s^S:'-:-y Entered according to Act of Congress, in the year 1858, by Drs. SAMUEL LOGAN & T. S. WARING, In the Clerk's Office of the District Court for the District of South Carolina. r / t OUTLINES f a Course of jTectmts ON THE PRINCIPLES AND PRACTICE OF SURGERY, DELITERED BV E. GEDDINGS, M. D., PROFESSOR OF SURGERY IN THE MEDICAL COLLEGE 01 THE STATE OF SOUTH CAROLINA PREPARED BV Thos. S. Waring, M. D., and Samuel Logan, M. D., k-k.<:»;vi xirrKH i-.vkkx ih'Ki>ig >iik gc»i«.sk- PUBLISHED WITH THE CONSENT OF, AND REVISE^ BY PROFESSOR GEDDIN«S CHARLESTON; S. G. COUtlTENAY & CO., PUBLISHF.I^- No. 9 Broad Strket. 1858. »l V. . 8442 wo GeZJScr Cjrarlest0n, £. the difficulty of treating this fracture, some have proposed to keep the arm permanently in a flexed position, by means of an angular splint at the elbow se- cured to the arm and body by a roller bandage, which is afterwards carried over the point of the shoulder to keep the fragments, with the aid of compresses, in apposition. Either of these methods may be adopted. I must now speak of fractures of the coracoid process. This- process is sometimes broken off; and then it will be drawn downwards and inwards, by three muscles, the pectoralvs minor coraco-brachialis, and short head of the biceps. Sometimes, owing to the depth of the process and its being covered by the pectoralis major, the fracture will be difficult to detect, and also difficult to reduce. But still it will be your duty to attempt to put the frag- ments in apposition, or as nearly so as possible; and I apprehend that the best way of effecting this will be to. place the hand over the opposite shoulder, as in the position for Velpeau's bandage, and applying a graduated compress to the process, to secure it by Velpeau's bandage. Next we go on to speak of Fractures of the Humerus. This is, as you know, a cylindrical bone, presenting various parts, interesting in a surgical, as well as in an anatomical point K 162 FRACTURES OF THE HUMERUS. of view. In the first place, we have the head; beneath this, and separating it from the rest o'f the bone, is a constricted portion, called the anatomical neck; below, between this point and the insertion of the latissimus dorsi and pectoralis major, is the portion known as the surgical neck; and this last must not be confounded with the anatomical neck. Next to this is the shaft of the bone, and then the inferior head, consisting of the two condyles, and the trochlea. Through any of these sections a fracture may take place, and it is necessary to consider each separately—first, fracture as occurring in the anatomical neck; secondly, in the sur- gical neck; thirdly, in the shaft; fourthly in the shaft above and near the condyles; and fifthly, through the condyles themselves. It is important to bear this division always in your mind. Now then, we will consider fractures through the anatomical neck. It is proper to remark, in the first place, that in young subjects—indeed up to the fifteenth year—the head of the humerus is attached to the body only by a cartilagenous substance, which occupies the position of the anatomical neck, and the head may here be separated from the bone ; though this fracture deserves to be considered also in another point of view. Should the fracture take place within the capsular ligament, the head floats every where in the synovial fluid; resting as a foreign body in the joint, it excites inflammation, which progresses to suppuration; and unless timely aid is afforded, the unfortunate victim may per- ish, from the extent to which the inflammatory action is carried. But in other instances the fracture may take place exterior to the capsular ligament; and here the accident is of a far less serious character, for life in the fragments may still be kept up ; even a reparative process may in a measure take place; and we may have at least a ligamentous union. These fractures are generally caused by force acting in the axis of the limb; as, for example, by falling from a height and catching on the hand. Force, acting in this manner, may not only detach the head from the neck, but may also cause a fracture through the head itself, thus producing a multiplex fracture. Again, we should discuss fractures occurring in that portion of the bone known as the surgical neck, or all that part of the bone lying between the anatomical neck, and the insertions of the pectoralis major and latissimus dorsi; but as this will occupy too much time for the present lecture, I shall resume the subject at our next meeting. FRACTURES OF THE HUMERUS. 163 LECTURE XIX. FRACTURES OF HUMERUS CONTINUED--FRACTURES OF BONES OF FORE- ARM--OLECRANON PROCESS--CORONOID PROCESS. I have remarked to you, gentlemen, that it was highly important, in a consideration of fractures of the humerus, to distinguish be- tween those that take place in the surgical neck, or that portion of the bone which lies between the anatomical neck, and the inser- tion of the latissimus dorsi and pectoralis major, and those which take place below the insertion of these muscles. We find that by the action of these two muscles, with that of the teres major, the arm is drawn to the side; so that, when fracture takes place above their insertion, the lower fragment will be drawn inward, towards the side. But this is not all. Inserted into the greater tuberosity of the humerus, we have the supra and infra spinatus muscles. The influence of these two muscles will be exerted on the upper fragment, and, by a rotatory movement in the glenoid cavity, cause it to glide outward over the lower. Now let us contrast what takes place here, with what would take place if the fracture were lower down. When the fracture occurs below the insertion of these muscles, the influence of their contraction would be exerted on the upper fragment, drawing it in, and thus causing the lower frag- ment to glide out, and over the upper one. This then is the dif- ference between fractures occurring in the surgical neck, or above it, and those occurring below it. In the one, the upper fragment glides outward and over the lower, the lower being drawn inward; in the other, on the contrary, the lower glides outward, over the upper, the upper being drawn inward. This distinction should al- ways be borne in mind, as it will have an important practical bearing. For the treatment of those fractures occurring through the sur- gical neck, or above it, a number of expedients may be resorted to. For example; after the adjustment and application of the tumefaction bandage, two or more splints may be put on, sur- rounding the arm, always taking care to introduce compresses under the splints, to prevent injury to the soft parts. These splints are to be secured by a roller bandage; and it is also advisable to apply a few turns of the roller, in the form of a spica bandage, over the shoulder. The arm is then brought to the side, a pad being placed in the axilla. Another plan is that of using an angular 164 FRACTURES OF THE HUMERUS. trough paste-board splint, placed at any angle, the right angle being the best. Having placed proper