the dura mater and the bone, in consequence of fracture, is also less common at the present period than when Mr. Poll wrote; a change which he refers to the stricter anti- phlogistic plan adopted by modern surgeons, whether the early symptoms be or be not of a dangerous de- scription. —(See Med. Chir. Trans, vol. 14, p. 411.) I think it not improper to recommend again the prac- tice of applying cold wet cloths to the head for the pre- vention and relief of inflammation of the dura mater; a plan to which, as already explained, Schmucker as- cribed a good deal ofthe success with which he treated injuries ofthe head. It is favourably mentioned by Dr. Hennen. and has received the recommendation of an- other modem writer, whose opinion must have great weight: " In the inflammation which succeeds slowly to injuries of the head, a species of inflammation not more insidious in its approach than dangerous in its consequences, cold is by far the most efficacious re- medy that has yet been discovered."—(See Thomson's Lectures on Inflammation, p. 181.) Both tables of the skull sometimes exfoliate in con- sequence of external violence. The dead bone must be removed, as soon as loose; and, if necessary, the scalp divided for the purpose. 3. Fissures and Fractures of the Cranium, without Depression. . Fractures ofthe cranium are divisible into " those in which the broken parts keep their proper level or equality of surface with the rest ofthe skull, and those in which they do not; or in other words, fractures without depression and fractures with. These two distinctions are all which are really ne- cessary to be made, and will be found to comprehend every violent division of the parts of the skuU (not made by a cutting instrument), from the finest eajrfl- lary fissure, up to the most complicated fracture."— (Pott.) In most instances, the fracture takes place-in the upper part of the cranium; and it is also correctly noticed by Mr. Brodie, that fractures of its basis arc always the consequence of very great -violence, and re- 466 HEAD. covcries from them comparatively -rare.—(Med. Chir Trans, vol. 14, p. 30*.) -sometimes the fracture does not occur_ai-rte point to which the violence has been directly applied, but elsev^here, as the effect of what the trench term a contre-coup. Various explanations or the tact have been offered. Mr. Earle has never known it happen, except when tbe occiput seemed to have been forcibly impelled against the atlas-(Brodie in Med. Clur. Trans, vol. 14, p. 329.) An ingenious at- tempt to account for the circumstance may be found in the wnti ngs of Mr. C. Bell; though certain cases on re- cord will not conform to any principles yet offered in ex- planation ol them. Thedisjunctionofthesuturesismuch more rare than fractures of the cranium, and can only happen in young subjects, in whom the sutures are not yet consolidated. They are accidents implying the ope- ration of great violence, and in this point of view may be viewed as dangerous.—(See Brodie, in Med.Chir.Trans. vol. 14, p. 332.) No truth in surgery is now better understood and established, than that the bad symptoms very fre- quently accompanying a broken skull are not produced by the breach made in the bone, nor indicate such breach to have been made. As Sir Astley Cooper re- marks, the danger of fractures of the skull depends upon their being united with concussion or extravasa- tion ; there is also a remote danger from inflammation. —(Lectures, ic. p. 289.) This was the doctrine so well explained by Pott, who observes " the sickness, giddiness, vomiting, and loss of sense and motion can only be the consequence of an affection ofthe brain, as the common sensorium. They may be produced by its having been violently shaken, by a derangement of its medullary structure, or by unnatural pressure made by a fluid extravasated on its surface, or within its ventricles; but never can be caused by the mere divi- sion of the bone (considered abstractedly); which di- vision, in a sjmple fracture, can neither press on nor derange the structure of the parts within the cranium. If the solution of continuity in the bone be either produced by such a degree of violence as hath caused 8 considerable disturbance in the medullary parts of me brain, or has disturbed any of the functions of the nerves going off from it; or has occasioned a breach of any vessel or vessels, whether sanguine or lymphatic, and that hath been followed by an extravasation or lodgement of fluid; the symptoms necessarily conse- quent upon such derangement, or such pressure, will foUow: but they do not follow because the bone is broken ; their causes are superadded to the fracture, and although produced by the same external violence, are yet perfectly and absolutely independent of it; so much so that they are frequently found where no fracture is. The operation of the trepan is frequently performed in the case of simple fractures, and that very judi- ciously and properly; but it is not performed because the bone is broken or cracked. A mere fracture or fissure of the skull can never require perforation, or that the dura mater under it be laid bare; the reason for doing this springs from other causes than the frac- ture, and those really independent of it: they spring from the nature ofthe mischief which the parts within the cranium have sustained, and not from the acciden- tal (Uvisiou of the bone. From these arise the threat- ening symptoms; from these all the hazard ; and from these the necessity and vindication of performing the operation ofthe trepan. If a simple fracture of the cranium was unattended in present with any of the before-mentioned symptoms, and there was no reason for apprehending any other 'wil in future, that is, if the solution of continuity in the bone was the whole disease, it could not possibly indicate any other curative intention but the general one in all fractures, viz. the union of the divided parts." Even fractures of the basis of the skull, which are most frequently fatal, prove so, not because this part ofthe cranium is broken (the fracture itself being here not more dangerous than elsewhere), bui " because it is almost invariably complicated with extensive injury of other and more important parts."—(Brodie, in Med. Chir. Trans, vol. 14, p. 328.) The post mortem ex- aminations which I have attended,lead me to believe that most of these cases are complicated with extravasation. 1 could relate numerous examples to the point, if it were any longer necessary', to '%'e present state of sur- gical knowledge, to cite facts in proof of the important truth, that the mere undepressed fissure or fracture of the skull itself cannot be the source of the Immediate bad symptoms, but that in these cases the whole ofthe sudden peril arises from the manner in which the brain and its membranes have been hurt by the same vio- lence which caused the injury of the bone. Professor Thomson had opportunities of witnessing in the Nether- lands several instances, which can leave no doubt upon this subject. " In some of the wounds (says he) in which the head had been struck obliquely by the sabre, portions of the cranium had been removed, without the brain appearing to have sustained much injury. In one case of this kind, where a considerable portion of the upper part of the occipital bone, along with the dura mater, had been removed, a tendency to protrusion of the brato took place during an attack of inflammation ; a slight degree of stupor with loss of memory occurred; but on the inflammatory state having been subdued, the brain sunk to its former level, the stupor went off, and the memory relumed:"—and in another remarka- ble sabre-cut, more than au inch in breadth of the left lobe of the cerebellum was exposed, and was seen pul- sating for a period of eight weeks, yet the injury was unaccompanied with any particular constitutional symptoms.—(See Obs. made in the Military Hospitals of Belgium, p. 50, 51.) In many cases of simple undepressed fractures of the cranium, it is true that trephining is necessary; but the reasons for the operation in these instances are, first, the immediate relief of present symptoms, arising from the pressure of extravasated fluid ; and, secondly, the discharge of matter, formed between the skull and dura mater, in consequence of inflammation. The operation of trephining was also recommended by Pott, as a pre- ventive of ill consequences; a practice, however, which is now never adopted ; and many writers of the highest reputation, especially Desault, Dease, Mr. John Bell, and Mr. Abernethy. have strongly remonstrated against it. The latter remarks, ." In the accounts which we have of tbe former practice in France, it is related, that surgeons made numerous perforations along the whole track of a fracture of the cranium ; and, as far as I am able to judge, without any clear design. Mr. Pott also advises such an operation, with a view to prevent the inflammation and suppuration of the dura mater, which he so much apprehended. But many cases have oc- curred of late, where, even in fractures with depres- sion, the patients have done well without an operation.** Mr. Abernethy next relates several cases of fracture ofthe cranium with depression, which terminated fa- vourably, although no operation was performed. This judicious surgeon thinks that these cases, as well as a great many others on record, prove that at all events a slight degree of pressure may not derange the functions ofthe brain, for a limited time after its application, and in this circumstance probably never; for all those pa- tients whom he had an opportunity of knowing for any length of time after the accident, continued as well as if nothing of the kind had happened to them. In Mr. Hill's Cases in Surgery, two instances of this sort are related, and Mr. Hill knew both the patients for many years afterward : yet no inconvenience arose. Indeed, it is not easy to conceive that the pressure, which caused no ill effects at a time when the contents ofthe cranium filled its cavity completely, should afterward prove injurious, when they have adapted themselves to its altered size and shape. Severe Ulness, it is true, of- ten intervenes between the receipt of the injury, and the time of its recovery; and many surgeons might be in- clined to attribute this to pressure ; but it equally oc- curs when the depressed portion is elevated. If a sur- geon, prepossessed with the opinion Ihat elevation of the bone is necessary in every instance of depressed cranium, should have acted upon this opinion in seve- ral of the cases which Mr. Abernethy has related, and afterward have employed proper evacuations, his pa- tients would probably have had no bad symptoms, and he would naturally have attributed their well-doing to the mode of treatment which he had pursued: yet these cases did equally well without an operation.—(See Aber- nethy'sSurgical Works,vol.2,p.4,i-c.8vo.Ijond. 1811.) Depressed fractures of the skull not being our imme- diate consideration, we need not expatiate upon them ; but it seemed right to make the preceding remarks, in order to show how unnecessary il must be to trephine a patient, merely because there is a fracture in the cra- nium, and with a view of preventing-baA consequences. E -en wh;-n the fracture is depress d, it is not utcts- HEAD. 467 sary, unless there are evident signs that the degree of pressure thus produced on the brain is tbe cause of existing bad symptoms. The inflammation and suppuration of the parts be- neath the skull, which Mr. Pott wished so much to prevent by trephining early, do not arise from the oc- currence of a breach in the cranium, but are the conse- quences of the same violence which was the occasion of the fracture. Hence it is obvious, that removing a portion of the bone cannot in the least prevent the in- flammation and suppuration, which must result from Ihe external violence which was first applied to the head; but, on the contrary, such a removal, being an additional violence, must have a tendency to increase the inevitable inflammatory mischief. From what has been said, it is not to be inferred, how- ever, that trephining is nev'er proper, when there is a simple undepressed fracture of the skull. Such injury may be joined with an extravasation of blood on the dura mater; or it may be followed by the formation of matter between this membrane and the cranium; in both which circumstances, the operation is essential to the preservation of the patient, immediately, but not before the symptoms indicative of the existence of dan- gerous pressure on the brain begin to show themselves. —(See Trephine.) A fracture of the skull, unattended with urgent symp- toms, and not brought into the surgeon's view by any accidental wound ofthe integuments, often remains for ever undiscovered; and as no benefit could arise from laying it bare by an incision, such practice should never be adopted. The surgeon ought only to be officious in this way, when he can accomplish by it some better object than the mere gratification of his own curiosity. And an we shall find from the perusal of this article, und the one entitled Trephine, that in these cases, the removal of pressure off the surface of the brain is the only possible reason for ever perforating the cranium with this instrument; and as dividing the scalp is only a useful measure when it is preparatory to such ope- ration ; neither the one nor the other should ever be practised, unless there exist unequivocal symptoms that there is a dangerous degree of pressure operating on the brain, and caused either by matter, extravasated blood, or a depressed portion of the skull. If any ex- ceptions can be made to this observation, these are cases in which it is advisable to remove loose splinters and fragments of bone, or balls, plainly felt under the scalp. The true mode of preventing the bad effects, fre- quently following, but not arising from, simple fractures of the skull, is not to trephine, but to put to practice all kinds of antiphlogistic means. For this purpose, let the patient be repeatedly and copiously bled, both from the arm and temporal arteries; let him be properly purged ; give him antimonials; keep him on the lowest diet; let him remain in the most quiet situation possible; and if, notwithstanding such steps, the symptoms of inflammation of the brain continue to increase, let a large blister be applied to the scalp. If the scalp be wounded, it is to be healed as speedily as possible. Bloodletting and purgatives (as Sir Astley Cooper re- marks) will sometimes remove the symptoms of con- cussion and extravasation, when they accompany the fracture, and a few hours will often show that the tre- phine, which was at first thought indispensable, is un- necessary. Irreparable mischief might arise from your making an incision, and converting a simple into a compound fracture. " If you act prudently (he adds), you will try bleeding and purgatives before you operate; and the depletion will prove of the greatest possible advantage i n preventinginflammation."—(Lectures, vol. l,p.299.) These are the cases, also, to which the topical application of cold water to the shaved and naked Read, by means of cloths kept constantly wet, is an eligible, though in this country a much-neglected practice. Nume- rous instances, however, in favour of the method are re- corded by the experienced Schmucker (CAi'r. Wahrneh- mungtn, b. 1, Berlin, 1774), and the trials which I have seen made of it, give me a high opinion of its superior efficacy. When, in spite of all these measures, matter forms under the cranium, attended with symptoms of pressure, a puffy tumour of the injured part of the scalp, or those changes of the wound, if there is one, which Mr. Pott has so excellently described ; not a mo- ment should be lost in delaying to perforate the bone with the trephine, and giving vent to the confined matter. Gg2 Experience teaches that fractures at the basis 6T xao skull are extremely dangerous, because they are gene- rally attended with extravasation, or followed by in- flammation of the brain, in consequence of the violence of the injury. According to Sir Astley Cooper, they are produced by falls from a great height on the summit of the head. The whole weight of the body is received on the foramen magnum, and cuneiform process of the os occipitis, and, in many instances, the consequence is a transverse fracture through the foramen magnum, the cuneiform process, and part of the temporal bone. A discharge of blood into each meatus auditorius accom- panies the accident. It is supposed, also, that the deaf- ness, which sometimes remains during life, in rare in- stances of recovery, is the result of this kind of injury. —{Lectures, i c. vol. l,p. 289.) A fracture within the orbit is sometimes occasioned by the forcible introduction of a stick, weapon, or pointed instrument, and is generally a fatal case, from the pressure and irritation of the depressed splinters of bone, and the simultaneous wound of the brain. The symptoms to the beginning, however, are fre- quently mild and deceitful, and it is not till inflamma- tion and suppuration ensue, that the patient's condition is always such as to create immediate alarm. A case, exemplifying this fact, is reported by Sir A. Cooper. —(Vol. cit. p. 295.) The same eminent surgeon men- tions the occasional production of a circular fracture of the entire cranium, by a blow on the vertex; also the emphysema of the forehead, or the escape of the air, if there be a wound, caused when the nose is blown, in the case of a fracture extending into the frontal sinuses; the complete detachment, sometimes met with, of the fragments, instead of their depression. His. observa- tions confirm the fact, that fractures of the skull, if un- accompanied with concussion or compression, become united like those of other bones; but, he adds, that it is more slowly, and that where the interspace is wide, it wUl not be filled up with bony matter.—(P. 297,298.) 4. Fractures of the Cranium with Depression. In simple fractures of the skull, or thdse in which the parts of the broken bone are not depressed from their situation, Mr. Pott remarks, that " the chirurgical intention and requisite treatment are the same in each, viz. to procure a discharge for any fluid which may be extravasated in present (provided the pressure of such extravasation produces urgent symptoms, a condition which should here be added), and to guard against the formation or confinement of matter." The prevention of suppuration will, as we have already remarked, be best accomplished, not by perforating the cranium, as Mr. Pott advised, but by copious bleeding, evacuations, cold washes to the head, blisters, and a rigorous an- tiphlogistic regimen. However, the confinement of matter, producing symptoms of pressure on the brain, certainly indicates the immediate use ofthe trephine. " But (says the author) in fractures attended with depression there are other intentions. In these the depressed parts are to be elevated, and such as are so separated as to be incapable of reunion, or of being brought to lie properly, and without pressing on the brain, are to be totally removed. These circumstances are peculiar to a depressed fracture; but although they are peculiar, they must not be considered as sole, but as additional to those which have been mentioned at large under the head of simple fracture ; commotion, extravasation, inflammation, suppuration, and every ill which can attend on or be found in the latter, are to be met with in the fomier, and wiU require the same method of treatment." That loose splintered pieces of the cranium, when quite detached, and already in view, in consequence of the scalp being wounded, ought to be taken away, no one will be inclined to question. That they ought also to be exposed by an incision, even when the scalp is unwounded, and then taken away whenever they cause symptoms of irritation or pressure, I be- lieve will be universally allowed. But the reader will already understand, from what has been said in the preceding section, that several excellent surgeons do not coincide with Pott in believing that every depressed fracture of the skull necessarily demands the applica- tion of the trephine. " There certainly are (says Mr. Abernethy) degrees or this injurv, which it would be highly imprudent to treat in this manner. Whenever the patient retains his senses perfectly, I should think it improper to trephiue 468 HEAD. mm, unless symptoms arose that indicated the necessity ol it.'