compresses in the splint, and made the proper adjustment, apply first the tumefaction ban- dage, commencing at the hand, and proceeding upward; and hav- ing arrived at the seat of fracture, it would be best to introduce an additional compress, and apply the bandage a little tighter. The upper end of the splint is to be curved in such a manner as to adapt itself to the shoulder; and it is then to be applied, and secured by bringing the roller down over it. If the splint is a rectangular one, the arm may be laid across the chest; and then precisely the same steps are pursued, as in the application of two or four splints. Soft compresses are introduced ; the apparatus is secured by a roller; and the arm is brought across the chest and suspended in a sling. Again; when the fracture is very low down, a hinged splint may be used, the angle of which is regulated by a screw; and this is to be secured as the previous. And I would re- mark, before leaving the consideration of fractures of this kind, that displacement here is not so great, on account of the muscula fibres of the brachialis anticus, which take their origin from the bone, and form strong bonds of union, keeping the fragments in their places. I have said that fractures, both oblique and transverse, might take place near the condyles, so as sometimes to affect the joint. This is a very difficult fracture to manage. When low down, it passes through the fossa magna, and produces inflamma- tion of the synovial membrane. If we are not very careful, there- fore, we shall have the accident to result in anchylosis ; while on the other hand, also, the tendency to displacement is constant. The difficulty, then, is two-fold. In this form of fracture, the diagnosis is very easy. Even when the arm rests by the side, the deformity is evident; but if you lay hold of the arm with one hand, and the upper part of fore-arm with the other, and move the one on the other, crepitus will be plainly perceived. Still, when you have discovered the existence of the fracture, it is necessary to push your examination one step further; for it is very frequently con- founded with fracture involving the condyles only; and indeed these are sometimes of simultaneous occurrence. When the latter takes place, you find that upon seizing the arm and fore-arm, as before, the elbow when flexed will be very broad. By the absence of this increase of width in the elbow, and from crepitus, and the mobility in the part, you will be enabled to distinguish a fracture above the condyles. As regards the treatment, you will observe, that the method of FRACTURES OF THE HUMERUS. 165 managing fractures higher up will not do here, the lower fragment being too short to be controlled by this plan. The best application is a trough paste-board splint, one segment of which is to act upon the arm, and the other on the lower portion of the arm and fore-arm. A variety of expedients, however, have been sug- gested for the treatment of this fracture. A very good method is to use simple angular splints, with compresses interposed; the splint being confined by a roller bandage also, and the arm being kept in a flexed position; while the tumefaction bandage shoula have been previously applied. I have already alluded to fractures occurring through the con- dyles. It sometimes happens, that small fragments of the inter- nal condyle are broken off, without the fracture entering the articulation. In this accident, there is seldom much displace- ment. The arm being flexed, you can easily press the small fragment into its position. Having done this, apply a compress before, behind, and below; and pass a common roller round the limb, from the hand to the elbow, where you should make several figure-of-eight turns, the arm being placed in a flexed position. It is seldom necessary to use any splint. But when the fracture extends more deeply, and the inner or outer condyle is broken off from the rest of the bone, we have to deal with a far more serious accident; for here the synovial membrane will be implicated, and in the process of cure, your patient will not only suffer great pain, but plasma may be thrown out, into the joint; and, unless care be taken, he may come out with a permanent an- chylosis of the elbow, a matter of the most serious importance. There are. then, two leading objects to be kept in view, in this connection ; first, to secure the condyle in its proper position, and secondly, to prevent anchylosis. We find, on reflection, that every consideration suggests the flexed position of the fore-arm on the arm, as the best to be selected for the treatment of this fracture. When it is possible, the hinged splint may be used : and it is best always to begin with the fore-arm at a right angle ; and gradually to change its position, as the case advances; the object of this be- ing to break up any bonds of union which may, from time to time, form in the joint; and thus to prevent the development of anchy- losis. Having made the proper adjustment, and flexed the fore- arm on the arm, the tumefaction bandage should be applied from the wrist upward. Having arrived at the elbow make a few figure- of-eight turns ; then ascend with the roller up to the shoulder; place a compress between the splint and the anterior portion of the 166 FRACTURE OF OLECRANON PROCESS. arm; and then, with the same roller, or another, descend over the splint, making again several figure-of-eight turns at the elbow, and continuing the bandage to the wrist. Lay the arm, lastly, on the chest, and support it in a sling. This apparatus should be worn for about a week or ten days; at the end of which time, it should be removed, and the arm carefully flexed and extended gently, and redressed ; being then careful to replace it at a different angle. If great inflammation be present, however, it will be highly improper to put on any apparatus whatever, before this has subsided. While carrying out the antiphlogistic treatment, the patient should be kept upon his back, and perfectly quiet; and should tumefac- tion arise, even after the splint has been applied, it should at once be taken off, and all the dressing should be removed. Great care will be required in the treatment of these cases ; and I have pointed out that plan which I regard as the best. I would remark, how- ever, in this connection, that some use two angular splints, one on the inner, the other on the outer side of the arm, and applied in the manner described above. This method I do not consider as good as the other; since it does not so completely prevent motion at the elbow. With these remarks, I conclude what I have to say on fractures of the humerus, and shall go on, in the next place, to consider fractures occurring in the Bones of the Fore-arm. The first of these of which we shall speak, is fracture of the olecranon process. This may be caused by either direct, or indi- rect violence ; and it may be transverse or oblique. Generally the displacement will be great, from the contraction of the triceps mus- cle carrying the fragment up, on the arm; there will be a depres- sion at the joint, where the process ought naturally to be found ; there will be, on the part of the patient, a total inability to extend the fore-arm; and, except where there is great tumefaction—which is apt to occur soon—there will be no difficulty in detecting the nature of the accident. Where there is tumefaction, by moving the fore-arm on the arm, the diagnosis may be easily made out. Let us now see what are the indications to be fulfilled in the treat- ment of this fracture. In the first place, as the fragment is carried upward by the triceps muscle, it is clearly indicated, that this fracture should be treated with the arm in the extended position; and therefore it is of importance to use in the adjustment, such FRACTURE OF CORONOID PROCESS. 167 means and appliances, as shall keep the arm in extension. The next indication is, to counteract the action of the triceps muscle. A good method is, after having applied the tumefaction bandage, to use what is called a uniting bandage. Carrying the tumefaction bandage as far as just below the elbow, and having provided our- selves with two strips of linen, we place one on the inner, the other on the outer side of the arm, and secure them there by a few turns of the roller. We then apply a compress above the fragment, make a few figure-of-eight turns, and continue the bandage up over the strips. Then, keeping the arm extended, we tie the strips of the uniting bandage, apply a splint to the front of the arm and fore-arm, and secure it by bringing the same or another roller down over it. I would here also remark, that this fracture is in connec- tion with the joint; and therefore, as in fracture through the con- dyles, great care must be taken to prevent anchylosis. In spite, however, of all your endeavors, and with the greatest care, you will sometimes find that you have failed to make a perfect cure; and instead of bony union, only a kind of ligamentous connection will have taken place, impairing very much the use of the member. But still, with proper care, we will generally succeed in effecting a firm union. We may also have a fracture of the coronoid process. This is nearly always associated with a rupture of the ligaments; and my principal reason for mentioning this, is that it is nearly always associated with luxation of the bones of the fore-arm on the arm, producing the same deformity as that accident. But, if the deformity be produced by a laxation of the fore-arm, it cannot be reduced, except by great force, and when removed, it does not re- appear; while if it be produced by fracture, then, by flexing the fore-arm on the arm, the deformity is at once removed, but returns again as soon as the arm is extended. By this circumstance you readily distinguish between the two cases. In treating a fracture of the coronoid process, all that you have to do is to put up the arm exactly as I have told you to do in frac- ture occurring through the condyles, maintaining the adjustment until bony or ligamentous union is obtained. 168 FRACTURE OF THE BONES OF THE FORE-ARM. LECTURE XX. FRACTURES OF BONES OF FORE-ARM CONTINUED--HEAD OF RADIUS-- LOWER PART OF RADIUS, ETC., ETC.--CARPAL BONES--META- CARPAL BONES--FINGERS. We propose, gentlemen, to continue the subject of fractures occurring in the fore-arm. You will recollect that, in our lecture of yesterday, we spoke of the fracture of the olecranon and coro- noid processes of the ulna, and of the treatment of these accidents. When we consider the other fractures of these bones, we find that we must vary our method of treatment, according to the points at which they occur. In the first place, fracture may occur through the neck of the radius, with or without a fracture of the ulna. When we have a fracture of this kind, there can be no difficulty in detecting it. Placing yourself by the side of your patient, press your thumb firmly upon the rounded head of the radius, and with the other hand pronate and supinate the hand of the patient. The nature of the accident will be at once detected by a want of motion in the head, while the rest of the bone moves freely with the hand. Coaptation here will be found very easy; after having performed which, a compress should be applied in front, the fore-arm flexed on the arm, and the whole put up as in frac- tures through the condyles. In a fracture which involves both bones, whether occurring at the same level or not, you also experience but little difficulty in discovering the nature of the accident. More or less deformity will generally be present; but where you have any doubt, by seizing the fore-arm at its upper and lower extremities, and bend- ing it as though you would break it, the kind of injury will become evident. Here, too, rotation of the radius will aid you, as it will serve to produce crepitus; the upper portion being also found not to move in harmony with the lower. In the cases of fractures occurring in these bones, at some point not in immediate proximity to either extremity, it matters not, so far as the treatment is concerned, whether one or both bones be broken, as it is exceedingly simple, and in both cases precisely the same. Apply a compress the whole length of the fore-arm in front, having first put on a tumefaction bandage quite loosely. Then, taking two splints, apply one behind, long enough to ex- tend from below the elbow, to beyond the knuckles, and the other FRACTURE OF THE LOWER PART OF THE RADIUS. 169 in front, extending from the elbow to the ends of the fingers; and secure these by bringing the roller down over them. The splints should be wide, in order to prevent the roller from compressing the fore-arm, and you should be careful so to apply the anterior splint, as to prevent it from rubbing the arm at the elbow. The arm is then to be flexed, and carried in a sling. When you have an angular hinged splint, such as that I here exhibit, it will be found very convenient in the treatment of these fractures, as, from its construction, we can place the fore-arm at any angle we may desire. You should remember always, that your compress should so bear upon the interosseous space, as to press the bones apart, and counteract the action of the pronator quadratus. Were you to neglect this precaution, and allow the bones to be drawn to- gether, after the fracture had united, you would find your patient unable to pronate or supinate the hand. It is with the object of avoiding this that we use the long compress. In reference to these fractures, I have next to call your attention to one of far greater importance than any I have yet spoken of as occurring in the fore-arm. I allude to fracture taking place in the lower part of the radius. This is a fracture which, whether it be connected with the joint or not, I have no hesitation in affirming, might often be mistaken for a dislocation; for the hand, with the lower fragment, may be displaced either forwards or backwards. I repeat, then, that this fracture, especially by one unskilled in such matters, would, in nine cases out of ten, be mistaken for a dislocation. The fracture being near