-—(p. 21.) ' it is extraordinary and unaccountable, but it is not less true, that ho calculation of the bad effects can be made by the degree in which a part of the skull is de- pressed. This is a fact which has been long known. It has also been particularly adverted to by an eminent modern writer. "Various instances also presented themselves, in which, though a considerable degree of compression must have been occasioned, sometimes by thedepressiou of both tables, and at other times by the depression of the inner table only ofthe skull, yet neither siupor, paralysis, nor loss of memory was produced. In one of these cases the middle of the right parietal bone was fractured, and considerably depressed by a ball, which was extracted on the 20th day. In this case, neither stupor nor paralysis appeared. In another, a musket-bail had struck the right parietal bone, fractured il, and was flattened and lodged between the tables of the skull. The inner table was much depressed, yet no bad symptoms supervened."—(See Thomson's Ob- servations made in the Military Hospitals in Belgium, p. 59, 60.) The same author also saw a singular case, in which a ball, entering behind the right temple, and passing backwards and downwards, had fractured the bones in its passage, and lodged in the surface of the brain, over the tentorium, from which place it was ex- tracted on the seventeenth day after the injury. No bad symptom had manifested itself previously to the operation, and the man recovered, under the strictest antiphlogistic regimen, with little or no constitutional derangement. Dr. Hennen has recorded two cases, fully proving the correctness of Mr. Abernethy's opi- nions about the impropriety of using the trephine in cases of depression unattended with urgent symptoms: in one of these instances, the upper and posterior angle of the parietal, which had been struck by a musket- ball, was depressed exactly an inch and a quarter from the surface of the scalp, yet no bad symptoms followed, and with the aid of bleeding and other antiphlogistic remedies, the sdldier recovered perfectly in a few weeks. " In a similar case, where the man survived thirteen years, with no other inconvenience than occasional de- termination of blood to the head on hard drinking, a funnel-like depression to tlie depth of un inch and. a half was formed in the vertex."—(See Hennen's Milu tary Surgery, p. 287, ed. 2.) If then the violence of tbe symptoms is not always in proportion to the compression, but is sometimes con- siderable when the pressure is slight, every surgeon cannot be loo fully impressed with the following truth, that existing symptoms of dangerous pressure on the brain, which symptoms will be presently related, can alone form a true reason for perforating the cranium. Although the doctrines of Sir Astley Cooper, gene- rally speaking, coincide very much with the preceding maxim, which I regard as a very important one; there is an exception to it in his advice, in relation to com- pound fractures of the skull, as will be understood from the following passage. " The old practice used to be, the moment an injury of the brain was suspected, and the least depression of the bone appeared, to make an incision into the scalp. This is putting the patient to considerable hazard; for the simple fracture would by the incision be rendered compound. In simple fracture, then, when it is attended with symptoms of injury of the brain, deplete before you trephine ; and when it is unattended with such symptoms, deplete merely, and do not divide the scalp, Sec If the fracture be com- pound, the treatment must be very different; because a compound fracture is very generally followed by inflam- mation of the brain; and it will be of little use to tre- phine, when inflammation is once produced. If the inflammation come on, tbe patient will generally die, whether you trephine or not," and it is added, that the operation will even be likely to increase the inflamma- tion which has been excited by a depressed portion of the skull. " The rule (says Sir Astley) which I always follow, is this: when I am called to a compound frac- ture with depression, which is exposed to view, whe- ther symptoms of injured brain exist or not, I generally use an elevator, and very rarely the trephine. I put the elevator under the bone, raise it, and if it has been com- minuted, remove the small portions of bone. -^(Lec- tures, i-c. vol. 1, p. 304. 308.) Of the propriety of using the elevator in such cases, and also of taking a.vay loose fragment-, th re cannot b-> a doubt, bui many surgeons object (and I confess myself one of the number) to saw out a portion of the skull while the patient is free from urgent symptoms. I believe, also, Ibat the inflammation, when it does arise, is mostly the effect of the violence itself, not of tbe depression of Ihe bone, and, therefore, more likely to be increased than prevented by the application of the trephine. I think a better reason for elevating Ihe bone, when it is ex- posed, and there are no bad symptoms, is the fact that many patients, after their recovery from the Imminent danger of the accident, become subject, whenever the circulation is hurried, to insanity, epilepsy, &c. Yet, here it is to be considered, that it may be quite time enough to trephine, when such ills follow the continu- ance of the depression, and that, perhaps, the operation would then be in itself less dangerous, inasmuch as the tendency to inflammation,- arising from the first vio- lence, must now have subsided. In children a portion of the skull is sometimes de- pressed or indented by a blow, but in a few days regains its natural level without the aid of the surgeon. In such examples, it is conceived by Mr. Brodie, that the earthy part of the bone gives way, while the animal part remains entire, so that there is not an actual solu- tion of continuity, and he supposes that the restoration of the bone to its proper level is brought about by the constant pulsations of the brain against its inner sur- face.— (See Med. Chir. Trans, vol. 14, p. 332.) Sometimes a considerable depression of the bone arises from the external table being driven into the di- ploe, while the inner table is entire. To trephine, there- fore, merely because there is a depression of the bone, would be completely erroneous, and the only safe prin- ciple is that which I have just now specified. The de- pression of the outer table in the foregoing manner I have never seen myself; Sir Astley Cooper, however, mentions it as a frequent occurrence; but that it is confined to persons of middle age, as in very young and very old persons the skull is thin and without di- ploe.—(Lectures, vol. 1, p. 302.) Another sort of de- pression, I believe, is more frequent; at least, I have seen several examples of the case; it consists in a fracture and depression of the internal table, while the external one continues unbroken. A case of this kind, attended with urgent symptoms of compression, I tre- phined at Brussels; a large splinter of the inner table was driven more than an inch into the brain, and on its extraction the patient's senses and power of voluntary motion instantly returned. Part of the skull to which the trephine was applied, of course, did not indicate ex- ternally any depression, and it was selected because the appearance of the scalp showed, that there the ex- ternal violence had operated. I rather expected to find extravasated blood, than a depression of the inner table of the skull.—(See also Saucerotte, in Mim. pour le Prixde PAcad. de Chir. t. 4, id. 1619, p. 322. Hennen's Military Surgery, p. 323, ed. 2; and B. C. Brodie, in Med. Chir. Trans, vol. 14, p. 331.) In military surgery particular cases present them- selves, which scarcely admit of being comprehended within the tenor of any general rules and principles. Thus, it sometimes happens, that a ball breaks the os frontis, and the whole or a part of it lodges in the frontal sinus, with or without fracture of the inner boundary of this cavity. In cases of this description, Baron Larrey recommends exposing the course of the fracture by a free incision, and the use of the trephine for the removal of the extraneous body. When the in- ner side of the sinus was found broken and depressed, he next perforated that part of the cavity with a small conical trephine, took away such pieces of bone as re- quired removal, and let out any extravasated blood. Sometimes, however, the front of the sinus is so splin- tered, that the fragments, when taken away with the forceps, leave the cavity sufficiently opened, not only for the extraction of the ball, but for the application of the trephine to the inside of the sinus as we find ex- emplified in one of the two cases of this nature which I.arrey met with in the Egyptian campaign.—(Mim de Chir. Militaire, t. 2, p. 138.) After the battle of Wi- tepsk, in 1812, he was called to two Russian soldiers, whose cases were remarkable; one of them had been struck above the right eyebrow with a grape-shot, which, after breaking and penetrating the frontal bone, entered the cavity of the cranium, so as to lodge upon the anterior right lobe of the brain, and the orbitar pro- i-r-s.-, and internal crista of the os frotitis. ,\oiwub- HEAD. 469 standing the large size of the ball, little of it could be seen externally, and the aperture through which it had passed was not more than three or four lines broad; every attempt to extract .it, therefore, was in vain. The patient experienced a painful sense of oppression and weight in the head, and, whenever he inclined it backwards, was seized with syncope. He kept him- . self constantly in a sitting posture with his head on his knees. Larrey adds, that every svmptoin of com- presHion of the brain also prevailed, though this ac- count is rather difficult to comprehend, considering that the patient could sit up, and choose his posture. As for any description given by himself of. his sufferings, that is another circumstance on which I should not be inclined to dwell, because in all probability the baron was not able to converse in tbe Russian language, and the inferences respecting the man's feelings were made in Foiue other way. But whatever might be the real state of ihe symptoms (and m a case of this kind a correct account of them would have been interesting), the ball was plainly ascertained, by-means of a probe, to be of iron, and of much larger .diameter than the opening through which it had entered; and that for the purpose of extracting it the application of the trepan was urgently necessary. The fracture was fairly brought into view by suitable incisions; three perfora- tions were made with a small trephine at its upper part, and after the removal of the angles of the bone between these perforations, the ball, which weighed seven French ounces, was readily extracted with the aid of a strong pair of forceps and an elevator. A considerable quantity of coagulated blood was also re- moved, under which the brain was found with a de- pression of three or four lines deep. As soon as some splinters of the bone had been taken away, the part was dressed with a bit of fine linen dipped in warm wine, sweetened with sugar, over which were placed charpie, several compresses, and a bandage. With re- spect to the application of warm wine and other sti- mulants to the surface ofthe brain, in wounds exposing or interesting that organ, it seems to be an invariable practice with Larrey, as well as Schmucker, and the older surgeons. On what principle the custom is still kept up, and whether it is truly right and useful, are questions which may be rationally put. In whatever way experience may hereafter decide these matters, suffice it to add, that the patient was relieved by the treatment, and fell into a quiet sleep for two hours; but in the evening he became feverish, and the wound acutely painful. A considerable quantity of blood was taken from the vena saphena (and why bleeding was not practised at first, seems extraordinary). The dressings, which, according to my ideas, were highly objectionable, were removed, and a large emollient poultice applied. Cooling beverages, containing a small quantity of tartarizod antimony, and antispas- modic anodyne medicines were prescribed. The fol- lowing day the patient's state appeared satisfactory, without the slightest disturbance of the senses, and in due time he perfectly recovered. The other soldier had been wounded in the left tem- ple with a leaden ball, five days before Larrey saw him. One half of the ball had gone into the cranium, through a very narrow breach; the other had burrowed under Ihe temporal muscle, and lodged near the mastoid pro- cess. The nulit side ofthe body was paralytic, the senses were annihilated, and the man was in a state of incessant agitation. After dilating the wound in the temple, and exposing the fracture, Larrey discovered the track of the piece of lead, which bad gone towards the mastoid process, and which he immediately ex- tracted by a counter-opening. At the lower part ofthe temporal wound, he applied a trepan very near the spot where the other (anion of the ball was lodged. This, with some fragments of the bone, and a quan- tity of extravasated blood, was easUy extracted. The patient, however, was not saved; a circumstance ascribed by Larrey to the operation Having been done loo late. In another case, one ofthe imperial guards, wounded at the battle of the Moskowa, died with symptoms of compression, and, after death, a quarter of a bullet, and a fragment of bone were found under the skull! attended with an ulcerated or wounded -state of the adjacent portion of the brain. Larrey very properly expresses his opinion, that this soldier would have bad a chance of beiug saved, had toe trepan been used — (Sec .V m. de Chir. Mil. t. 4. p. 183, i-c.) The practice ■nf trephining for the removal of balls, situated near a fracture of the skull,.within this bony cavity, or lodged among the fragments, or between the two tables forced asunder (see Engel's case, in Vermischte Chir. Schrif- ten von J. L. Scluri•icker, b. 1, p. 242), is not peculiarto Larrey, for it has been done by many other surgeons (see Schmucker's Wahrnehmungen, b. 1, p. 298); but I do not know that he has been anticipated in his bold prac- tice of making a counter-opening in the skull, when the ball is lodged at such a distance from the fracture, that it cannot be extracted through any perforation made in the vicinity of the original injury; for it is a principle which he ventures to lay down, that when a ball has entered the cranium, without quitting the roof of this cavity, the case is one requiring the application of the trepan.—(Mim. de Chir. Mil. t. 4, p. 180.) In the 2d vol. of this work (p. 139), the reader will find the account of a soldier, who was struck on the mid- dle of the forehead with a ball which penetrated the os frontis, and then passed obliquely backwards, be- tween the skull and the dura mater, in the course of the longitudinal sinus, as far as the lambdoidal suture, where it stopped. Larrey traced the situation of tbe ball, by the introduction of an elastic gum catheter into the opening; and measuring the distance between the fracture and the place where he felt the ball, he cut down upon that part of the skull, beneath which he concluded that the ball was lodged. The bone was then perforated with a large trepan; a good deal of pus was discharged; the ball was extracted, and the patient recovered. One thing here merits the attention of surgeons: Larrey tells us, that a good deal of pus issued as soon as an opening was made in the skull: there must then have been suppuration under the bone, and infiamination and detachment of the dura mater; circumstances always indicated, according to Pott, by a corresponding separation of the pericranium, and a puffy tumour of the scalp. Did these symptoms take place in the foregoing case, so as to be of any assistance to Larrey, in judging of the place where the ball was lodged > and has the mention of them been omitted only by accident! or are we to infer that suppuration may happen between the cranium and dura mater, without any detachment of the pericranium and puffy tumour of the scalp ? a thing which Bichat asserts is proved by daily experience in the Hdtel-Dieu, at Paris.—(See U-'.uvres Chir. de Desault, t. 2, p. 29.) I.arrey, in his 3d vol. (p. 82), gives us another case, in which a ball pierced the left parietal bone, and lodged near the lamb- doidal suture. Its situation was detected with the aid of an elastic gum catheter, and partly in consequence of there being a slight ecchymosis over the part. Here a crucial incision was made through the scalp, and a small fissure discovered. As the symptoms of compression increased, the trepan was applied, so as to include the fissure. A half of the ball flattened was found directly under the perforation, and a good deal of blood was voided from the two openings in the cranium. For a fortnight the case went on favourably, but the patient was then attacked with what Larrey terms hospital fever, but wbich in all probability was inflam- mation and suppuration ofthe membranes ofthe brain, and died. The records of surgery furnish numerous instances in which the patients lived a considerable time with balls lodged in the cavity of the cranium. Thus, one is related by Paroisse, where the patient soon reco- vered his senses after the injury, and at the end of six months felt no inconvenience, except a difficulty of opening the mouth.- (Opuscules de Chir. Obs.l, Svo. Paris, 1806.) Ramdohr has published another case, where a soldier was shot through tbe frontal sinus, and the ball was found after death in the medullary sub- stance ofthe left hemisphere of the brain, half an inch above the ventricle; yet this patient lived four months after the injury, and soon recovered his senses after its occurrence. For a considerable part of this time he was also free from any bad symptoms. At last he was affected with a kind of stupor, and an inability to open his left e\e, and fell into a lethargic and convulsed state.—(Schmucker, Vermischte Chir. Schriften, b. 1, p. 277.) A French soldier, at the battle of Waterloo, was wounded with a musket-ball, which entered al the anterior portion of the squamous suture, lodged in the substance of the brain, and on the fifth da> alter' an enlargement ofthe wound, and the removal oi'scve- 470 HEAD. ral fragments of bone, was extracted from the poste- rior lobe of the right hemisphere of the brain, where it was found resting on the tentorium. Yet, during the several previous days, the man, with the exception of a slight headache, and partial deafness of the right ear seemed to enjoy perfect health. The case ended well. —(See Hennen's Mil. Surg. p. 289, ed. 2.) Still more remarkable instances or the duration of life, and even of the absence of very serious symptoms, after great and serious wounds ofthe brain, and the lodgement of balls, might here be cited; but it will suffice to refer to the instructive Essay of M. Quesnay on the subject, in vol. 1, of the Mim. de PAcad. de Chir. 4to., and to the account of twenty-two French soldiers, whose vertices, with more or less of the brain, were cut off by sabre- strokes. All these men ultimately died; but at first had not a single bad symptom, and performed a journey of thirty leagues after being wounded, and one-half of this distance on foot.—(See Paroisse, Opuscules de Chir. p. 41, i-c.) 5. Extravasation under the Cranium, Symptoms of Pressure on the Brain, i-c. Mr. Pott remarks, " the shock which the head some- times receives by falls from on high, or by strokes from ponderous bodies, does not unfrequently cause a breach in some of the vessels either of the brain or its menin- ges, and thereby occasions extravasation of the fluid which should circulate through them. This extrava- sation may be the only complaint produced by the ac- cident ; or it may be joined with, or added to, a fracture of the skull. But this is not all; for it may be pro- duced not only when the cranium is unhurt by the blow, but even when no violence of any kind has been offered to or received by the head." The effused blood may lie between the cranium and dura mater; between the latter membrane and the arachnoides; on the surface of the pia mater, or under this membrane, on the surface, in the substance, or ca- vities ofthe brain. The first species of extravasation, which is observed to be always more or less circum- scribed, may occur at any part of the skull, but when situated at its base, is generally fatal. In the second, which is the most common species of extravasation within the dura mater (see Brodie, in Med. Chir. Trans, vol. 14, p. 333), tbe blood is widely scattered about between tho dura mater and arachnoides, and on this account, unless its quantity be very consider- able, it does not cause any great degree of pressure. In the third example, if the blood be situated in the convolutions, it is also widely diffused, but if it be within the substance or ventricles ofthe brain, which is rare (Brodie, vol. cit.), it is circumscribed.