the joint, and inflammation coming on very rapidly, the relation of parts is soon destroyed. When this is the case, any one who mistakes the fracture for a dis- location, would, by extension and counter-extension, adjust the parts and leave them so. But when it is examined again at the next visit, it is found that the displacement has returned; and this goes on, from day to day, until union at last occurs, and the unfor- tunate patient is turned out with a permanent and incurable de- formity. I have seen so many instances of this kind that I must impress this accident particularly upon your attention, and request you always to recollect, that while, on the one hand, fractures * the lower portion of the radius is quite a common accident, dislocation of the wrist joint is, on the other hand, an accident so exceedingly rare that surgeons of great experience and high authority, deny that it can ever happen. But if you will bear in mind the remarks I have made, and particularly if you remember that dislocation is 170 FRACTURE OF THE LOWER PART OF THE RADIUS. a very rare accident, while fracture is a common one, and that the deformity is the same in both, you will at least be placed upon your guard, and your eyes be opened to the necessity, in all cases, of mak- ing an attentive examination and carefully seeking for crepitus. Taking for grantea, then, that the nature of the accident is discovered, let us, in the next place, proceed to consider what method of treatment may be best adapted to such cases. For many years no difference was made between the treatment of these cases and that of other fractures of the arm, and notwithstanding all the care that was taken, the patient would nearly always come out with a deformed limb. To the late Baron Dupuytren we are indebted, for first pointing out the proper indications to be fulfilled in these cases. In any plan of adjustment which we may adopt, we should make use of such means as will counteract those muscles which tend to draw the fragment up. We use two splints, long enough to extend from the elbow to the ends of the fingers, and so formed that each shall be bent downwards at the wrist. The splints are thus formed in order to retain the carpus in a position bent completely to the ulnar side—that bone thus afford- ing a firm support. In addition it will be well to apply a third splint, formed of soft iron, and so curved and moulded as exactly to fit the ulnar side of the fore-arm and hand, to which it is to be applied. This supports the hand at the angle of the other splints. We also use two triangular shaped compresses. Where the prominence of bone is on the posterior part of the wrist, place here the large end of one of the compresses, and the small end upon the radial fragment; so also place the other compress where the prominence is in the front, with its large end opposite the small end of the other, and complete the adjustment as in fracture of both bones of the fore-arm. A more simple, and per- haps equally efficient method of treating this fracture, is one proposed by Dr. Bond, of Philadelphia. It consists of a wooden splint, cut to the shape of the outline of the fore-arm and hand, and long enough to extend from the fold of the arm to the phalan- geal end of the metacarpal bones. Across the palmar face of this, a convex block, large enough to fill the palm of the hand, is attached, over which the fingers are placed and secured by a few turns of the roller bandage used in securing the splint to the arm in the ordinary way. Dr. Hays has employed successfully a very simple, extemporaneous modification of this apparatus, con- sisting of the head of a roller-bandage of sufficient size, instead of FRACTURES OF THE METACARPAL BONES. 171 the block, the tail of the roller being carried, first, longitudinally over the opposite end of the splint, then by a few circular turns around it. The apparatus, thus prepared, is to be applied, and secured to the arm and hand by circular turns of another roller, a compress being interposed. By this simple means I have re- cently treated four cases of fracture of the lower end of the radius, and with very satisfactory results. Here, as the fracture is in the neighborhood of the joint, or involving it, we have much more inflammation to contend with; and whenever we meet with high inflammatory action, we should subdue it by antiphlogistic measures before we apply any apparatus. Ever be particularly on your guard against the serious mistakes which ignorant sur- geons are continually making here,—confounding fractures and dislocations with each other. Bear in mind, that fracture is a very common accident, but that, owing to the strong ligaments uniting the parts, together with flexor and extensor tendons, dislocation at the wrist joint is exceedingly rare; and, I apprehend, that in ninety-nine cases out of one hundred, the bone will sooner give way in some of its parts, than a dislocation will occur. I have never seen a case of this kind, and, as I have before remarked, it is an accident so rare, that surgeons of distinction have even doubted the possibility of its occurrence. Fractures of Bones of Carpus and Metacarpus. i might go on in the next place to speak of fractures of the indivi- dual bones of the carpus ; but, from the minuteness of these bones, and the strong ligaments which bind them together, fracture seldom takes place here, unless caused by gunshot wounds, the explosion of powder, or some crushing force. In general terms, however, we may say, that the fragments should be placed in apposition, a compress applied, and, to prevent motion, two splints should be used, one placed anteriorly, and the other posteriorly. When extensive comminuted fracture takes place, and necrosis results, a cure cannot be effected until the dead portions of bone are removed, on account of the continual irritation and suppuration which is kept up by them. Fractures of the metacarpal bones are of much more frequent oc- currence. In type, the bones are cylindrical; and the fracture may take place through the neck, or the shaft, and it may also involve one or more of these bones. From the strong and numerous bonds of connection between the bones, there will be little or no deformity. 172 FRACTURE OF THE PHALANGES. In nearly all cases, however, by flexing the hand in such a manner as to bend the carpus, a slight angular displacement will be perceived on the dorsum of the hand, and this will be all the deformity which will occur. There will be but little difficulty in the diagnosis. But it is my duty to state here, that I have seen a greater number of false joints arising from this fracture, than from any other. One reason for this no doubt is, that both the patient and surgeon are apt to regard the fracture as of but little impor- tance, and therefore fail to treat it with sufficient care, and to pre- vent motion between the fragments. Another reason is to be found in the want of recuperative power; which is found to exist in these bones in but a low degree. Hence, too, in many diseases and injuries of the metacarpal bones, they are found to fall very readily into necrosis. This being the case, it is a matter of im- portance never to underrate the importance of these simple frac- tures, and always to impress upon your patient not to remove the apparatus until you are sure that union has been secured. Now, when you have to treat a fracture of the metacarpal bones, the simplest plan is to use two compresses—one to fill up the palm of the hand, the other to be placed on its back—and two splints, one in front, and the other behind. These must be secured in such a manner, as to prevent all motion at the point of fracture; and they must be worn until perfect union has taken place. As regards the Fractures of the Phalanges. I may dismiss the subject with a very few words. They will be easily diagnosticated by flexion and extension, crepitus being always produced. All that is necessary is, a narrow roller-band- age, half an inch wide, to be used as a tumefaction bandage. Apply an elongated compress over this, and then an ordinary paste-board splint, which had better extend over two or three fingers, so as to make these act as lateral splints. Passing the roller up, upon and around the hand, secure it there. It may be necessary to include all the fingers in the roller, and thus, as it were, to glove the whole hand—an expedient which is very useful in many diseases of the hand and fingers. In our next, we will go on to the consideration of fractures occur- ring in the lower extremities. FRACTURES OF OS INNOMINATUM. 173 LECTURF AXI. FRACTURES CONTINUED--OF OS INNOMINATUM--OF FEMUR IN THE CAP- SULAR LIGAMENT--OUT OF THE LIGAMENT. Next in order, gentlemen, we proceed to the consideration of fractures occurring in the lower extremity. Under this head, we will first speak of Fractures of the Os Innominatum. This bone, as you are aware, includes, or is made up by the Ilium, Ischium, and Pubis, and with its fellow of the opposite side, consti- tutes the anterior and lateral portions of the pelvis—the posterior portion of which is formed by the sacrum. Now, from the intimacy of union which exists between these bones, they form a strong bony arch, and are seldom broken, unless submitted to violence from two forces acting in opposite directions,—as, for example, where the pelvis is crushed upon a hard pavement by a wheel passing over it, &c.—and by gun-shot wounds. As a general rule, there will be but little displacement, this aJso resulting from the firm connection existing between the different parts; though in some cases, as in fracture of the tuberosity of the ischium, the deformity may be great. Simple inspection and manipulation, aided by the crepitus generally produced by moving the thigh, will, in most cases, at once reveal the nature of the accident. In speaking of fractures occurring in these bones, there is one species which should be particularly mentioned. I allude to frac- tures taking place at the bottom of the acetabulum, produced by the head of the femur being driven violently against, and sometimes even entirely through it, and into the cavity of the pelvis. A de- gree of deformity is thus impressed upon the hips, which, together with the entire loss of motion, will point out the kind of accident. As a general rule, in the treatment of these fractures, the pa- tient should be placed in that position which is best calculated to relax the muscles of the part. The thighs, with this view, should be flexed upon the trunk, and the legs on the thighs. The frag- ments are to be replaced as nearly as possible in their natural positions; a bandage is to be passed round the pelvis; and such compresses are to be used as may be required. It is proper that I should, in this connection, remark, that these accidents may sometimes be complicated with laceration and inflammation of the 174 FRACTURES OF THE FEMUR. bladder, and with suppression of urine. As soon as this is per- ceived, copious venesection should at once be resorted to; the hip bath should be used; and, in short, the anti-phlogistic treat- ment should be vigorously employed, the catheter also being freely used. In fractures through the acetabulum, a modification of the plan of adjustment becomes requisite. A large cushion should be placed between the upper parts of the thighs, and the knees should be brought together. The head of the bone is thus drawn out of the cavity—the cushion acting as the fulcrum of a lever. If exten- sion or counter-extension is necessary, it must be performed in the usual manner; and sometimes the neck of the femur is confined in the fracture, when it becomes necessary to extract it by a rotary movement of the thigh. These fractures, too, like all others which involve the joints, will cause inflammation in the hip-joints, which must be combatted by leeches, fomentations, &c, combined with general antiphlogistic treatment. The other fractures of these parts are of such little importance, that they need not be consid- ered here; and we now pass to the consideration of Fractures of the Femur. When we consider the weight sustained by the femur, its ex- posed situation, &c, it becomes a subject of wonder, that fractures of this bone are not of more frequent occurrence. Though they are not very common, yet they are sufficiently so to render it necessary for the surgeon to be fully acquainted with them. Like the other long bones, the femur is liable to fracture at several points; as, through the head, neck, shaft, &c. The rounded head may be fractured from the neck, just at that point at which it is, up to the eighteenth year, connected only by cartilage to the rest of the bone; and again, a fracture may occur in the neck of the bone, either within or without the capsular ligament; and it will be a matter of great importance to distinguish properly between these two. Yet it may, by extending obliquely, be partly within and partly without the capsule; and sometimes it may even extend through the trochanter. When fractures occur within the ligament they bear so strong a resemblance to those taking place in the analogous part of the humerus, that it will not be necessary for me to speak of them at length. The, diagnosis will be very difficult, particularly in young subjects. The outer part is so slightly removed, that there will be very little or no displacement; and if the surfaces of the FRACTURES OF THE NECK OF THE FEMUR. 