—(OJ.uvres Chir. de Desault, t. 2, p. 23.) Sometimes in cases of great violence, as Mr. Pott has justly observed, the blood is found at the same time to all these different parts. According to Mr. Brodie's experience, which confirms the observations of Mr. Abernethy, there is never such hemorrhage from a rupture of the blood-vessels, by which the dura mater is connected to the bone, as will produce dangerous pressure on the brain, except When the middle meningeal artery has been lacerated, from which vessel the bleeding is sometimes very co- pious. Mr. Brodie has never seen this artery lace- rated, except in the combination with a fracture run- ning across the bony canal in which it is situated; but he adverts to other cases, recorded by Mr. Latta and Mr. Abernethy, in which no such fracture accompanied the rupture ofthe vessel.—(See Med. Chir. Trans, vol. 14, p. 333.) Another observation made by Mr. Brodie is, that large extravasations are sometimes found upon the up- per surface of the brain, but more frequently at its basis, where they are usually the consequence of a rupture ofthe substance ofthe brain. The same surgeon has never seen an instance, to which the blood from a wounded sinus collected between the dura mater and the skull, or between that membrane and the brain, in sufficient quantity to interfere with the ftmctions ofthe latter organ. When the blood is extravasated beneath the skull, the violence which produces the rupture of the vessel usually stuns the patient, from which state, provided the quantity and pressure ofthe blood and the force of the eoncuasion be not too great.he gradually recovers ami regains his senses. If the first extravasation be I trivial, the patient, after regaining his senses, may only feel a little drowsiness and go to bed. Tho bleeding from the ruptured vessel continuing, and the pressure on the brain increasing, he becomes more and more in- sensible, and begins to breathe in a .slow, interrupted, stertorous manner. In cases of compression, whether from blood or a depressed portion of the skull, there is a general insensibility; the eyes are half open; the pu- pils dilated and motionless, even before the vivid light of a candle; the retina is insensible; the limbs relaxed; the breathing stertorous; the pulse slow, and, according to Mr. Abernethy, less subject to intermission, than in cases of concussion. The absence of stertor, however, as this gentleman admits, must not be relied upon as a proof of their being no compression; for Morgagni re- lates dissections of apoplectic persons, in whom the effu- sion was considerable, yet no stertor had occurred. In a case of wound of the posterior part of the skull, with depression, seen by Dr. J. Thomson, the pulse a' one time sunk as low as 36 strokes in a minute. This eminent professor, however, is at variance with Mr. Abernethy upon one point, by stating that irregu- larity of the pulse is a frequent attendant upon com- pressed brain.—(Report of Obs. i-c. p. 54, 55.) Mr. Brodie does not give any positive opinion on the statement made by Mr. Abernethy. that intermission of the pulse is less frequent in compression than concus- sion ; but he expresses his belief, that pressure on the brain for the most part affects the action ofthe heart; not by producing actual interruption, but by causing its contractions to be either lessfrequent, or less forci- ble than natural.—(Med. Chir. Trans, vol. 14, p. 355.) In the cases referred to in Dr. Thomson's report, con- vulsions sometimes arose from the pressure of por- tions of the skull, forced inwards upon the brain. This is a very dangerous symptom; but Dr. Thomson saw it cease in a few examples, after the depressed piece of bone had been elevated, and the antiphlogistic regimen adopted.—(P. 60.) Convulsions 1 am disposed to re- gard, with Bichat, rather as a symptom of injury ofthe brain, than of compression.—((Euvres Chir. de Desault, t. 2, p. 27.) Mr. Brodie, seemingly unaware of the corresponding remark published in the foregoing work, considers it questionable, whether convulsive-twitches of the mus- cles ought to be regarded as the consequence of sim- ple pressure on the brain ? We find them occur, says he, in cases of punctured and wounded brain, where there is no pressure; and whenever he has noticed them as attendant on depression of the skull or ex- travasated blood, and has afterward had the oppor- tunity of ascertaining the exact nature of the injury, the pressure has always been found to be complicated with wound or laceration ofthe substance of tlie brain. The convulsive twitches to which Mr. Brodie alludes, he particularly describes as slight and. partial, and different from the more violent and general convulsions, —(See Med. Chir. Trans, vol. 14, p. 352.) Indeed, the difficulty ofthe diagnosis of many cases may be well conceived by what Dr. Hennen remarked in his practice; viz. that in some instances the pupils were contracted, in others dilated, where the injury was nearly of a similar nature and degree; while sometimes, in the same patient, one pupil was dilated and the other much contracted. He saw, also, paraly- sis occur on one side, and convulsions on the other, when the blow had been on the forehead, and the same when it bad been on the occiput.—(Op. cit. p. 300, 301.) Mr. Brodie has seen the pupils dilate with the ab- sence, and contract with the presence of light, although the patient lay in a state of complete insensibility, and did not seem to be at all conscious ofthe impressions made on the retina He admits, however, that this is a rare occurrence, and that, when the other symptoms of pressure are present, the pupils are generally insen- sible and motionless, and mostly dUated, though some- times contracted* Every surgeon of experience must be aware of another circumstance mentioned by the same surgeon; namely, that u is not uncommon for tbe pupils to remain for a time in a state of dilatation, then to become suddenly contracted, and after remain- ing so for a longer or shorter time, to become again di- lated; thesechanges taking place independently of light and darkness. When the pupils have been dilated, Mr. Brodie has frequently known 'them to become, con- tracted after the abstraction of hiood; the dilatation HEAD. 471 returning as soon as the immediate effect of the blood-1 letting had ceased. He adverts to a curious case, re- j ported by Dr. Hennen, in which blood was extravasated between the membranes of the brain, and the pupils sometimes dilated in an increased light, and contracted in a diminution of it.—(See Med. Chir. Trans, vol. 14, p. 352.) Another observation made by Mr. Brodie is, an occasional insensibility Of one iris, dilatation ofthe pupil, and aptosis, continuing after the subsidence of the general insensibility of the body, and even unat- tended with loss of vision.—(Vol. cit. p. 354.) The patient is hardly ever sick when the pressure on the brain and the general insensibility are consider- able ; for the very action of vomiting betrays sensibility in the stomach and (esophagus. The truth of this statement, which agrees with Mr. Abernethy's expe- rience, is strikingly confirmed by an observation made by Mr. Brodie; namely, that when he has had occasion to apply the trephine on account of a fracture and de- pression, and no sickness existed previously, he has sometimes known the patient become sick and vomit immediately the depressed bone was elevated.—(See Med. Chir. Trans, vol. 14, p. 356.) These symptoms are not peculiar to pressure from blood, but arise also from that of many depressed fractures of the skull and of suppuration under this part. They are all attribu- table to the unnatural pressure made on the brain and nerves, and have too often been mistaken as indications of au injury, which, considered abstractedly, can never cause them; I allude to a simple undepressed fracture of the cranium, which may be accompanied with them but cannot cause them. They differ in degree, according to the quantity, kind, and situation ofthe pressing fluid. The hemorrhage from the nose and ears, which otten fol- lows violence applied to the head, is generally conceived to lead to no particular or useful inference: we cannot even calculate, by this sign, that the force has exceeded a certain degree; for such bleedings take place from much slighter causes in some persons than others. Mr. Brodie's observations on this point merit atten- tion : " There is often a considerable effusion of blood from the ear, especially in cases of fracture of the basis of the cranium. This may, as far as I know, sometimes arise, from other sources; but it seems pro- bable that it must in most instances arise from the laceration ofthe lateral sinus, where it extends down- wards behind the petrous process of the temporal bone and the external meatus; and in one instance I ascer- tained it to have been so by the examination of the body after death. In another case which fell under my observation, there was hemorrhage both from the ear and the nostrils. The patient, a boy, died shortly af- ter the accident; and it was found, on dissection, that there was a fracture of the base of the cranium, with laceration of the cavernous sinus, and that the hemor- rhage had taken place from this sinus."— (See Med. Chir. Trans, vol. 14, p. 334.) According to my expe- rience, bleedings from the ear and nose from injuries of the bead are particularly frequent in children, and often manifestly consist of arterial blood. Paralysis is a symptom which generally attends hurtful pressure on the brain. The particular circum- stances, however, which determine its degree, extent, and situation, are not well understood. " In some to- stances of paralysis from sabre-wounds, as well as in those made by gun-sbot (says Dr. J. Thomson), para- lysis was confined to the upper, and in others to the lower extremity. In every instance in which it dis- tinctly appeared that the injury existed on one side of the head, tlie paralysis uniformly manifested itself upon the other; but we were unable to perceive any other fixed relation between the part of the brain which had been injured and the part of the body affected with palsy. A wound of the right parietal bone by a mus- ket-ball was followed by palsy of the left arm and leg. In another ease, a wound penetrating the upper part of the right parietal bone was accompanied with a slight paralytic affecuon of the left side of the mouth, and complete palsy of the left leg. In a third case, a sabre-wound of the same bone, followed by extensive exfoliations, gave rise to a complete palsy of the left side.''—(06s. miute in tlie MUitary Hospitals in Bel- gium, p. 52,53.) When the destruction of sensibility is complete, the tolunury muscles are entirely paralyzed. The patient lies motiouless in any position in which he happens to bo placed. The bladder, incapable of contraction, be- comes preternaturally distended with urine; and the relaxation of the sphincter ani aUows the involuntary discharge of feces from the rectum. Afterward the muscles of respiration become affected also; the pa- tient breathes with stertor, as in a most profound sleep; and the diaphragm contracts at longer and longer in- tervals, until respiration altogether ceases. It is this paralysis of the muscles of respiration witich in ordi- nary cases of pressure on the brain is the immediate cause of death. When the loss of sense is imperfect, there are often no marks of paralysis whatever. At other times, there is hemiplegia, which, however, is much more rarely the consequence of accidental vio- lence than of apoplexy. Mr. Brodie conceives that this difference is referrible to the different situation of the pressure. In apoplexy, the extravasation is mostly situated in one of the ventricles, or in the substance of the brain; but after a blow on the head, the cause of pressure commonly operates upon the surface.— (Med. Chir. Trans, vol. 14, p. 349, 350.) With respect to paralysis, it is unquestionably one of the common symptoms of pressure on the brain ; but, according to Bichat, it may also be caused by con- cussion ; and we know thai it may arise in cases of inflammation and suppuration within the skull. Tlie above statement respecting the paralysis being alwajs on the side of the body opposite that on which the brain is compressed, agrees with what is generally re- marked by other surgical writers.—(See Larrey's Mem. de Chir. Mil. t. 4, p. 180; Hennen's Principles, p. 301, ed. 2, ic.) Yet, at the H6tel-Dieu, at Paris, extrava- sation has very olien been noticed both on the side affected with paralysis and on the opposite one; or else the blood w as generally diffused, while the paraly- sis was local.—(ih.uvres Chir. de Desault, t. 2, ;>. 27.) The preceding class of symptoms only informs us, that the brain is suffering compression ; and leaves us quite in the dark respecting several other very import- ant circumstances. " We not only have no certain infallible rule, whereby io distinguish what the press- ing fluid is, or where it is situated, but we are, in many instances, absolutely incapable of knowing whether the symptoms be occasioned by any fluid at all; for a fragment of bone broken off from the internal table of the cranium, and making an equal degree of pres- sure, will produce exactly the same complaints."—'■ (Pott.) In detailing the symptoms of pressure from blood, I took particular notice of the patient being at first generally stunned by the blow, of his gradually regaining his senses, and of his afterward relapsing into a state of insensibility again. The intirval of sense which thus occurs, was pointed out by Petit as a circumstance of the greatest consequence to elucida- tion of the nature of the case. "A concussion and an extravasation (as Mr. Pott ob- serves) are very distinct causes of mischief, though not always very distinguishable, M. Le Dran, and others of the modern French wri- ters, have made a very sensible and just distinction between that kind and degree of loss of sense which arises from a mere commotion of the brain, and that which is caused by a mere extravasation, to those in- stances m which the time of the attack or appearance of such symptoms are different or distinct. The loss of sense which immediately follows the violence, say they, is most probably owing to a commotion; but that which comes on after aft interval of time has passed is most probably caused by extravasation. This distinction is certainly just and good as far as it will go. That degree of abolition or diminution of sense which immediately attends or follows the blow or fall, and goes off again without the assistance of art, is in all probability occasioned by the sudden shake or temporary derangement ofthe contents of the head : and the same kind of symptoms recurring again some time after tbey had ceased, or not coming on until some time has passed from the receipt of the violence, do most probablv proceed from the breach of a vessel within or upon the brain. But, unluckily, we have it not very often in our power to make this exact distinc- tion. An extravasation is often made so immediately, and so largely, at the instant of the accident, that all sense and motion are instantaneously lost, and never again return. And it also sometimes happens, that al- though an extravasation may possibly not have been. made at the moment of the accident, and the first com- plaints may have been owing tocoiiunotiou merely, yet 47-2 HEAD. a quantity of fluid having been shed from its proner vessels very soon after the accident, and producing its proper symptoms, before those caused by the commo- tion have had time to go off, the similarity of the effects of each of these different causes is such, as to deprive us of all power of distinguishing between the one and the other, or of determining, with any tolerable preci- sion, to which of them such symptoms as remain are really owing."- A man meets with a fall; a slight concussion of the bram isi the consequence, and the patient is instantly stunned. The effects of concussion gradually subside, but an extravasation takes place, and the loss of the senses continues, though from a different cause. Here, according to the principles of Petit, the case would be set down as concussion; yet, things are quite the con- trary, the extravasation now keeping up the symptom which was only temporarily produced by concussion. In many instances, also, the effects of concussion and extravasation exist together, and then how is a sur- geon to judge of the nature of the case '—(See (Euvres Cfiir. de Desault, t. 2, p. 25.) " When an extravasation of any kind is made either upon or within the brain, if it be in such quantity, or so situated, as to disorder the economy of the animal, it always produces such disorder by making an unna- tural pressure on the parts where it lies. The nature and degree of the symptoms hereby produced are va- rious and different in different persons, according to the kind, quantity, and situation of the pressing fluid. Sometimes it is merely fluid blood, sometimes blood in a state of coagulation; sometimes it is a clear lymph, and at others blood and water are found mixed to- gether : each of these is found either simple or mixed in different situations, that is, between the skull and dura mater, between Ihe dura and pia mater, or in the natural cavities of the brain called its ventricles, and sometimes, in cases of great violence, they are found St the same time in all these different parts. Some- limes a considerable quantity is shed instantly at the time of the aceident; and sometimes the breach by which the effusion is made is so circumstanced, both as to nature and situation, that it is at first very small, and increases by faster or slower degrees. In the for- mer, the symptoms are generally immediate and ur- gent, and the extravasation is of the bloody kind; in the latter, they are frequently slight at first, appear after some little interval of time, increase gradually till they become urgent or fatal, and arc in such case ge- nerally occasioned by extravasated lymph. So that al- though the immediate appearance of bad symptoms does most certainly imply mischief of some kind or other, yet, on the other hand, no man ought to suppose his patient free from hazard, either because such symp- toms do not show themselves at first, or because they appear to be but slight; those which come on late, or, appearing slight at first, increase gradually, being full as much to be dreaded, as to consequence, as the more immediately alarming ones; with this material differ- ence between them, that the one may be the conse- quence of a mere concussion of the brain, and may by means of quietude and evacuation go quite off; whereas, the other being most frequently owing to an .extravasa- tion of .lymph (though sometimes of blood also) within the substance of the brain, are very seldom removed by art."—(Pott.) The case of extravasation between the cranium and dura mater is almost the only one which admits of relief from trephining. Mr. Abernethy informs us, that in the cases which he has seen of blood extrava- sated between the dura and pia mater, on a division of the former membrane being made for its discharge, only the serous part of it could be evacuated; for the coagulum was spread over the hemisphere of the brain, and had descended as low as possible towards its inferior part, so that very Utile relief was obtained by th6 operation.—(Surgical Works, vol. 2, p. 46.) This statement is confirmed by that of Bichat, and the practice inculcated agrees with what Sir Astley Cooper also directs, as will be presently noticed. Fractures of the cranium which take place across the lower and front angle of the parietal bone, and the rest of the track of the trunk, and large branches of the spinous artery of the dura mater, are cases very apt to be attended with a copious extravasation. This vessel, and others more deeply seated, however, may Lie raptured, pour out a considerable quantily of blood, and induce urgent symptoms of pressure '»n the brain, not only without the co-existence of a fracture, bul even of any external mark of violence on the scalp. The effused blood is frequently situated below the part on which the violence has operated, and hence, when such part is pointed out by a wound or discolor- ation of the scalp, or a fracture, and the symptoms of pressure are considerable, I should have no hesitation about immediately trephining in the situation of the external injury. I have seen many cases in which such practice was justified by the result, and even when no extravasation exists, this plan will sometimes detect a depression of the inner table of the skull, and be the means of saving life, as happened in one very remarkable case, which I trephined at Brussels after the battle of Waterloo. At the same lime, it would be wrong to hold out the expectation, that by acting on this principle, the surgeon will always find blood im- mediately under the part of the oranium which he perforates. With respect to a fracture also, as a guide to the place for the application of the trephine in cases of extravasation, Desault regards il as ver>y fallacious, dissections proving that numerous fractures of the skull are unattended with any effusion of blood imme- diately under them; and his experience taught him that the most frequent cases were those in which there was either extravasation without fracture, or a fracture with blood effused in a part of the head remote from the injury of the bone.