175 fragments be rough, there will be but slight deformity from ro- tation. Some patients, indeed experience so little loss of mo- tion, that they are even able to continue to go about. In time, however, there will be perceived a halt in the gait, a kind of up-and-down, gliding motion. Sometimes a slight deformity supervenes; for when the patient is placed on his back and care- fully examined, shortening to the amount of one, one-and-a-half, or two inches will be detected; which produces a peculiar appear- ance, the trochanter of the injured, being higher up than that of the sound side. A falling backwards of the upper portion of the thigh, from the rotator muscles prevailing over the others, will also attract attention, as was first pointed out by Ambrose Pare; and where the limbs are brought together, the deformity of rotation will also be found to exist, the toes being, in most cases, turned out- wards ; though sometimes, however, they are turned inwards, and thus the case may be confounded with one of dislocation. To confirm our diagnosis, we may rotate the thigh, and if fracture exists within the capsule, the arc described by the trochanter major will be much smaller than that described by the trochanter of the opposite leg. Here, too, our object is, if possible, to detect crep- itus; and, should we fail to do so by the above mentioned method, we should vary the position of the limb; and it may even be necessary, from one fragment being drawn over or above the other, to extend it, so as to bring the rough edges in contact, before we can produce the crepitus. Again: in obscure cases, you may detect crepitus by requiring your patient to stand on the sound foot, leaning on the edge of a bed or table, by placing the leg between your knees and seizing the thigh, and by forcing it upwards and downwards. So much,, then, for the diagnosis of this most serious accident; and this, I may say, is a very impor- tant point, as we shall hereafter see. Whenever a fracture takes place here, whether it is oblique or not, a change takes place in the neck of the bone. Owing to an absorption of the earthy mat- ter, there is a greater or less removal or disappearance of the neck, causing the hip of the injured side to be considerably shortened. And in this connection, there is still one subject remaining for discussion. It is the question whether, in fractures occurring within the capsular ligament, a bony union ever does take place. Now, there may appear no valid reason why it should not take place, as well in those fractures occurring within, as in those, oc- curring without the ligament; but, however plausible this may appear, experience shows that the reverse is the case. Again 176 FRACTURES OF THE NECK OF THE FEMUR. and again, after having experienced all the care which judicious attention could afford, the patient has left his couch a miserable cripple for life, and doomed, ever after, to suffer from all the inconveniences of a false joint. This general want of success led the surgeons of former times into the directly opposite extreme; for they maintained that bony union here could seldom or never be procured ; and to this number belonged even the distinguished Sir A. Cooper. Even at the present day, this may be considered as still almost true; for though experience has shown, that bony union may take place in some cases, yet these are but exceptions to the general rule. I have seen but one case in which it has been obtained ; and this was in the person of an individual of twenty- one or two years of age. I might here enter into a discussion concerning the various causes of this result; but this would be unnecessary, and I shall content myself with a mere enumeration of the principal ones. In the first place, we may mention the great difficulty which is encountered in bringing the fragments into proper apposition; and secondly, the redundency of synovial fluid; which may materially interfere with union, by washing away any bony matter which may be deposited; while a gradual and progressive absorption of the neck, the scarcity of blood-vessels in the internal fragment, and so on, must all be taken into consider- ation; though there is no one of these circumstances which may, alone, be assigned as the sufficient cause. Whether we should at- tempt, in any particular case, to procure this union or not, is a grave question; in determining which, all the circumstances bearing on each individual case must be carefully considered. The disposi- tion of the individual, whether tractable or not, his age, constitu- tion, general health, and the circumstances which surround him, should ail be taken into account. If the case is one in which we believe that bony union cannot be procured, it would be utterly unnecessary to subject the patient to the tedious restraint attend- ing any attempt at procuring such a union. But if, on the other hand, we think that this desirable object may be attained, it then be- comes our imperative duty to give our patient every chance of obtaining it; and we must take such steps as shall most tend to the production of this result. The decision of this question must, in each individual case, be left entirely to your own judgments. If you determine not to attempt to procure union, you should make use of simple, treatment, as in other fractures. The patient should be placed on his back, kept quiet, and the antiphlogistic treatment FRACTURE OF THE NECK OF THE FEMUR. 177 must be enforced until the inflammation has subsided. Our palli- ative treatment, then, consists in flexing the leg on the thigh, placing the thigh on an inclined plane, and applying a bandage around the pelvis, to support the parts, and keep them as much as possible in apposition, until the inflammation has subsided, when the patient may be allowed to walk with the aid of a stick, and gradually to use the limb. This is the course recommended by Sir A. Cooper. But when the patient is young, and willing to undergo the necessary treatment, and when there is room to hope for a bony union, you should resort to the use of a fracture appara- tus; and as the means to be employed are the same here as in fractures exterior to the capsular ligament, we will defer the con- sideration of them until we come to speak of the treatment of the other fractures of the bone. Let us, in the next place, suppose a fracture to have taken place outside of the capsular ligament. In this case, the limb will be shortened to the extent of two, three, or even four inches; and there will nearly always be the deformity of rotation, either in or out. In the greater number of cases, however, the rotation will be outward. The only accident with which this fracture can be confounded is dislocation. It can easily, however, be distinguished from this accident; for, if the dislocation be backwards, for exam- ple, there will be, it is true, shortening of the limb, and the toes will be turned inward; but where there is fracture, if we place the patient on his back, we can, by traction, easily bring the limb to its proper length, and on omitting this traction, it at once returns to its shortened slate. Again, in dislocations, we find that rotation can only be effected by considerable force; whereas, in fractures, it is very easy ; and if, by force, we effect rotation, the arc de- scribed by the trochanter major, will be of much smaller extent in the latter than in the former case. Taking all these circumstances into consideration, there will be no difficulty in properly diagnos- ticating the nature of the accident. If, in these cases, the parts be brought into proper apposition, and kept so, bony union may take place. But, as I have already said, the fracture some- times extends partly within and partly without the capsular liga- ment- and in this case it frequently