—((Euvres Chir. t. 2, p. 130.) Even when blood is seen issuing from the fissure, he regards it as no proof of the dura mater being de- tached, as such blood may proceed from the vessels of the diploe.—(P. 31.) But what is to be done when dan- gerous symptoms of pressure prevail, without any ex- ternal mark to denote what part of the head has re- ceived the blow, or whether any at all ? for a general concussion of the head may produce an effusion of blood within the cranium. Under these circumstances, Mr. Pott was against the operation, and says, that " the only chance of relief is from phlebotomy and an open belly; by which we may hope so to lessen the quantity of the circulating fluids as to assist nature in the dissi- pation or absorption of what has been extravasated. This is an effect which, although not highly improba- ble in itself, yet is not to be expected from a slight or trifling application of the means proposed. The use of them must be proportioned to the hazard ofthe case. Blood must be drawn off freely and repeatedly, and from different veins; the belly must be kept constantly open, the body qiiiet, and the strictest regularity of ge- neral regimen must he rigidly observed. By these means, very alarming symptoms have now and then been removed, and people in seemingly very hazardous circumstances have been recovered." Desault also promulgated the same advice, and blamed the doctrine formerly in vogue, that it was better to apply the tre- phine many times uselessly than to let a stogie extra- vasation remain undetected; for he was firmly con vinced that the trephine, when used on this principle, was a source of greater mischief than the effused blood itself.—((Euvres Chir. t. 2, p. 34.) The same doctrine is espoused by Sir Astley Cooper (Lectures, ire. vol. I,p. 288), and, I believe, by all the best modem surgeons. But should the mode of judging whether blood lies immediately under the skull, suggested by Mr. Aber- nethy, prove invariably correct, the question whether the trephine should be applied or not, may in future be more easily determined. Even when the injured scalp shows where the violence has operated, the criterion about to be noticed may inform us whether we should perforate the bone or not; for though the extravasa- tion is sometimes found immediately under the external mark, yet it often is not so, but is in a part distant from that mark, to which situation we have nothing to lead us, and to which, indeed, if we knew it, we could not reach. Mr. Abernethy has observed, " that unless one of the large arteries of the dura mater be wounded, the quantity of blood poured out will probably be in- considerable; and the slight compression of the bram, which this occasions, may not be attended with any pecuUar symptoms, or perhaps it may occasion some stupor, or excite an irritation, disposing the subjacent parts to become inflamed. It is indeed highly probable, that in many cases which have done well without an operation, such an extravasation has existed. But if there be so much blood on the dura mater as materially to derange the functions of the brain, tbe bone, to a HEAD. 473 certain extent, will no longer receive blood from within, and by the operation performed for its expo- sure, the pericranium must have been separated from its outside. I believe that a bone so circumstanced will not be found to bleed; and I am at least certain it cannot with the same freedom and celerity as it does when the dura mater remains connected With it inter- nally."—(See Abernethy's Surgical Works, vol. 2, p. 47.)" In some cases related by this gentleman, there was no hemorrhage; twice he was able, by attending to this circumstance, to tell how far the detachment of the dura mater extended ; and often, when symptoms seemed to demand a perforation of the skull, he has Been the operation contra-indicated by the hemorrhage from tbe bone, and, as tbe event showed, with accu- racy. Mr. Abernethy admits, however, that in aged persons, and in those in whom the circulation has been rendered languid by the accident, the mode of distinction which he has pointed out will be less con- clusive. Pott remarks, that "if the extravasation be of blood, and that blood be in a fluid state, small in quantity, and lying between the skull and dura mater, immediately under or near to the place perforated, it may happily be all discharged by such perforation, and the patient's life may thereby be saved; of which many instances are producible. But if the event does not prove so fortunate, if the extravasation be so large or so situ- ated that the operation proves insufficient, yet the symptom* having been urgent, general evacuation hav- ing been used ineffectually, and a wound or bruise of the scalp having pointed out the part which most pro- bably received the blow, although the removal of that part of the scalp (a simple incision ought to have been said) should not delect any injury done to the bone, yet the symptoms still subsisting, I cannot help think- ing that perforation of the cranium is in these circum- stances so fully warranted, that the omission of it may truly be called a neglect of having done that which might have proved serviceable, and, rebus sic stantibus, can do no harm. It is very true, that no man can be- forehand tell whether such operation will prove bene- ficial or not, because he cannot know the precise na- ture, degree, or situation of the mischief; but this uncertainty, properly considered, is so far from being a dissuasive from the attempt, that it is really a strong incitement to make it; it being fully as impossible to know that the extravasated fluid does not lie between the skull and dura mater, and that under the part stricken, as that it does; and if the latter should be the case, and the operation be not performed, one, and most probably the only, means of relief wiU have been omitted." On some of the foregoing points, Mr. Brodie's ad- vice coincides very much with the precepts of Mr. Abernethy, and with the doctrines which have been for many years inculcated in this work. Blood, he ob- serves, is seldom poured out in any considerable quan-. dty between the dura mater and the bone, except in consequence of a laceration of the middle meningeal urtory, or one of its principal branches. If, therefore, we find the patient lying in a state of stupor, and dis- cover a fracture with or without depression, extending in the direction of the middle meningeal artery, Mr. Brodie is an advocate for the trephine. When no frac- ture is discoverable, but there is other evidence of the injury having fkllen on that part of the cranium under which the middle meningeal artery is situated, the tre- phine, he sa>s, may be employed on speculation, rattier than that the patient should be left to die without any I attempt being made for his preservation.—(See Med, ' Cktr. Trans, vol. 14, p. 385.) When there is no interval of sense between the blow and the coining on of perilous symptoms, it is frequently impossible to determine whether the mis- ch.et be owing to the largeness and suddenness ofthe euravasauon, to the violence of the shock which the bram lias received, or to both these causes at once, which, unfortunately, is too often the case. In this Utter complication, indeed, trephining will frequently be of no avail, even though it serve for the entire re- tnoval of all pressure off the brain; for the oatient cannot recover from the violence of the concussion und never regains his senses. This is noreaaon how- ever, why the chance of the operatiou doing good siLiuld not lie taken wlieu there are evident symptoms 11 pressure. Let us, in these darkeued cases, call to mind the sentiment. .,#• t> .. who is at all acm^n'L1;0 -, ^° ■P*". "»» man venture to pronoun "o^! ,hl8 subJect wi» ever of the trephine, even to1ftHf«£'cce"' fi"°m the ^ cases: he Knows tha?honestly he canZ^M^ ""'iSf that it has often been suece^^be-Ve "a^Then every other means has failed. The true and tost con" sideration is this: does the operation of perforatine the cranium in such case add at all to that degree of hazard which the patient is in before it is performed ' or can he in many instances do well without it ? if jt does add to the patient's hazard, that is certainly a very good reason for laying it aside, or for using it very cautiously; but if it does not, and the only objection made to it is, that it frequently fails of being success- ful, surely it cannot be right to disuse that which has often been, not only salutary, but the causa sine quu non of preservation, merely because it is also often unsuccessful, that is, because it is not infallible." Giving vent to the confined blood " may produce a cure, or it may prove only a temporary relief, accord- ing to the different circumstances of different cases. The disapjiearance and even the alleviation ofthe most pressing symptoms, is undoubtedly a favourable cir- cumstance, but is not to be depended upon as abso- lutely portending a good event. Either a bloody or limpid extravasation may be formed or forming be- tween the meninges, or upon or within the brain, and may prove as certainly pernicious in future, as the more external effusion would have done had it not been discharged ; or the dura mater may have been so damaged by the violence of the blow as to inflame and suppurate, and thereby destroy the patient. If the disease lies between the dura and pia mater, mere perforation of the skull can do nothing; and, therefore, if the symptoms are pressing, there is no re- medy but division of the outer of these membranes. The division of the dura mater is an operation which I have several times seen done by others, and have often done myself; I have seen it, and found it now and then successful; and, from those instancts of suc- cess, am satisfied of the propriety and necessity of its being sometimes done." He next states, however, his sentiment, that wounding the dura mater is itself at- tended with dangerous consequences. Mr. Aberne- thy's opinion of such operation has already been given. It is also disapproved of by Sir Astley Cooper, who says, that if blood he not found between the dura mater and skull, do not puncture the dura mater to seek for it; which would be of no use, as the blood is coagulated, and could not escape, being seated under the pia mater, or in the brain itself.—(Lectures, i-c. p. 289.) If, after the removal of a portion of bone, the dura mater should present itself of a blue colour, be lifted up by blood underneath it, and bulge, as it were, into the aperture, Mr. Brodie approves of a puncture being made in that membrane; and, though he'joins Pott in regarding a wound of the dura mater as a dangerous measure itself, he considers it here justified by circum- stances, and supports his advice by a reference to a case in which Mr. Chevalier thus discharged a con- siderable quantity of blood, and the patient recovered. —(See Med. and Physical Journ. vol. 8, p. 505.) He has also adduced another instance of the success of the practice, in the hands of my friend and neighbour Mr Ogle. Upon the removal of a piece of bone by means of the trephine; if the operation has been performed over the part where the disease is situated, and the extra- vasation be of the fluid kind, and between the cranium and dura mater; such fluid, whether it be blood, water, or both, is immediately seen, and is partly discharged by such opening: if, on the other hand, the extravasa- tion be of blood in a coagulated or gnunous state, it is either loose or in some degree adherent to the dura mater; if the former of these be the case, it is either totally or partially discharged at the time of, or soon after, the operation, according to tbe quantity or extent of the mischief; if the latter, the perforation disco- vers, but does not immediately discharge it." Mr, Pott then lays it down as a rule, that a large extrava- sation must necessarily require a more free removal of bone than a small one ; and a grumous or coagulated extravasation a still more free use of the instrument. In applying the trephine, on account of a fracture with depression, Mr. Brodie deems the removal of a small portion of bone generally sufficient; but when 474 HKAD. blood is extravasated on the surface of tbe dura mater, - sible if his skin be pinched; but he lies stupid and in- he recommends the bone to be more freely taken away, j attentive to slight external impressions. As the effects He founds this advice on the circumstances of a case I of concuss.on diminish, he becomes capable of replying to questions put to him in a loud tone of voice, espe- cially when they refer to his chief suffering at the time, as pain in the head, i£c; otherwise lie answers inco- herently, and as if h:s attention wasoccupied by some- thing else. As long as the stupor remains, the inflam- mation of the brain seems to be moderate; but as the former abates, the latter seldom fails to increase; and this constitutes Ihe third stage, which is the most im- portant of the senes of effects proceeding from con- cussion. These several stages vary considerably in their de- gree and duration; but more or less of each will be found to take place in every instance where the brain has been violently shaken. Whether they bear any certain proportion to each other or not, 1 do not know. Indeed, this will depend ujion such a variety of circum- stances in the constitution, the injury, and the after- treatment, that it must be difficult to determine. With regard to ihe treatment of concussion, it would appear that in the first stage very little can be done; and, perhaps, what little is done had belter be omitted, as the brain and nerves are probably insensible to any stimulants that can be employed. From a loose and, I think, fallacious analogy between the insensibility m fainting and that which occurs in concussion, the more powerful stimulants, such as wine, brandy, and vola- tile alkali, are commonly had recourse to, as soon as the patient can be got to swallow. The same rea- soning winch led to the employment of these reme- dies in the first stage, in order to recall sensibility, bas given a kind of sanction to their repetiUon in the second with a view to continue and increase it. But here the practice becomes more pernicious and less defensible. The circumstance of the brain having so-far recovered its powers as to carry on the animal functions in a degree sufficient to maintain life, is surely a strong argument that it wUl continue to do so, with- out the aid of means which probably tend to exhaust parts already weakened by the violent action they in- duce. And it seems probable that these stimulating liquors will aggravate that inflammation which must sooner or later ensue." —(Essayon Injuries oflheHead,p. 59.) In most cases of concussion, the patient vomits after the accident. According to Mr. Brodie, sickness and vomiting are generally early symptoms, and seldom continue after the patient has recovered from the first shock of the accident.—(Med. Chir. Trans, vol. 14, p. 339.) In the beginning, a torpor exists to the intesti- nal canal, and considerable difficulty 'n procuring an evacuation ; but afterward the feces are sometimes involuntarily discharged; and the bladder becomes dis- tended, so as to require tbe catheter ; but after a time, the urine also comes away involuntarily. There is sometimes bleeding at the nose, and a part of the blood 'which drops into the throat is vomited up. The pupils of the eyes are generally natural; but if changed, both are a little dilated, or sometimes only one. The state of the pupils, however, is differently represented by different writers, and my experience has taught me that it is subject to much variety. In that stage in which the sensibility of the patient is Unpaired, but not annihi- lated, "the pupUs contract on exposure to light, and are sometimes more contracted than under ordinary circumstances."—(Brodie, vol. cit. p. 338.) According to Sir Astley Cooper, the pulse, although natural when which he has recorded, where a more limited opening did not give a sufficiently ready outlet to the suppura- tion that ensued, and the paUent died.—(See Med. Chir. Trans, vol. 14, p. 386.) In the treatment of pressure from extravasation, Sir Astley Cooper joins the generality of surgeons in re- commending free depletion, in order to prevent inflam- mation ; the bowels, he says, are to be opened, and tlie patient kept very quiet. " If there be a bruise, indi- cating tbe spot at which the injury has been sustained, you may trephine after every other means has been tried ineffeduiUly. If a fracture exists, and the symp- i toms do not yield to depletion, you will trephine to seek the extravasation."— (Lectures, p. 288.) Al! cases of pressure on the brain are attended with hazard of inflammation of this organ and its mem- branes. The danger must be averted as much as pos- sible, by applying cold washes to the head, and em- ploying free and repeated bleeding, leeches, antimo- nials, saline purgatives, and other antiphlogistic means. After the depleting method has been con- tinued some time, blisters may be applied to the head, and the cold wash omitted. CONCUSSION OR COMMOTION OF THE BRAIN. It is observed by Mr. Pott, that "very alarming symptoms, followed sometimes by the most fatal con- sequences, are found to attend great violence offered to the head; and, upon the strictest examination both of the living and the dead, neither fissure, fracture, nor extravasation of any kind can be discovered. The same symptoms, and the same event, are met with, when the head has received no injury at all ab externo, but has only been violently shaken ; nay, when only the body or general frame has seemed to have sus- tained the whole violence." And he afterward re- marks, that "the symptoms attending a concussion are generally in proportion to the degree of violence which the brain itself has sustained, and which, indeed, is cognizable only by the symptoms. If the concussion be very great, all sense and power of motion are imme- diately abolished, and death follows soon; but be- tween this degree and that slight confusion (or stun- ning as it is caUed) which attends most violences done to the head, there are many stages." But besides the foregoing description of concussion, which seems ra- ther to consist in a lesion of function than in any visible disorganization, >ir Astley Cooper has found the more violent degrees of it attended with laceration of the brain, and slight extravasation.—(Lectures, ic. p. 262.) The latter, however, are rather to be con- sidered as compound cases than as instances of pure concussion. Mr. Brodie has observed, that tbe symp- toms of concussion do not depend upon any such de- rangement of the organization of the brain as admits of being disclosed to us by dissection; yet he thinks the inference not justified, that there is really no or- ganic change. It is difficult, he says, to conceive in what other manner concussion of the brain can ope- rate so as to produce the effects which it is known to produce; and if we consider that the ultimate struc- ture of the brain is on so minute a scale that our senses are incapable of detecting it. it is evident that there may be changes and alterations of structure which our senses are also incapable of detecting.—(Brodie in Med. Chir. Trans, vol. 14, p. 337.) Mr. Abernethy, I think, has removed a good deal of the patient is undisturbed, scarcely ever fails to be the perplexity of this subject by dividing concussion into three stages. In fact, without discriminating them, the various descriptions of the symptoms, as given by different writers, cannot be at all reconciled. " The first is, that state of insensibility and de- rangement of the bodily powers wbich immediately succeeds the accident. While it lasts, the patient scarcely feels any injury that may be inflicted on him His breathing is difficult, but in general without ster- tor; his pulse intermits, and his extremities are cold. But such a state cannot last long; it goes off gradually, and is succeeded by another, which I consider as the second stage of concussion. In this, the pulse and res- niration become better, and though not regularly per- formed, are sufficient to maintain life, and to diffuse warmth over the extreme parts of the body. The feel- ing of the patient is now so far restored, that he is sen- quickened by any exertion made by the patient: and the carotids sometimes pulsate with great force; but the latter symptom is generally not noticed till alter a few hours. The state of; the pulse is very different, ac- cording to the stage of the disorder. In severe cases, the pulse is at first intermitting, irregular, feeble, per- haps scarcely perceptible, and the patient in a condi- tion approaching that of syncope. Such may be his si- tuation for several hours after the accident. When concussion proves fatal, the cause of death is imputed by Mr. Brodie to thiB disturbance of the action ol' ihe heart. " In general, when the patient has lain for some time in the stale which has been described, a reaction ofthe circulating system takes place,aqil the pulse beats with greaier strength in proportion a3 the failure of it was greater in the first instance. But where the shock has been unusually severe, there is no such HE.J reaction. The pulse becomes more and more feeble, more irregular and intermittent; the extremities grow cold, and at last the action of the heart being altoge- ther suspended, the patient expires. In some cases, even after reaction has begun to take place, it seems as if the constitution were unequal to the effort: there is another failure of tbe circulation, the result of which is Ihe same as if the patient had never rallied from the beginning."—(Brodie;in Mid. Chir. Trans, vol. 14, p. 341.) The mind, as Sir Astley Cooper remarks, is va- riously affected, according to the degree of injury which the patient has sustained. In some cases, there is a io:al loss of mental power; in others, the patient is cajiable, though with difficulty, of being roused to make a rational answer, but immediately sinks again into coma. Sometimes the memory is lost; while in other instances, it is only partially impaired. A total forget- fulness of any foreign language is a common effect of concussion. It frequently happens that the patient, when roused, will be perfectly sensible and answer questions rationally; but if left undisturbed, the mind appears to be occupied by some particular circumstance (often an incoherent one), of which he is constantly talking. Patients recollect nothing about the mode to which their accidents took place. If the injury has been occasioned by a fall from a horse, they can only remem- ber mounting and riding to some distance, but not that the animal ran away or threw them; nor, however perfectly ihey may recover in other respects, do they ever have any recollection of the kind of accident. The change produced by injuries of the brain is re- marked to be somewhat similar to the effects of age; the patient loses impressions of a recent date, and is sensible of those which he received in his earlier years- But, as Sir Astley correctly explains, ihe degree of in- jury sustained by the brain varies considerably in dif- ferent cases. Some patients are only stunned, or de- prived of sense for a moment; others recover in a few hours ; some remain in a great degree insensible for fifteen or twenty days. Some recover entirely; others have afterward an imperfect memory. A par- tial loss of sense will be produced in the function of one eye, or deafness in one ear; and so of volition, the squinting caused by an injury of the brain being Romctimes permanent. In some cases a degree of fa- tuity ; in some, great irritability; in others, vertigo, and tendency to severe headache from the slightest ex- citement, will remain. In one example seen by Sir Astley Cooper, a remarkable irritability of the stomach and disposition to vomit were the permanent conse- quences of a concussion of the brain. In particular instances, the faculty of readily uttering the proper words for expressing ideas is lost and never regained, and wrong terms are used. Often the judgment re- mains enfeebled.—(Letures, vol. 1, p. 254, A c.) Many of the observations in the foregoing statement coincide with the accounts given of the subject in the writings of Bichat and Desault. The following passage, extracted from a writer who has already been of material assistance in this article, cannot be too deeply impressed ou the memory of every surgical practitioner. "To distinguish between an extravasation and com- motion by the symptoms only, is frequently a very dif- ficult matter, sometimes an impossible one. The si- milarity ofthe effects in some cases, and the very small space of time which may intervene between the going off of the one and accession of the other, render this a very nice exercise of the judgment. The first stun- ning or deprivation of sense, whether total or partial, may be from either, and no man can tell from which; but when thAe first symptoms have been removed, or have spontaneously disappeared, if suclyiatient is again oppressed with drowsiness or stupidity, or a totai or partial loss of sense, it then becomes most probable, that the first complaints were from commotion, and that ihe latter ara from extravasation ; and the greater the distance of Ume between the two, the greater is the pro- bability not only that an extravasation is the cause, but ihat the extravasation is of the limpid kind, made gra- datnn.and within the brain. When there is no reason to apprehend any other in- jury, and commotion seems to be the sole disease, plentiful evacuation by phlebotomy and lenient cathar- inss, a dark room, the most perfect quietude, and a very low regim?n, are the only means in our power; and are sometimes successful."—(Pott.) When the patient iD. 475 is at all sensible, every thing likely to irritate the mind is to be avoided.—(A. Cooper, Lectures, i-c. p. 27'J,iio-. 1.) With these means should also be associated the constant application to the head of cloths dipped in very cold water, or Schmucker's frigorific lotion. When the effects of the violence are not necessarily fatal in a very short time after the accident, the great danger which is to be guarded against is certainly in- flammation of the brain. Hence the necessity of freely employing the lancet and antiphlogistic means. The discrimination which Mr. Abernethy introduced into the views of the present subject, by his division of concussion into three stages, has led also to more ra- tional and successful practice. For, though bleeding is now generally allowed to be the great means of re- lief in concussion, it is not rashly practised at the beginning of many cases, when the pulse can hardly be felt, when the circulation scarcely goes on, and every action in the system is nearly annihilated. But the state of the pulse and circulation is closely watched, and the surgeon bleeds to sufficient time and quantity, to prevent in many instances that immoderate frequency and hardness which the pulse always has a tendency in these cases to assume, immediately the first shock of the accident begins to abate. " Bleed- ing," as Sir Astley Cooper correctly notices, " may be carried to excess. You must, in the repetition of bleed- ing, regulate your conduct by the symptoms; observe whether there be any hardness in your patient's pulse, and whether he complains of pain in the head, if he have still the power of complaining. Watch your pa- tient with the greatest possible anxiety; visit him at least three times a day : arid if you find any hardness of the pulse supervening after the first copious bleed- ing, take away a tea-cupful of blood; but do not go on bleeding him largely; for you would, by this means, reduce the strength too much, and prevent the reparative process of nature." Sir Astley admits, how- ever, that it is frequently necessary lo take away blood after the first bleeding; but he directs this to be generally done in small quantities. He acknowledges, also, that it is sometimes necessary to take away large quantities by repeated bleedings.—(P. 271.) The re- covery of many cases which have fallen under my own observation, I have imputed to the frequent and even copious abstraction of blood, by means of the lancet, leeches, and cupping; at the same time, I know that this practice is often carried beyond all modera- tion, without due attention to those circumstances which I have mentioned as the proper guide. I believe, with Mr. Abernethy and Mr. Brodie, that in the very first stage of concussion, when all the powers of life are depressed, cordials and stimulants can rarely be employed with advantage. The latter gentleman has lately offered some considerations against the method which merit attention. There are, he observes, sufficient reasons why we should regard that condition of the system which approaches to syn- cope, as being mostly conducive to the patient's wel- fare, and why we should wish to prolong rather than abridge the period of its duration. The same blow which gives rise to symptoms of concussion, he re- marks, frequently occasions the rupture of some small vessels within the cranium. The same state of the system which produces an enfeebled action of the heart, is calculated to prevent the ruptured vessels from pouring out their contents; and the longer it con- tinues, the less is the danger of internal hemorrhage. If we excite the action of the heart with wine and am- monia, we may bring on symptoms of pressure on the brain. If, ou the contrary, we watch the gradual re- storation of the pulse, and bleed at tbe proper moment in quantity sufficient to keep down the action of the heart, we may often check extravasation. Mr. Brodie also argues, that as the state of depression is followed by one of excitement, it is another strong consideration in favour of avoiding stimuli, and having recourse lo bleeding in time to prevent the action ofthe heart from becoming too vehement.—(See Med, Chir. Trans, vol. 14, p. 377.) With respect to emetics, I have no confidence my- self in their usefulness in cases of concussion, and much doubt even their safety, especially when the dis- order is complicated with extravasation (A. Coojkt, Uctures, i-c. vol. 1, p. 276), a point often incapable of positive decision. 476 HEA HcribeTand *" ami",f,ni*'l medlrinei should be prr- has been freefv ZrirTVT'^' Af,or »***«* " . oeetl; Ireely practised and the bowels emntieH hii, ZVuX T!*n 1"ape ?f the "** ™S ">y very uselul in preventing or lessening the tendenev to Inflammation of the brain and its membranes > vatL eh?famg fr"r\the, arm cannot be employed in tion oY eL.o™', *,r-£ C0°P,,r ret0"»*»'nds the exhibi- S,,°f,C„aJ°mel; Wlth *ces«nt drinks, so as to purge them, and leeches, or opening the jugular vein. mainm, !flee,"ef °f Certain W™». "reqS-ntly re- maining after concussion, as pain in he lead iriddi- tZr —J""1 ~° *? washed with sPirlt <"" w»'e •»«) S5£ ' ,7,he "^ 0f the shower-bath. Sometimes he orders the ung. canthar. to be rubbed on the head, and pil. hydrarg and exlr. colocynth. to be given. In cases or nervousi debility of an organ, electricity is sometimes useful; and occasionally, in long-continued pains ofthe nead, he forms an issue in the scalp, benefit sometimes resulting even from slight exfoliations.—(Lectures, vol.1, p. 280.) These measures are infinitely more prudent than the old custom of trephining. I cannot conclude this article without adverting to the great propensity to relapse, after patients have long appeared out of every danger from wounds ofthe head, the bad symptoms sometimes coming on again, and proving fatal many years after the original injury, as is strongly exemplified in a case related in a work of high character.—(See Schmucker's Vermischte Schrif- ten, b.l, p. 247.) (In the third number of the Amer. Jour, of the Med. and Phys. Sciences, Professor Sewatl, of Washington city, bas reported two cases of fracture of the cranium, with lots of a portion of the substance of the brain. The wound in one of them was inflicted with a spade, which penetrated through the dura mater and into the medullary portion ofthe brain. The antiphlogistic treat- ment was relied upon from the commencement, and during the suppuration which followed : the brain it- self protruded and sloughed away, and subsequently portions of it were removed by the spatula. This pa- tient, nevertheless, recovered entirely in six weeks after the accident. Professor Dudley has also written a valuable paper on injuries of the head, which may be found in the first number ofthe Transylvania Journal of Medicine. He reports a number of cases of epilepsy occurring after injuries of the cranium, which he has cured by tre- phining. In confirmation of his views I may here refer to a case published in the 5th vol. of the N. Y. Med. and Phys. Journal, in which epilepsy, originating from depression of bone, was cured by trephining, by Dr. David L. Rogers, of this city.—Reese.] Hippocrates, lie Capitis Vulneribus, l2mo. Lutetia, 1578. Jac. Berengarius, De Fradurd Cranii, Bologna, 1513. James Yonge, Wounds of the Brain, proved curable, not mUy by the Opinion and Experience of many of the best Authors, but the remarkable History of a Child cured of two very large Depressions, with the Loss of a great Part of the Skull; a Portion of the Brain also issuing through a penetrating Wound of the Dura and Pia Mater, 12mo. Lond. 1682. J. J. Wepfer, Observationes Medico-pradica de Affedibus Capitis internis et externis, Scaphusii, 1727. Murray, An post graoem ab ictu vel casu capitis percussionem, non juvante etiam iterata tercbratione, dura meninx incisione aperienda? Luttt. Paris, 1736. (Haller, Disp. Chir voL 1, p. 97.) R. C. Wagner, De Contrqfissura, Jena, 1708. (Haller, Disp. Chir. vol. 1, p. 15.1 J. C. Teubtler De Vulneribus Cerebri non semper lethalibus, Halm 1760. /. Chr. Camerarius, Diss. Inaug. exhi- bits 'ranssimam Sanatumem Cerebri Quassati cum notabili Substantia Deperditioru, Tubing. 1719. Alex. Camerarius,et Th.Fr.Faber, DeApostemattP^Ma- tris Tubin' 1722. J. A. Ctmradi, De Vulnere Fronti Trained im. M. E. Boretius, et J. G. Arnoldt, ^^sTaexDepresso Cranio, Ke^^nrmt. 1724 G A Lanaguth, Programmadt Sinus Frontalis Vulr nereinTTZbatioiucuran^, WUtemb. 1748 Cto- vart Mi-none sur les Lesions de la Tite par Cirntre- Cp,8c Palis, 1771. J. La Fosse, De CerebriAffect,, IZaCausis externis evidnUilms, Mtmsp. 1763. A. J. V^Hutt^De Cerebri ejusqveMe^ranantmlnfla^ LaHonTet Suppuratwne occulta, Ghullenop, 1,84. P. ™p7meU,,*De Utuitate Incisumis '<*f ^/?"» Capitis in LasionibusCapitisM. AeUhre, 1,8*. Bar- HEM denave, in Mim. de rAcad. de Chirurgie, t. 2. Le Dran, Traiti des Opirations de Chirurgie. J. L. Petit, Trait dts Mid. Chir. t. 1. Dease, Obs. on Wounds of the Head, Urn. Lond. 1776. Pott on Injuries of the Head from External Violence. HilPs Cases in Sur- gery. O'Halloran on the different Disorders arising from External Injuries of tin Head, Svo. Dublin, 1793. Some cases in Desault's Parisian Chirurgical Journal. M moire sur les Plaies de Tite, m Ouirres Chir. de Desault, par Bichat, t. 2. Lassus, Patliologie Chirur- gicale, t. 2, p. 252, A c. edit. 1809. Schmucker's Wahr- nehmungen, b. 1 ; and Vermischte Chir. Schrtflen, b. 1 and 3,8ro. Berlin, 1785. Richerand, Nosographie Chir. t. 2, p. 230, et seq. idit. 4. J. Abernethy on In- juries of the Head, in his Surgical Works, vol. 2, ed. 1811. Larrey. in Mim. de Chir, Militaire, t. 2, 3, et 4, Svo. Paris, 1812—1817. Dr. Hennen, Principles of Military Surgery, ed. 2 8™. Edin. 1820. The three last works, and those of Le Dran, Petit, Desault, and Bichat, Dease, O'Hallnrnn, Pott, and Schmucker, de- senie particular attention. Also, Dr. J. Thomson's Re- port of Observations made in tlie Military Hospitals in Belgnnn, Edinb. 1816. Sir Astley Cooper, Lectures on the Principles, ic. of Surgery, vol. 1, 1824. B. C. Brodie,in Med Chir.Trans.vol.14,1828. SveTrephine. HEMKRALOPIA. According to M. Dujardin, this term is derived from fipipa, the day, a\adf, blind, and ib\p, the eye, and its right signification is therefore in- ferred to be diurna cacitudo, or day-blindness.—(See Journal de Mid. t. 19, p. 348.) In the same sense, Dr. Hillary (Obs. on tlie Diseases of Barbadoes, p. 298, edit. 2) and Dr. Heberden (Med. Trans, vol. 1, art. 5) have employed the term. Hemeralopia, then, which is of very rare occurrence, stands in opposition to the nyctalopia of the ancients, or night-blindness. Numerous modern writers, how- ever, have used these terms in the contrary sense; considering the hemeralopia as denoting sight during the day, and blindness in the night; and nyctalopia as expressing night-seeing, owl-sight, as the French call it, and blindness during the daytime. Hemeralopia, in the meaning of day-blindness, is a very uncommon affection. Dr. Hillary never met with but two examples. He mentions a report, however, that there are a people in Siam, in the East Indies, and also in Africa, who are subject to the disease of being blind in the daytime, and seeing well by night.—(Mod. Univ. Hist. vol. 7.) According to Sauvages, hemeralopia (in his nomen- clature called amblyopia crepuscularis) was in some degree epidemic in the neighbourhood of Montpellier, in the villages in damp situations, adjoining rivers, and it particularly affected the soldiers, who slept in the open damp air. They were cured, he says, by blister- ing, together with emetics and cathartics, and other evacuants.—(Nosol. Method, class 6, gen. 3, spec. 1.) See some ingenious observations on the subject in Dr. Rees's Cyctopadia, art. Hemeralopia, and by Mr. Bampfield, in Med. Chir. Trans, vol. 5, p. 34, ic. Scarpa, with the generality of modern writers, has considered hemeralopia as an affection, in wbich the patient sees very well in the day, but not in the night- time. The abolition of eyesight by night (observes Mr. Bampfield) has occurred in all ages, and is a common disease of seamen in the East and West Indies, Medi- terranean, and in all hot and tropical countries and latitudes, and affects more or less the natives likewise of those regions of the globe. It also occurs frequently among soldiers in the East and West Indies; but he has been informed that it is by no means so prevalent among them as sailors. It is not an uncommon com- plaint of the Lascars employed in the East India Com- pany's ships trading between India and Europe. It has very rarely indeed affected the officers of his Ma- jesty's or of the East India Company's ships. Celsus has remarked, that women and virgins, whose men- strual returns are regular, are exempt from this disease (lib. 6, cap. 6); and it may be observed, that the in- habitants of cold latitudes are less subject to hemera- lopia in their own climate, than the natives of tropical countries are in theirs; but more so, when they visit the tropics.—(Med. Chir. Trans, vol. 5, p. 38.) "Hemeralopia, or nocturnal blindness (nays Scarpa), is properly nothing but a kind of imperfect periodical amaurosis, most commonly sympathetic with the sto- mach. Its paroxysms come on towards tlie evening, and HEMERALOPIA. 477 disappear in the morning. The disease is endemic in some countries, and epidemic at certain seasons of the year in others. At sunset, objects appear to persons affected with the complaint, as if covered with an ash-coloured veil, which gradually changes into a dense cloud, which in- tervenes between the eyes and surrounding objects. Patients with hemeralopia have the pupil, both in the day and night-time, more dilated and less moveable than it usually is in healthy eyes. The majority of them, however, have the pupil more or less moveable In the daytime, and always expanded and motionless al night. When brought into u room faintly lighted by a candle, where all the bystanders can see tolerably well, they cannot discern at all. or in a very feeble manner, scarcely any one object: or they only find themselves able to distinguish light from darkness : and at moonlight their sight is still worse. At day- break they recover their sight, which continues perfect all the rest of the day till sunset."—(Cap. 19, p. 322, ed. Svo.) According to Mr. Bampfield, the disease always af- fects both eyes at the same time. " In general (says this gentleman), the nocturnal blindness is at first par- tial, the patient is enabled to see objects a short time after sunset, and perhaps will be able to see a little by clear moonlight. At this period of the complaint, he is capable of seeing distinctly by bright candlelight. The nocturnal sight, however, becomes daily more impaired and imperfect; and, after a few days, the patient is unable to discriminate the largest objects after sunset, or by moonlight, &c.; and finally, after a longer lapse of time, he cannot perceive any object distinctly by the brightest candlelight. If the patient Is permitted to re- main in this state of disease, the sight will become weak by daylight, the rays of the sun will be too power- ful to be endured, whether they are direct or reflected; lippiiude is sometimes induced; myopism, or short- ness of sight succeeds; and in progress of time vision becomes so impaired and imperfect, that apprehensions of a total loss of sight are entertained ; and this dread- ful consequence bas been known to ensue, where the complaint has been totally neglected, or left to nature, or where ineffectual remedies have been employed."— (Boutins, p. 73.) •' It has been remarked by some, that the patients are capable of seeing distinctly, at all periods of the complaint, with the aid of a strong artificial light; but in bad cases of hemeralopia, in my practice, the pa- tients positively denied the existence of the sense of distinct sight by very clear candlelight."