happens that we will obtain bony union. We shall consider, in our next, the appliances used for treating fractures of the femur. L 178 FRACTURES OF THE FEMUR. LECTURE XXII. FRACTURES OF FEMUR NEAR JOINT CONTINUED--OTHER FRACTURES OF FEMUR. In the preceding Lecture, we entered into considerable detail concerning fractures of the femur occurring near the joint. We were led to do this by the importance of the subject. You will remember, then, in the first place, that unless very circumspect, you will be liable to make a false diagnosis; and, in the second place, that, after the nature of the accident has been ascertained, there will nearly always be more or less uncertainty in the treat- ment. The diagnosis is sometimes difficult, the prognosis gener- ally doubtful. You will also remember, that your prognosis will differ widely, in accordance with the situation of the fracture, whether within or outside of the capsular ligament. When within, there is scarcely any hope of obtaining bony union; and this being the testimony of universal experience, you will readily understand how absurd it is, to keep the patient subjected to the long and tedious confinement of a fracture apparatus, a proceed- ing from which we can expect nothing, and which, particularly in old and debilitated subjects, may even eventuate in death. But when the patient is young and strong, and when all other circum- stances are favorable, and there is even a slight hope of obtaining ossific connection, we are bound to afford our patient every chance which can be offered from the resources of our science. Not to dwell longer here, however, we pass, in the next place, to treat of fractures of the shaft. These may be of all the various types, oblique, transverse, &c; and they may occur in different parts of the shaft. The fracture to which I shall now direct your atten- tion, is that which takes place low down, directly above the con- dyles. Here we will find great difficulty in retaining the frag- ments in their proper position. Violent inflammation and tume- faction of the joint is apt to result, from the synovial membrane, which, as you are aware, forms a fold under the quadriceps exten- sor muscle, extending some distance above the joint—becoming involved in the injury; and this inflammation may finally result in anchylosis of the joint. Here, then, you will at once recognize a great difference between this fracture and those occurring higher up on the shaft; and, if you will bear in mind the remarks already FRACTURES OF THE FEMUR. 179 made on fractures through the condyles of the humerus, you will immediately perceive the important character of the accident, and be able to appreciate the serious consequences which may arise from it, as these two accidents are exactly analogous. But we will now proceed to the treatment of these fractures. With regard to those occurring within the capsular ligament, having already dwelt particularly on them, we will only repeat here, that if the patient is old, we would simply confine him to H^i back, until inflammatory action has subsided, and then allow him to move about a little on crutches, and thus gradually regain a partial use of the limb; while if the subject is young, and other circumstances are favorable, we should attempt to procure a bony union; and for this purpose we should proceed as in fractures occur- ring outside of the capsular ligament. Now, in considering the treatment of the various fractures of the femur, we are met on the very threshold by a disputed point. I allude to the question, whether these fractures should be treated with the leg in '.e semiflexed, or in the straight position. This matter is still under discussion, and though speaking from my own experience, I regard the semiflexed as equally as good as the other, I am free to confess that I have adopted the straight position also, and, as a mechanic would say, in both cases, I have succeeded in turning out a very good job. Perhaps, after all, this is not a question of so much importance as has been supposed. For the treatment there has been proposed a variety of apparatus. All of them we will not undertake to dis- cuss, but shall only mention some of the most prominent. Here, first, we have Dessault's apparatus, as modified by Dr. Physic. It consists essentially of three splints, one to be placed on the inner side of the thigh, and extending from the perineum to the the foot; one on the front of the thigh, extending along its whole front aspect; and the third on the outer side, and extending from the axilla to beyond the foot. The upper end of this long splint is surmounted by a crutch-head to rest against the axilla. At its lower end is a projecting block, over which a handkerchief, which has been previously attached around the ankle and to the foot, is to be passed and secured to the lower end of the splint; by which means extension is to be kept up. If you will bear in mind the flexible nature of the spinal column, and the constant inclination of the patient to bend towards the opposite side, you will at once see, that the proper extension could not be kept up. Another method of treating these fractures is by what has been known as 180 TREATMENT OF FRACTURED FEMUR. Hartshorn's splint, consisting of a long splint for the outer side, which extends from just below the arm-pit to beyond the foot, and a short splint, padded at its upper end, which is to be placed on the inner side of the thigh, and which should extend from the perineum above, down as low as the outer splint below the foot. These two splints are united at their lower extremities by a cross- bar, and extension is to be kept up by a screw working a movable foot-board, which slides up and down. Counter-extension is made from the perineum by aid of the short padded splint. Now, I have no doubt that fractures of the thigh may be successfully treated by either of these methods; but, in fractures particularly, I am opposed to the use of any complicated apparatus, and feel bound, therefore, to point out and to recommend to you the sim- plest possible successful methods. Where you have determined to treat a case of fracture occurring in the lower extremities by per- manent extension and counter-extension, an easy, simple and effi- cient method is to employ the long splint of Liston, extending from the arm-pit to a Jittle below the foot, the upper end being secured by a roller passed around the chest, and counter-extension being kept up by a band passing under the perineum, and attached to the upper end of the splint. There have been many and various other methods proposed for the treatment of fracture of the lower limbs in the extended position ; and among them we may mention the apparatus of Hagerdorn. Contrary to what you would expect, in using it, the long splint is to be applied to the sound limb, the pelvis being kept perfectly motionless. The apparatus is, per- haps, a very good one. But even it is found to be uncomfortable, from the pressure it exerts, and has been modified by Professor Gibson; who recommends the employment of two long splints, one of which is to be placed on each side of the body, extending from the axilla to a short distance below the foot. The lower ends of these pass through a foot-board, which slides on them, and is kept in its proper position by pegs passing through the splints. I have no doubt that this apparatus will be found very effica- cious; but I am by no means certain that it will be found more so than many others which are far more simple. Some prefer to treat these fractures with the leg in a semiflexed position; and a variety of apparatus has been proposed with this object in view. The simplest of these is the ordinary double in- clined plane. The apparatus of junks is convenient, and, if at hand, it may be employed with advantage. The double inclined TREATMENT OF FRACTURED FEMUR. 