—(Bampfield, in Medico-Chir. Trans, vol. 5, p. 39, 40.) The duration of the disease, when left to itself, is generally from two weeks to three or six months. Ex- perience has not proved that the disposition to the complaint depends upon any particular colour of the iris, as several writers have conjectured ; nor upon the largeness of the eyes, as idleged by Hippocrates.— (Lib. 6, sec. 7.) In idiopathic cases, the health does not in general suffer, and, except in the worst stage, the eye is not altered in appearapce. But in cases of long duration the pupil, according to .Mr. Bampfield, " is often con- tracted, and the eyes and actions of the patient evince marks of painful irritation, if the eyes are exposed to a vivid light, or if he looks upwards. But if they meet Ihe direct rays of the sun, which in the tropics are always powerftil, or a strong glaring reflection of them, pain and temporary' blindness are induced, from which the patient recovers by closing his eyelids for a time to exclude the rays of light, and retiring to the shade. The pupil of the eye is considerably dilated both by day and night, in the proportion of about one case in twelve, and at night the pupil is often dilated, and does not perform its expansions and contractions when exposed to the moon or artificial light. The cases attended with di- lated pupil were generally those of long duration, A-c. " Europeans, who have been once affected with he- meralopia in tropical climates, are particularly liable to a recurrence of this disease as long as they remain ill them."—(Bampfield, op. cit. p. 42, 43.) In two examples, described by Dr. Andrew Smith, Ihe pupils were observed to contract and dilate regu- larly in the davtinie. acconling to the quantity of light; but after sunset they seemed a little more dilated than mtuml, and contracted but sluggishly upon exposure lo light, while the eyes themselves suemrd devoid of their usual energy and vivacity.—(See Edinb. tied. and Surgical Journ. No. 74, p. 22.) The remote causes of idiopathic hemeralopia are not well ascertained. Sleeping with the face exposed to the brilliancy of daylight, the vivid reflection of the sun's rays from the sandy shores of hot countries, and bright moonlight, have been enumerated as causes. Dr. Pye thinks the disorder intermittent.—(Med. Obs. and In- quiries,vol. l,art. 13.) But, as Mr. Bampfield properly observes, though the complaint is certainly periodical, there is nothing in its character tending to prove ihat it is influenced by the same causes as intermittent fever. Tbe latter gentleman conjectures, " that too much light suddenly transmitted to the retina, or for a long period acting on it, may afterward render it unsus- ceptible of being stimulated to action by the weaker or smaller quantities of light transmitted to it by night,"* —(P. 44.) The same sentiment is adopted by Dr. Smith.—(Edinb. Med. Journ. No. 74, p. 23.) Among other objections to this explanation, however, it might be remarked, that the patients do not always see, though the light be good; and Mr. Bampfleld's own " patients positively denied the existence of distinct sight by very clear candlelight." Besides, if the dis- ease were entirely caused by the sudden or long opera- tion of vivid Ught, one would conclude that all persons subjected to that cause ought to have the effect pro- duced, which is far from being the case. When the tongue is while, and the patient has head- ache and bilious complaints, M. Lassus tbinks the cause of the disease is in the stomach and prima? vis. The same author likewise states, that hemeralopia attacks debilitated persons subject to catarrhal affec- tions, residing to damp situations, and living on indi- gestible food. From the combination of such causes (says he) the disorder was epidemic in the vicinity of Montpellier (Sauvage, Nosolog. M thod. t. 2, p. 732); at Belle-Isle sur Mer. (Recueil d'Observ. de Midecine des Hdpitavjc Militaires, par Richard, t. 2, p. 573); and hence it is endemic in watery situations where the nights are cold and damp. They who expose them- selves to this humidity (says M. Lassus), or who navi- gate along the eastern coasts of Africa, who traverse the Mozambique channel, or sail along the coasts of Ma- labar and Coromandel, are sometimes attacked by it. —(See Pathologie Chir. t. 2, p. 542, 543.) Hemeralopia sometimes occurs as a symptom of the scurvy. This fact was noticed by Mr. Telford, in Sir G. Blane's Trea- tise on Diseases of Seamen, and it is likewise con- firmed by Mr. Bampfield, who remarks that hemeralopia should be referred to the same causes as scurvy, " when the subject of it has for a long period subsisted on a salted diet at sea, Ac, and if any other scorbutic symptom be present, such as "spongy gums, ecchy- moses, saline smell ofthe secretions, ulcers, with liver- like fungus, Ac ."—{Medico-Chir. Trans, vol. 5, p. 45.) This disease, according to Scarpa, may commonly be completely cured, and oftentimes in a very short time, by treating it on the same plan by whieh the imperfect amaurosis is remedied (see Amaurosis); viz. by em- ploying emetics, the resolvent powders and pills, and a bUster on the nape of the neck; and topically, the va- pours of ammonia; lastly, by prescribing towards the end of the treatment bark conjoined with valerian. In cases in which the disease has been preceded by ple- thora and suppressed perspiration, bleeding and su- dorifics are also indicated.—(Cap. 19, p. 322. 333.) Scarpa supports this statement by the relation of three cases in which he cured the disease by such treatment. These patients were all unhealthy, and evidently labouring under disorder of the gastric organs. One hundred cases, however, of idiopathic, and two hundred of symptomatic hemeralopia, occurred in the practice of Mr. Bampfield in different parts ofthe globe, but chiefly in the East Indies. All these cases per- pectly recovered : and hence we may inter that under proper treatment a favourable prognosis may always be given. Celsus has stated that persons who have been for some time affected with amaurosis, have regained their sight on being attacked by a diarrheea. This seems to Searpa to be corroborated bv the case related by Dr. Pye.—(Med. Obs. mid Inq. vol. 1.) Searpa entertains no doubt that many similar facts, showing the influence of what he tenns'morbific gastric stimuli over the or- gan of sight, might be found in the records of medi- cine, and proving tin great utility of a spontaneous 478 HEM HEM looseness of the bowels in the cure of imperfect amau- rosis. But, says Scarpa, even if such examples of incom- plete amaurosis being dissipated in consequence of spontaneous vomiting or copious evacuations from the bowels, produced entirely by nature, were rare, and noticed by few, we now have many cases evincing the successful cure of this disease by means of such eva- cuations artificially produced by emetics and purgative medicines. Of this the accurate observations of Schmucker and Richter" furnish us with numerous satisfactory proofs, and it is added, that our confidence in the above method of curing the imperfect and pe- riodical amaurosis must increase when we take notice that the most respectable practitioners of past times have, in the majority of cases, cured this disease only by means of emetics and opening medicines, though in their writings they may have imputed the success of* the treatment to other causes, or the efficaey of other remedies which were also prescribed. Scarpa, after several valuable remarks on amaurosis in general, refers to the Mercure de France, for Febru- ary, 1756, where there is an account of the cures per- formed by Foumier, by means of bleeding and emetics. Night-blindness is sometimes congenital, and there- fore constitutional, and altogether beyond the reach of any curative measure. It is said sometimes to be he- reditary, and the writer of the article Nyctalopia in Dr. Rees's Cyclopaedia was acquainted with an instance in which it occurred to two children of the same family. A case of congenital nyctalopia, which had continued many years without change, and independently of any disease, is related by Dr. Parham.—(See Med. Obs. and Inquiries, vol. 1, p. 122, note.) Peltier (Recueil de Mim. et Obs. sur l'(Eil, obs. 132) cured hemeralopia by repeated doses of tartar-emetic, a seton in the nape of the neck, and cooling, aperient beverages. The method of treatment which Mr. Bampfield adopted is certainly quite simple. "A succession of blisters to the temples (says he), of the size of a crown or half-crown piece, applied tolerably close to the ex- ternal canthus of the eye, has succeeded in every case of idiopathic hemeralopia which I have seen, no longer bleed.—(John Bell's Principles of Sur- gery, vol. 1, p. 142.) But not oiUy as a consequence of surgery is hemorrhage to be feared ; it is also one of Ihe most alarming accidents which surgery is called upon to relieve. " Un sentiment naturel attache a Pidie deperdre son sang ; un terreur machinate, dont Vtnfant qui commence a parler, et Pliommt le plus di- cide, sont egalement susceptibles. On ne peut point dire, que cette peur soit chim rique. Si Pon comptoit ceux, qui perdent la vie dans une bataille, on verroit, que les trois quarts ant peri par quelque hemorrhagic ; et dans les grandes op rations de chirurgie cet acci- dent est presque toujours le plus formidable."—(Mo- rand, Mim. de l'Acad. Royalede Chirurgie, vol. 5, Svo.) As the blood circulates in the arteries with much greater impetus and rapidity than in the veins, it ne- . cessarily follows, that their wounds are generaHy at- tended with much more hemorrhage than those of the latter vessels, and thnt such hemorrhage is more diffi- cult to suppress. However, as the blood also flows through veins of great magnitude with much velo- city, bleedings from them are frequently highly danger- ous, and sometimes unavoidably fatal. When an artery is wounded the blood is of a bright scarlet colour, and gushes from the vessel per saltum, in a very rapid manner. The blood issues from a vein in an even, un- broken stream, and is of a dark purple red colour. It is of great practical use to remember these distinguish- ing differences between arterial and venous hemor- rhage, because, though in both cases the oozing of blood may be equal in quantity, yet, in the latter instance, the surgeon is often justified in bringing the sides of a wound together, without taking farther means to sup- press the bleeding, while it would not be proper to adopt the same conduct were there an equal discharge of arterial blood. Dr. Jones has favoured the world with a matchless work on the present subject; and as one grand object of this Dictionary is to present a careful account of the principal modern improvements in surgical science, I shall first endeavour to make the reader acquainted with the more accurate doctrines first promulgated by this gentleman relative to the subject of hemorrhage. Afterward, the surgical means to oe practised in dif- ferent cases will be considered. The sides of the arteries are divisible into three coats. The mternal one is extremely thin and smooth. Il is elastic and firm (considering its delicate structure) in ihe longitudinal direction, but so weak in the cir- cular as to be very easily torn by the slightest force applied in that direction. Its diseases show that it is vascular, and it is also probably sensible. The middle coat is the thickest and is composed of muscular fibres all arranged in a circular manner; Ihey differ, however, from common muscular fibres in being more elastic, by which they tend to keep a dead artery open, and of a cylindrical form. As this middle roat has no longitudinal fibres, the circular fibres are held together by a slender connexion, ivhich yields readily to any force applied in the circumference ofthe artery. HEM 479 The external coat is remarkable for its whiteness, density, and great elasticity. When an artery is sur- rounded with a tight ligature, its middle and internal coats are as completely divided by it as they could be by a knife, while the external coat remains entire. Besides these proper coats, all the arteries to their natural situations are connected by means of fine cel- lular substance, with surrounding membranous sheaths. If an artery be divided, the divided parts, owing to their elasticity, recede from each other, and the length of the cellular substance connecting the artery with the sheath admits of its retracting a certain way within the sheath. Another important fact is: that when an artery is divided, its truncated extremities contract in a greater or less degree, and the contraction is generally, if not always, permanent. Arteries are furnished with arteries, veins, absorb- ents and nerves; a structure which makes them sus- ceptible of every change to which living parts are sub- jected in common; enables them to inflame when in- jured, and to pour out coagulable lymph, by which tlie injury is repaired or tlie lube permanently closed.—(See Jones on Hemorrhage.) Petit the surgeon, in 1731, first endeavoured to ex- plain the means which nature employs for the suppres sion of hemorrhage. He thought that bleeding from a di- vided artery is stopped by the formation of a coagulum of blood, which is situated partly within and partly withJ out the vessel. The clot, ne says, afterward adheres to the inside of the artery, to its orifice, and to the sur- rounding pans; and he adds, that when hemorrhage is stopped by a ligature, a coagulum is formed above the ligature, which only differs in shape from the one which takes place when no ligature is employed. His theory leads him to recommend compression for the support ofthe coagulum. In 1736, Morand published additional interesting remarks. He allowed, that a coagulum had some effect in stopping hemorrhage, but contended that a corruga- tion, or plaiting of the circular fibres ofthe artery which diminish its canal, and a shortening and consequent thickening of its longitudinal ones, which nearly ren- dered it impervious, had some share in the process. He thought that the cavity of an artery might be ob- literated, by the puckering or corrugation, when circu- lar pressure like that of a ligature was made. Morand erred chiefly in his mode of explanation, and in his belief in the existence of longitudinal fibres, which no modern anatomists admit; for the contraction and retraction of divided arteries are indisputable facts, and as Dr. Jones remarks, this does not affect the truth of his general conclusion, that the change produced on a divided artery, contributes with the coagulum to stop the flow of blood. Mr. S. Sharp (2d edit, of Operations of Surgery, 1739) supported the same doctrine. " The blood-ves- sels, immediately upon their division, bleed freely, and continue bleeding till they are either stopped by art, or at length contracting and withdrawing themselves into the wound, their extremities are shut up by co- agulated blood." Pouteau (Melanges de Chirurgie, 1760) denied that a coagulum is always found after an artery is divided; and when it is, he thought it only a feeble subsidiary means towards the suppression of hemorrhage. He contended that the retraction of the artery had not been demonstrated, and could not be more effectual than a coagulum. His theory was, that the swelling of the cellular membrane at the circumference of the cut extremity of.the artery forms the principal impe- diment to the flow of blood; and that a ligature is use- ful in promoting a more immediate and extensive in- duration of the cellular substance. Gooch, White, Aikin, and Kirkland, all oppose Fe- tit's doctrine of coagulum. The first blends some ol Pouteau's theory with his own, by observing, tnat " when a small artery is totally divided, us retraction may bring it under the surrounding parts, and withithe natural contraction of tlie diameter of its mouth, assisted by the compressive power of those parts increased by thefrVLing tumid, the efflux of blood may be ""wtotewas convinced, from what Gooch had sug- gesred and Kirkland confirmed, that the arteries, by tiieir. natural contraction, coalesce as far as their first ramifi ation. 480 HEMORRHAGE. Dr. Jones admits, that an artery contracts after it bas been divided, and his experiments authorize him to say, that the contraction of an artery is an important means, but certainly not the only nor even the chief me^ns, by which hemorrhage is stopped. When the artery is above a certain size, the impetuous flow of blood through the wound of the artery would resist the contraction ofthe vessel in such a degree, that the con- sequences would be fatal in almost every instance, were it not for the formation of coagulum. Mr. J. Bell thinks, that when hemorrhage stops of its own accord, it is neither from the retraction of an artery, nor the constriction of its fibres, nor the form- ation of clots, but by the cellular substance which surrounds the artery being injected with blood. We must refer the reader to Dr. Jones's work for a complete exposure of the inconsistencies and absurdi- ties in Mr. Bell's account of lus own theory__.See p. 25, A-c.) Dr. Jones concludes his criticisms on Mr. Bell with observing, that if this gentleman really mean to con- fine his doctrine of the natural mean of suppressing hemorrhage to the injection of the cellular substance round the artery with blood, he dwells improperly on one of the attendant circumstances, to the exclusion of the retraction and contraction of an artery, and the form- ation of a distinct clot, all primary parts of the process. The blood, besides filling the cellular substance round the artery, also fills the cellular substance at the mouth of the artery in a particular manner; for the divided vessel, by its retraction within its cellular sheath, leaves a space of a determinate form, which, when all the circumstances necessary for the suppres- sion of hemorrhage operate, is gradually filled up by a distinct clot.—{Jones.) MEANS OF NATI'RE IN STOPPING BLEEDING FROM PIVIDKD ARTERIES. Dr. Jones has given a faithful and accurate detail of a series of experiments on animals, which demon- strate "that the blood, the action, and even the structure of the arteries, their sheath, and the cellular substance connecting them with it," are concerned in stopping bleeding from a divided artery of moderate size in the following manner: "An impetuous flow of blood, a sudden and forcible retraction of the artery within its sheath, and a slight contraction of its extre- mity, are the immediate and almost simultaneous ef- fects of its division. The natural impulse, however, with which the blood is driven on in some measure counteracts the retraction, and resists the contraction of the artery. The blood is effused into the cellular substance, between the artery and its sheath, and pass- ing through that canal of the sheath, which had been formed by the retraction of the artery, flows freely ex- | ternally, or is extravasated into the surrounding cellu- lar membrane, in proportion to the open or confined state of the wound. The retracting artery leaves the internal surface of the sheath uneven, by lacerating or stretching the cellular fibres that connected them. These fibres entangle the blood as it flows, and thus the foun- dation is laid for the formation of a coagulum at the mouth of the artery, and which appears to be com- pleted by the blood as it passes through this canal of the sheath, gradually adhering and coagulating around its internal surface, till it completely fills it up from the circumference to the centre.--{Jones, p. 53.) The effusion of blood into the surrounding cellular membrane, and between the artery and its sheath; but in particular the diminished force of tbe circulation from loss of blood, and the speedy coagulation of this fluid under these circumstances, most essentially con- tribute, says Dr. Jones, to the desirable effect. It appears then, that a coagulum, which Dr. Jones calls the external one, situated at the mouth of the ar- tery and within its sheath, forma the first complete ob- stacle to the continuance of bleeding; and though il seems externally like a continuation of the arterj, yet, on slitting open this vessel, its termination can be plainly observed, with the coagulum shutting up its mouth, and contained in its sheath. No collateral branch being very near the impervious mouth of the artery, the blood just within it is at rest, and usually forms a slender corneal coagulum, which neither fills up the canal of the artery nor adheres to its sides, except by a small portion of the circumfe- rence of its base near Ihe extremity "of the vessel. This coagulum is distinct from the former, and what Dr. Jones calls the internal one. The cut end of the artery next inflames, and the vasa vasorum pour out lymph, which fills up the ex- tremity of the artery, is situated between the internal and external coagula, and is somewhat intermingled with them, or adheres to them, and is firmly united all round to the internal coat of ihe vessel. Dr. Jones farther states, that the permanent suppression of he- morrhage chiefly depends on this coagulum of lymph; but that the end of the artery is also secured by a gra- dual contraction which it undergoes, and by an effusion of lymph between its tunics, and into the surrounding cellular substance; wherebythe.se parts become thick- ened, and so incorporated with each other, that one cannot be discerned from the other. Should the wound in the integuments nol heal by the first intention, the coagulating lymph, soon effused, attaches the artery firmly to the subjacent and lateral parts, gives it a new covering, and entirely excludes it from the outward wound. The same circumstances are also remarkable to the portion of the vessel most remote from the heart. Its orifice, however, is usually more contracted, and ita external coagulum smaller, than the one which at- taches itself to the other cut end ofthe artery.—(Jones on Hemorrhage, p. 5G.) The impervious extremity of the artery no longer al- lowing blood to circulate through it, the portion which lies between it and the first lateral branch gradu- ally contracts, till its cavity is completely obliterated and its tunics assume a ligamentous appearance. In a few days the external coagulum, which in the first in- stance stopped the hemorrhage, is absorbed, and the coagulating lymph effused around it, and by which the parts were thickened, is gradually removed, so that they resume again their cellular texture. At a still later period the ligamentous portion is re- duced to a filamentous slate, so that the artery is, as it were, completely annihilated from its cut end to tbe first lateral branch; but long before this final change is accomplished, the inosculating branches have become considerably enlarged, so as to establish a free commu- nication between the disunited parts of the main artery. When an artery has been divided at some distance from a lateral branch, three coagula are formed; one of blood externally, which shuts up its mouth; one of lymph, just within the extremity of its canal; and one of blood within its cavity and contiguous to that of lymph. But when tlie artery has been divided near a lateral branch, no internal coagulum of blood isformtd. —(Jones, p. 63.) The external coagulum is always formed when the divided artery is left to nature; not so, however, if art | interfere, for under the application of the ligature it can never form. If agaric, lycoperdon, or sponge be used, its formation is doubtful, depending entirely upon the degree of pressure that is used ; but the internal coagulum of blood will be equally formed, whether the treatment be left to art or nature, if no collateral branch be near the truncated extremity of the artery; and lastly, effused lymph, which, when in sufficient quantity, forms a distinct coagulum just at the mouth of the artery, will be always found, if the hemorrhage be per- manently suppressed.—(Jones, p. 74.) MEANS WHICH NATURE EMPLOYS FOR StPPRKSSlNO THE HEMOKKHAOE FROM PUNLTI RED OR PAR- TIALLY DIVIDED ARTERIES. The suppression of hemorrhage by the natural means is sometimes more easily accomplished when an artery is completely divided, than when merely punctured or partially divided. Completely dividing a wounded ar- tery was one means practised by the ancients for the stoppage of hemorrhage: the moderns frequently do the same thing when bleeding from the temporal artery proves troublesome. Dr. Jones has related many experiments highly worthy of perusal, and which were undertaken lo in- vestigate the present part of the subject of hemorrhage. He candidly acknowledges, however, that in regard to the temporary means by which the bleeding from a punctured artery is stopped, he has but little to add to what Petit has explained in his third publication on hemorrhage.—(Mem de PAcad. des Sciences, 1735.) The blood is effused into the cellular substance, be- tween the artrrs and its sheath, for some distance both HEMORRHAGE. 481 above and below the wounded part; and when the parts arc examined a short time alter the hemorrhage has completely stopped, we find a stratum of coagula- ted blood between the artery and its sheath, extending from a few inches below the wounded part to two or three inches above it, and somewhat thicker or more prominent over tho wounded part than elsewhere. Hence, rather ihan say that the hemorrhage is stopped by a cnugulum, it is more correct to say, that it is stopped by a thick lamina of coagulated blood, which, though somewhat thicker at the wounded part, is per- fectly continuous with the coagulated blood lying be- tween the artery and its sheath.—(Jones, p. 113.) When an artery is punctured, the immediate hemor- rhage, by filling up the space between the artery and its sheath with blood, and consequently distending the sheath, alters the relative situation of the puncture in the sheath to that in the artery, so that they are not exactly opposite to each other; and by this means a layer of blood is confined by the sheath over the punc- ture in the artery, and by coagulating there prevents any farther effusion of blood. But this coagulated blood, like the external coagulum of a divided artery, affords only a temporary barrier to the hemorrhage: its permanent suppression is effected by a process of reparation or of obliteration. Dr. Jones's experiments prove, that an artery, if wounded only to a moderate extent, is capable of re- uniting and healing so completely, that after a certain time Ihe cicatrization cannot be discovered, either on its internal or external surface; and that even oblique and transverse wounds (which gape most), when they do not open the artery to a greater extent than one- fourth of ita circumference, are also filled up and healed by an effusion of coagulating lymph from their inflamed lips, so as to occasion but little or no obstruction to the canal of the artery. The utmost magnitude W a wound, which will still allow the continuity of the canal to be preserved, is difficult to be learned; for when the wound is large, but yet capable of being united, such a quan- tity of coagulating lymph is poured out, that the canal of the vessel at the wounded part is more or less filled up by it. And when the wound is still larger, the ves- sel soon becomes either torn or ulcerated completely across, bv which its complete division is accomplished. Beelard made a series of experiments upon dogs, whose arteries are said not to differ much from those of man, though the impulse of the heart is not so strong, and the blood is more coagulable; two circum- stances which should be duly considered in applying any of the inferences drawn from such experiments to the human subject. " In his first experiment he pricked the femoral artery wth a needle; the blood flowed, but soon stopped. On removing the coagulum it again flowed, but in a smaller stream ; it gradually ceased to bleed, and finally stopped, though the coagu- lum was again scraped off. On examination of the artery no trace of the cicatrix was found. Several similar experiments had the same result. In experi- ment 4, he denuded the femoral artery, and made a lon- gitudinal cut in it from two to three lines. The lips of the wound were seen in contact during the diastole of the ventricle, and to be separated by a jet of blood during the systole. The blood was stopped by a coagu- lum ; this was removed twice, and each time the blood flowed in a diminished stream, but the animal died. In experiment 6, he made the same incision, but did not detach the sheath from the artery, and the wound was left to nature. The hemorrhage was not^reat; there was an infiltration of blood into the sheath, the size of an almond, which at the end of some days began to dimi- nish, and disappeared in two or three weeks. On the limb being examined, fifteen days afterward, a little white ridge was found adhering firmly to the artery and to the sheath, and completely closing the wound. In the interior, there was a depressed longitudinal cica- trix of the breadth of the fifth of a line. The canal was regular and pennons through its whole extent. I n experiments 7,8,9, he made transverse incisions of i, \, and H of the circumference of the femoral ar- tery separated from its sheath: all the animals died. In experiment 10, he made a transverse incision through ' of the circumference, without disturbing the sheath. The bleeding was stopped by a coagulum, but on the animal moving it again flowed, and the dog died. But in the next experiment ofthe same kind the blood was Kiopped by a coagnlnm, and the artery was closed by Vol. I.—Hh nearly the same process as to the 6th experiment. So completely was the cure at the end of six weeks that the external part of the artery did not show any mark of a wound, and the cicatrix was scarcely observable on the interior surface. In his 12th experiment he cut one-half of the circumference: the animal died; and so did it in several simUar experiments. In experiment 13, he cut j ofthe circumference: after the animal was much reduced the bleeding ceased, and the artery was closed in the same manner that it is when the section is complete. From these experiments he concludes wounds of the arteries of dogs are cured by nature when they are only occasioned by a puncture, or a longitudinal incision, whether the artery be denuded or not; but when arising from transverse incisions they are always mor- tal if the artery be laid bare. If the artery retain its sheath, and the wound be i or J of the circumference, it may be cured by the efforts of nature ; but it is al- ways fatal if J of it be cut through.—(See Quarterly Journ. of Foreign Medicine and Surgery, vol. 1, p. 26.) The inferences respecting the curability of a wound extending through % of the circumference, and the incurability of one that affects only J of the cir- cumference of the vessel, I should presume must re- quire farther examination, notwithstanding an acci- dental faintness produced by the sudden loss of blood in the first instance may have been the means of saving one or two of the animals on which Beelard made lus experiments. This author thinks it probable that a puncture, or longitudinal incision, in the artery of a man may be cured by nature; but that a transverse wound never cicatrizes properly, as the clot becomes displaced, or, if a cicatrix be formed, it wili be distended and torn. One fact made out by the same professor is, that when an artery is deprived of its sheath for an extent greater than its distance of retraction, the hemorrhage is mortal. I have not yet had time to look over the ori- ginal paper; but it appears to me, that it would be de- sirable to know precisely to what sized arteries the author is referring, when he is making some of the above inferences. The size and condition of each ani- mal, the subject of experiment, should also be particu- larly specified; as experiments made on the femoral artery of a lady's lapdog would surely not have the same results as those performed on the same artery of a large terrier, setter, or Newfoundland dog. According to Dr. Jones, the lymph which fills up the wound of an artery is poured out very freely both from the vessel and the surrounding parts, and it accumulates around the artery, particularly over the wound, where it forms a more distinct tumour. The exposed sur- rounding parts at the same time inflame, and pour out coagulating lymph, with which the whole surface ofthe wound becomes covered, and which completely exclud*s the artery from the external wound. This lymph granu- lates, and the wound is filled up and healed in the usual manner.—(See Jones on Hemorrhage, p. 113, ic.) S IRQICAL MEANS OF SUPPRESSING HEMORRHAGE. It must be plain to every one who understands the course of the circulation, that pressure, made on that portion of a wounded artery which adjoins the wound towards the heart, must check the effusion of blood. The current of blood in the veins, ninningin the oppo- site direction, requires the pressure to be applied to that side of the wound which is most remote from the heart. However, on account of the freedom and facility with which the blood is transmitted through the anastomoses, from the portion of the artery above the point of pres- sure into the lower continuation of the artery, such pressure will often only check, and not effectually stop the bleeding, unless the part of the vessel directly below the wound be also compressed or secured. As pressure is the most rational means of impeding hemorrhage, so it is the most effectual; and almost all the plans, em- ployed for this purpose, are only modifications of it. The tourniquet, the ligature, the application of a roller and compresses, even agaric itself, only become useful in the suppression of hemorrhage, on the principle of pressure: the cautery, caustics, and stypies, however, have a different mode of operation. In order to prevent a wounded person from dying of hemorrhage, Celsus advised the wound to be filled wkh dry lint, over which was laid a sponge dipped in cold water, and pre-s«l on the part wkh Ihe hand. If, not 489 HEMORRHAGE. withstanding these means, the hemorrhage should con- tinue, he recommends repeatedly applying fresh lint, wet with vinegar; but he is against the use of corroding escharotic appUcations, on account of the inflammation which they produce; or only sanctions theemplovment of the mildest ones. When the hemorrhage resists these methods, he advises two ligatures to be applied to the wounded part of the vessel, and then dividing the portion situated between them: "Quod si ilia quoque profluvio vincuntur, vena, qua sanguinem fundunt, apprehendenda, circaque id, quod ictum est, iuobus locis deliganda, intercidtndaque sunt, ut et in se ipsa coeant, et vihilominus ora praclusa habeant." —(Lib. 5, cap. 26.) When the ligature was imprac- ticable, the wound bled dangerously, and no large nerves nor muscles were situated in the bleeding part Celsus proposed the actual cautery. Galen also mentions tying the vessels for the purpose of stopping hemorrhage; and there are some traces of the same information in other authors, who lived before him, as Archigenes and Rufus. Probably, however, the ligature was little used at these early periods, as may be inferred from the multitude of astringents, caustics, and other applications, which were advised for stopping bleeding, and in which less confidence would have been put, had the use of the ligature been familiarly known. No one can doubt, that if the old surgeons had had many opportunities of seeing the ad- vantages of the ligature, they would soon have used it after amputations; but so far were they from adopting such practice, that Albucasis, a long while afterward, refused to amputate at the wrist, lest he should see his patie'nt bleed to death. Pare is considered as the first who regularly employed the ligature after amputation. His method having been attacked, he modestly defends it in the part of his works entitled Apologie, where he takes great care to impute the origin of it to the ancients, and cites many of them who have made mention of it. However, he thinks its utility in amputations of such consequence, that he ascribes his first adoption of this practice to in- spiration of the Deity. The method in which the ancients placed most con- fidence for stopping hemorrhage after the amputation of a limb, was the cauterization of the cut vessel, and surrounding flesh. The parts thus affected by the heat formed an eschar, of greater or less thickness, which blocked up the opening of the vessel, and hin- dered the blood from escaping. The separation of the eschar, however, which frequently took place too soon, occasioned a return of hemorrhage, and rendered it the more dangerous, as its suppression was now more difficult than U*fbre the cautery had been applied. Sometimes the instrument, being too much heated, im- mediately brought away with it the eschar. At the present time, the cautery is never employed as a means of suppressing hemorrhage, or, at most, only in a few very unusual cases, in which neither compression nor the ligature can be made use of. In Great Britain, the cautery may be said to be entirely exploded; but in France, the best hospital surgeons now and then employ it to stop bleedings from the antrum and the mouth. The old surgeons -.lso very commonly applied to bleeding parts pledgets, dipped in boiling turpentine—a practice that has long been most justly abandoned. ASTRINGENTS, STYPTICS, &C Le Dran, in his Treatise on the Operations of Surgery, says that a button of vitriol, or alum, applied and pro- perly confined on the extremity of the vessel, is suffi- cient to stop the hemorrhage in amputations. Heister recommends the apphcation of vitriol, in preference to the Ugature, in the amputation of the forearm. Great praises have also been conferred on agaric, and sponge, for their styptic properties. Solutions of iron, and all the mineral acids in various forms, have been recom- mended to the public, as remedies of the same kind, and possessing great efficacy. The ancients, centuries ago left no application of this nature untried, and the pretended discoveries of new and more effectual styp- tics in later times may almost all be met with in their writings. This fact merits particular notice, because the little success attending their practice, especially when bleeding from a considerable artery was to be suppressed, clearly proves what little reliance ought to b" placed on means of thisdescription.-<£ncs/etop«<,K V thodique, partu Chir.) T.,e mo^i which styptics can do is to stop hemorrhages from small arteries; bul they ought never to be trusted when large vessels are concerned. There is no doubt, that cold air has a styptic property; by which expression I mean, that it promotes the con- traction of the vessels ; for no styptics can contribute to make the blood coagulate, though such an erroneous idea is not uncommon. We frequently tie, on the sur- face of a wound, every artery that betrays the least disposition to bleed, as long as the wound continues exposed to the air. We bring the opposite sides of this wound into contact, and put the patient to bed. Not an hour elapses before the renewal of hemorrhage compels us to remove the dressings. The wound is again ex- posed to the air, and again the bleeding ceases. This often happens to the scrotum, after the removal of a testicle, and on the chest, after the removal of a breast. The proper conduct in such cases, is not to open the wound unnecessarily, but to apply pressure, or else wet linen to the part, so as to produce such an evaporation from its surface, as shall create a sufficient degree of cold to stop the bleeding. As aU styptics are more or less irritating, no judicious practitioners apply them to recent wounds. However, for the suppression of he- morrhage from diseased surfaces, where the vessela seem to have lost their natural disposition to contract, these applications are sometimes indicated. COMPRESSION. We have already remarked that all the best means of checking hemorrhage operate on the principle of pres- sure ; the actual and potential cautery, and some styp- tics excepted: the first two of which operate by forming a slough, which stops up the mouths of the vessels; while the latter operate by promoting their contraction. Let us next consider the various modifications of pressure. * In a dissertation on the manner of stopping hemor- rhage, printed in the Mim. de PAcad. des Sciences, annie 1731, Petit endeavoured to prove, that different articles, praised as infallible specifics, would seldom or never have succeeded without compression. Even when caustics were employed, it was usual to bind compresses tightly on the part, so as to resist the impulse of the blood in the artery, and the premature separation of the eschar. Had this precaution not been taken, Petit be- lieves hemorrhage would almost invariably have fol- lowed, and indeed, notwithstanding the pains taken to avert it by suitable compression, it did too frequently take place ou the detachment of the eschar. Petit has noticed that the end of a finger, gently compressing tbe mouth of a vessel, is a sufficient means of stopping he- morrhage from it, and that nothing else would be necessary, if the finger and stump could always be kept in this posture. Hence he endeavoured to obviate these difficulties by inventing a machine winch securely and incessantly executed the office of the finger. The instrument was a double tourniquet, which, when ap- plied, compressed at once both the extremity of the di- vided artery and its trunk above the wound. The com- pression on the end of the vessel was permanent; that on the trunk was made only at the time of dressing the wound, or when it was necessary to relax the other. An engraving and particular description of the instru- ment are to be found in Petit's memoir. •Surgeons formerly filled the cavities of wounds with lint or charpie, and then made pressure on the bleeding vessels, by applying compresses and a tight roller over the part. Tl^e practitioners of the present day are too well acquainted with the advantages of not allowing any extraneous substance to intervene between Ihe op- posite surfaces of a recent wound, to persist in the above plan. They know that the sides of the wound may be brought into contact, and that compression may yet be adopted, so as both to restrain particular hemorrhages, and rather promote than retard the union of the wound. When the blood does not issue from any particular vessel, but from numerous small ones, compression is preferable to the ligature. In the employment of the latter, it would be necessary to tie the whole surface of the wound. The sides of the wound are to be brought accurately together, and compresses are then to be placed over the part, and a roller to be applied with sufficient tightness to make effectual pressure, but not so forcibly as to produce any chance of the crr-ulu tion in ;iii limb being t/ompleady sioppud HEMORRHAGE. • 483 If, in bleedings from large arteries, compression can ever be prudently tried, it is when these vessels lie im- mediately over a bone, lileedings from the radial and temporal arteries are generally cited as cases of this kind, though from the many instances of failure which I have seen happen where the first of these vessels is concerned, I should be reluctant either to advise or make such an attempt. Compression is-sometimes tried, when the brachial artery is wounded in phlebo- tomy. Il« re it is occasionally tried, in preference to the ligature, because the latter cannot be employed without an operation to expose the artery. When there Is a small wound in a large artery, the following plan may be tried: a tourniquet is to be ap- plied, so as lo command the flow of blood into the vessel. The edges of the external wound are next to be brought into contact. Then a compress, shaped like a blunt cone, and which is best formed of a series of compresses, gradually increasing in size, is to be placed with its apex exactly on the situation of the wound in the artery. This graduated compress, as it is termed, is then to be bound on the part with a roller. In this manner, I once healed a wound of the super- ficial palmar arch, in a young lady in Great Pulleney- street. The outward wound was very small, and though the hemorrhage was profuse, I conceived that it might be permanently stopped, if compression could be so made as to keep the external wound incessantly and firmly covered for the space of a day or two. At first, I tried a compress of lint, bound on the part with a roller; but this proving ineffectual, I took some pieces of money, from the size of a farthing to that of a half-crown, and, wrapping them up in linen, put the smallest one accurately over the wound, so as com- pletely to cover it. Then the others were arranged, and all of them were firmly confined with a roller, and the arm kept as quiet as possible in a sling. They were taken off after three days, and no hemorrhage ensued. It is to be observed, that the palmar fascia, in this instance, would prevent the compression from operat- ing on the vessel; but the case shows that this artery, when wounded, is capable of healing, if the blood be completely prevented from getting out of the external wound by the proper application of compression. Were the outer wound too large to admit of this plan, it would probably be the safest practice to cut down, at once, to the ulnar artery, and put a ligature round it, though, as this would only certainly stop the bleed- ing from one end of the vessel in the hand, pressure on the wound would yet be necessary. I have never seen a surgeon succeed in taking up the artery in the hand. Besides compressing the wounded part ofthe artery, some surgeons also apply a longitudinal compress over the track of the vessel above the wound, with a view of weakening the flow of blood into it. Whatever good effect it may have in this way, is more than coun- terbalanced by the difficulty which it must create to the circulation in the arm. If the graduated compress be properK arranged, an efftision of blood cannot pos- Ribly happen, and pressure along the course of the ar- tery must at all events be unnecessary. After relax- ing the tourniquet, if no blood escape from the artery, the surgeon (supposing it to be the brachial artery wounded) should feel the pulse at the wrist, in order to ascertain that the compression employed is not so powerful as entirely to impede the circulation in the forearm and hand. The arm is to be kept quietly in a sling, and, in forty-eight hours, if no bleeding take place, there will be great reason to expect that the case will do well. In another work, I have given an engrav- ing and description of an instrument invented by PlencK, for making pressure on the wounded brachial artery, at the bend of the arm, without pressing upon Ihe whole circumference ofthe limb and consequently without stopping the circulation. No one, however, would prefer compression when large arteries are in- jured, except in the kind of cases to which we have just now adverted, or in those in which the wounded vessel can be firmly compressed against a subjacent bone. Sometimes the compresses slip off, or the band- aces become slack, and a fatal hemorrhage may arise • and a still greater risk is that of mortification from the constricted state of the limb. When the method is tried, the tourniquet should always he left loosely round the limb, ready to be tightened in an instant Sometimes the external wound heals, while the open- ing in the artery remains unclosed, and a false aneu- rism is the consequence. TOURNIQUET. When hemorrhage takes place from a large artery in one of the limbs, where the vessel can be conveniently compressed above the wound in it, a tourniquet, judi- ciously applied, never fails to put an immediate stop to the bleeding. Before the invention of this instrument, which did not take place till the latter part of the 17th century, surgery was really a very defective art. No important opera- tion could be undertaken on the extremities, without placing the patient in the most imminent peril; and many wounds were mortal, which, with the aid of this simple contrivance, would not have been attended with the least danger. The first invention of the tourniquet has been claimed by different surgeons, and even different nations. But, whoever was the inventor, it was first presented to the public in a form exceedingly simple ; so much so, in- deed, that it seems extraordinary that its invenrion did not happen sooner. A small pad being placed on the principal artery of a limb, a band was applied over it, so as to encircle the limb twice. Then a stick was introduced between the two circles of the band, which was twisted: thus the pad was made completely to stop the flow of blood into the lower part of thevessel. Although in the Armamentarium Chirurgicum of Scultetus there is a plate of a machine invented by this author for compressing the radial artery by rrjeana of a screw, J. L. Petit is universally allowed to be the first who brought the tourniquet to perfection, by com- bining the circular band with a screw, so that the greatest pressure may operate on the principal artery. The advantages of the modem tourniquet are, that its pressure can be regulated with the utmost exact- ness ; that it operates chiefly ou the point where the pad is placed, and where the main artery Ues; that it does not require the aid of an assistant to keep it tense; that it completely commands the flow of blood into a limb; that it can be relaxed or tightened in a moment; and that, when there is reason to fear a sud- den renewal of hemorrhage, it can be left slackly round the limb, and, in case of need, tightened in an instant. Its utility, however, is confined to the limbs, and as the pressure necessary to stop the flow of blood through the principal artery completely prevents the return of blood through the veins, its application cannot be made very long without inducing mortification. It is only of use also in putting a sudden stop to profuse hemorrhages for a time, that is, untU the surgeon has put to practice some means, the effect of which is more permanent. LIGATURE. The ancients were quite unacquainted with the use of the tourniquet, and though some of their writers have made mention of the Ugature, they do not seem to have known how to make proper use of it, nor to have possessed any other certain means of suppress- ing hemorrhage from wounds. In modern times, it is easily comprehensible, that wheu any great operation was undertaken, while surgery was so imperfect, there was more likelihood of the patient's life being short- ened than lengthened, by what was attempted. Under these circumstances, it is not surprising that the old practitioners should have taken immense pains to in- vent a great many topical astringents. But now that the ligature is known to be a means which is safer and less painftil than former methods, no longer search need be made for specifics against hemorrhage. It may, indeed, be set down as a rule to surgery, that whenever large arteries are wounded, no styptic application should ever be employed, but immediate re- course had to the ligature, as being, when properly applied, the most simple and safe of all methods. In order to qualify the reader to judge of the beat mode of applying ligatures to arteries, I shall first ex- plain to him tbeir effect on these vessels, as related by Dr. Jones. This gentleman learned from Dr. J. Thomson, of Edinburgh, that in every instance in which a ligature is applied around an artery, without including the sur- rounding parts, the internal coat of the vessel is torn through by it; and that this feet had been orieinally 484 * HEMORRHAGE. noticed by Desault. Dr. Thomson even demonstrated to Dr. Jones, on a portion of artery taken from the hu- man subject, that the internal and middle coats are divided by the ligature.—(Jones, p. 126.) This led Dr. Jones to make some experiments on the arteries of dogs and horses, tending to the conclusion that when several ligatures are applied round an ar- tery with sufficient tightness to cut through its internal and middle coats, although tbe cords be immediately afterward removed, the vessel will always become im- pervious at the part which was tied, as far as the first collateral branches above and below the obstructed part. Dr. Jones thinks it reasonable to expect that the obstruction produced in the arteries of dog* and horses, to the manner he has related, " might be effected by the same treatment in the arteries of the human sub- ject ; and, if it should prove successful, it might be employed in some of the most important cases in sur- gery. The success of the late important improve- ments which have been introduced in the operation for aneurism, may perhaps appear to most surgeons to have rendered that operation sufficiently simple and safe; but if it be possible to produce obstruction in the canal of an artery of the human subject in the above- mentioned manner, may it not be advantageously em- ployed in the cure of aneurism; inasmuch as nothing need be done to prevent the immediate union of the ex- ternal wound?" Dr. Jones next questions whether this mode of obstructing the passage of blood through the arteries may not also be advantageously practised in cases of bronchocele 1—(P. 136.) Subsequent experimenters have not been equally suc- cessful with Dr. Jones in obtaining the obliteration of the cavity of the vessel after this operation. Did this difference depend upon their having tied the vessel only in one place ? Mr. Hodgson tried the experiment in two instances upon the carotid arteries of dogs; and in neither of them was the cavity of the vessel oblite- rated. The same experiment has been repeated by several surgeons upon the arteries of dogs and horses; but in no example, as far as Mr. Hodgson knows, has the complete obliteration of the cavity of the vessel been accomplished. However, as an effusion of lymph is an invariable consequence of the operation, the want of union is owing to the opposite sides of the vessel not being retained in a state of contact, so as to allow of their adhesion.—(See Observations on the Applica- tion of tlie Ligature to Arteries, i-c. by B. Travers, vol. 4, Med. Chir. Trans.) The presence of the liga- ture, to the common mode of its application, effects this object; and for the success of Dr. Jones's experi- ment., it appeared only necessary that the opposite sides of the wounded vessel should be retained in contact until their adhesion is sufficiently accomplished to re- sist the passage of the blood through the tube. This object might probably be effected by compression; but the inconveniences attending such a degree of pressure as shall retain the opposite sides of an artery in con- tact at the bottom of a recent wound, are too great to permit its employment. It occurred to Mr. Travers, that if a ligature were applied to an artery, and suf- fered to remain only a few hours, the adhesion of the wounded surfaces would be sufficiently accomplished to ensure the obliteration of the canal; and by the re- moval of the ligature at this period, the inconveniences attending its stay would be obviated. The danger pro- duced by the continuance of a ligature upon an artery arises from the irritation which, as a foreign body, it produces in its coats. Ulceration has never been ob- served to commence in less than twenty-four hours after the application of a ligature; while it is an ascer- tained fact that lymjh is in a favourable state for or- ganization in less than six hours, in a wound the sides of which are preserved in contact.—(/ewes, chap. 4, exp. 1.) If it be sufficient, therefore, to ensure their adhesion, that tbe wounded coats of an artery be kept in contact by a ligature only three or four hours, ulcer- ation and sloughing may to a great degree be obviated by promoting the immediate adhesion of the wound. Justified by this reasoning, Mr. Travers performed several experiments, by which be ascertained, that if a Ugature be kept six, two hours, or even ene hour upon the carotid artery of a horse, and then removed, the adhesion is sufficiently advanced to secure the per- manent obliteration of the canal. It appeared probable that the same result would be obtained upon the heilthvartery of a human subject.—(Hodgson on the Diseases of Arteries, i-c. p. 228, et seq.) Mr. A. C. Hutchison, in the year 1800, tied the lirachal arteries of two dogs, and removed the ligatures immediately after their application. In both instances, the complete obliteration of the canal ol" the artery was the conse- quence of the operation.—(See Practical Observations in Surgery, p. 103.) He has also tried this method, as modified by Mr. Travers, in an operation which he performed for a popliteal aneurism in a sailor, in Nov. 1813. A double ligature was passed under the femoral artery. The ligatures were tied with loops or slip- knots, about a quarter of an inch of the vessel being left undivided between them. All that now remained of the pulsation in the tumour was a slight undula- tory motion. Nearly six hours having elapsed from the application of the ligatures, the wound was care- fully opened, and the ligatures untied and removed. without the slightest disturbance of the vessel. In less than half a minute afterward the artery became distended with blood, and the pulsations in the tumour were as strong as they had been before the operation. Mr. Hutchison then applied two fresh ligatures; he morrhage afterward came on; amputation was per- formed, and the patient died.—(See Practical Observa- tions in Surgery, p. 102, ire) Now, as Mr. Hutchison chose to apply other ligatures, on finding that the pul- sation returned, the above case only proves that the artery was not obliterated in about six hours, and we are left in the dark respecting the grand question, namely, whether the vessel would have become obli- terated by the effusion of coagulating lymph and the adhesive inflammation, notwithstanding the return of circulation through it. As for the hemorrhage which occurred, I think it might have been expected, consider- ing the disturbance and irritation which the artery must have sustained in the proceedings absolutely ne- cessary for the application of not less than four liga- tures, and the removal of two of them. According to my ideas, only one ligature ought to have been used, and none ofthe artery detached. We also have no de- scription of the sort of ligatures which were employed; an essential piece of information in forming a judg- ment of the merits of the preceding method. The application, removal, and reapplication of ligatures are not consistent with the wise principles inculcated by the late Dr. Jones, and have, in more instances than that recorded by my friend Mr. Hutchison, brought on ulceration of the artery and hemorrhage. For farther information on the question concerning the propriety of withdrawing the Ugature previously to its detach- ment, see the article Aneurism. From Dr. Jones's experiments, it appears that the first effects of a ligature upon an artery are, a com- plete division of its internal and middle coats, the bringing of its wounded surfaces into contact with each other, and an obstruction to the circulation of the blood through its canal. There must be a small quantity of stagnant blood just within the extremity of the artery; but this does not, in every instance, immediately form a coagulum capable of filling up the canal of the artery, In most cases, only a slender coagulum •■-> formed at first, which gradually becomes larger by successive coagulations of the blood; and hence the coagulum is always at first of a tapering form, with its ba«;e at the extremity of the artery. But, as Dr. Jones remarks, the formation of this coagulum is not material; for soon after the ligature has been applied, the end ofthe artery inflames, and the wounded internal surface of its canal being kept in close contact by the ligature, adheres and converts this portion of tbe artery into an impervious and, at first, slightly conical sac. It is to the effused lymph that the base of tbe coagulum adheres, when found to be adherent. Lymph is also effused between the coats ofthe artery, and among the parts surround- ing its extremity. In a little time, the ligature makes the part on which it is directly applied ulcerate, and, acting as a tent, a small aperture is formed iii the layer of lymph effused over the artery. Through this aper- ture a small quantity of'pus is discharged, as long as tbe ligature remains; and finally, the ligature itself also escapes, and the little cavity which it has occasioned granulates and fills up, and the external wound heals. leaving the cellular substance a little beyond the end of the artery much thickened and indurated.—(Jones, p. 159. 161.) In short, when an artery is properly tied, the follow- ing are the effects, as enumerated by Dr. Jones: HEMORRHAGE. 485 1. To cut through the internal and middle coats of the artery, and to bring the wounded surfaces into per- fect apposition. 2. Te occasion a determination of blood to the colla- teral branches. 3. To allow the formation of a coagulum of blood just within the artery, provided a collateral branch be not very near the ligature. It merits particular notice, however, that though the nearness of a collateral branch prevents the formation ofthe coagulum, it cannot always prevent the completion ofthe adhesive process. In the experiments made on the arteries of horses and dogs by Mr. Travers, the ligature was purposely appUed close to large collateral branches, vit the vessels were safely obliterated.—(.'See Med. Chir. Trans, vol. 6, p. 658. 600.) 4. To excite inflammation in the internal and middle coats of the artery, by having cut them through, and, consecpiently, to give rise, to an effusion of lymph, by which the wounded surfaces are united, and the canal is rendered impervious; to produce a simultaneous inflammation on the corresponding external surface of the artery, by which it becomes very much thickened with effused lymph; and, at the same time, from the exposure and inevitable wounding of the surrounding parts, to occasion inflammation in them, and an effusion of lymph, which covers the artery, and forms the sur- face of the wound. 5. To produce ulceration in the part of the artery around which the ligature is immediately applied, viz. its external coat. 6. To produce indirectly a complete obliteration, not only ofthe canal of the artery, but even of the artery itself, to the collateral branches on both sides of the part which has been tied. 7. To give rise to an enlargement of the collateral branches.—(Jones, p. 163, 164.) Every part of an artery is organized in a similar manner to the other soft parts, and its coats are suscep- tible ofthe same process of adhesion, ulceration,