181 plane may be formed extemporaneously. The following will be found a good plan for most cases : first, envelop the limb in a bandage of strips, beginning below and applying the strips so that one shall overlap the other like the shingles on a house-top, the last being secured with a pin. Next, apply four elongated com- presses of sufficient length, and then two splints, an external one to extend from the trochanter major to a short distance below the knee, and an internal one of corresponding length. Sometimes a third may be used, as an anterior splint. The whole, having been folded in the splint cloth, and secured by three or more tapes or strips of bandage, the limb thus dressed is to be placed upon a double inclined plane. There is one caution which you should al- ways bear in mind in these cases. It is to avoid too much pres- sure upon, and the consequent sloughing of, the heel, to accom- modate which, a hole may be cut in the plane, corresponding to the position of the foot. By precisely the same means you may put up fractures of the leg also. In relation to the treatment in the semiflexed po- sition, I will now show you an apparatus devised by my former colleague, Professor Smith, of Baltimore. When you desire to use this, the fracture should be reduced as usual; and then, having filled the cradle with some soft substance, to prevent excoriation, the leg should be placed in it at any desirable angle, which, as you see, may be varied at pleasure, by turning a screw. The foot should be attached to a foot-board, and the whole secured by a roller bandage. A very important advantage arises from the employment of this apparatus. By means of a cord attached to it, the limb may be suspended at any convenient height, and the patient is thus ena- bled to turn in his bed, and, after a day or two, he may even move from the bed to a chair. This will be found a great comfort, and of considerable advantage to your patient. Here I exhibit to you another apparatus. It is an American improvement upon an English plan ; but, as I have already ex- plained several methods of treating fractures of the lower extrem- ities, we shall at our next meeting proceed to another subject. 182 FRACTURES OF THE CONDYLES OF THE FEMUR. LECTURE XXIII. FRACTURES ABOVE AND THROUGH THE CONDYLES OF THE FEMUR, COMPLICATED WITH INFLAMMATION OF PARTS--FRACTURE OF PATELLA--FRACTURES OF TIBIA AND FI- BULA--BOXES OF FOOT, ETC. In the general observations made a few days ago, I stated that in cases of fracture of the femur just above the condyles, very serious consequences might result from the accident, and great difficulty arise to the surgeon in its treatment. Here the lower fragment is short, and almost any apparatus would fail to exercise the proper leverage upon it. I would, therefore, advise that, in- stead of adopting the extended, you should treat such a case in the semiflexed position, as better calculated to relax the muscles. It would be well to use angular paste-board splints, moistened pre- viously to their application, and having their angles corresponding to the angle of the leg. One is to be placed internally against the perineum, and the other outwardly, both extending to the malleoli below. The whole should be placed over a double inclined plane, or be suspended in a Smith's cradle, such as has been already ex- hibited, and which you will find a good substitute for the splints. But, besides these fractures through the shaft, and above the con- dyles, I also mentioned that a fracture could take place through the condyles themselves. Owing to the amount of synovial mem- brane, and the liability of the joint to be involved, a high degree of inflammation may follow this accident, and this must be sub- dued before any apparatus whatever can be applied. To avoid anchylosis, the joint should be gently moved from time to time, during the treatment. You should apply a compress on the con- dyles, and paste-board splints to the internal and external parts of the thigh; and the whole should be secured by a roller bandage. It is a matter of the highest importance that you should always bear in mind, that in these fractures, no retentive apparatus of any kind is to be put on, until the inflammation has subsided. The leg should merely be flexed on the thigh, the thigh on the pelvis, and the limb supported by pillows properly arranged, the patient being kept perfectly quiet, until, by appropriate treatment, the inflammation has been subdued. FRACTURES OF THE PATELLA. 183 Next in order we come to speak of Fractures of the Patella. These may be oblique, longitudinal, or transverse. They may be brought about by disease, or by violence alone or aided by an involuntary contraction of the muscles attached to the bone. This is always a serious accident. The inflammation is apt to run on to a troublesome extent, and to lead to the same results which I have already alluded to, as accruing to fractures through the con- dyles of the femur. Recollecting that the quadriceps extensor has its insertion into this bone, you will perceive, that by its action the fragments will be kept widely apart. Thus, unless particular care be taken, the only union which can be obtained will be of a ligamentous nature. This ligamentous structure is sometimes found to be an inch and a half or two inches in extent; in which case the action of the limb will be more or less impaired. Hence, it becomes a matter of very great importance that the fragments be kept in such perfect contact as to prevent this result, and se- cure a bony union. As regards the diagnosis, there can be no difficulty whatever; the bone being superficial, its fracture is easily felt. Where the fracture is longitudinal, one fragment will be thrown to the inner, and the other to the outer side of the knee, and a line of depression will be distinctly perceived, marking the point of separation between the fragments. In the treatment of transverse fractures it has been adopted, as a universal rule, that the extended position should be selected. Perhaps the most convenient appa- ratus is that which is used in fractures of the olecranon process. This is sufficiently simple. Put on a common uniting bandage as follows:—Placing a strip of bandage on each side, of the limb, se- cure both of them by a few circular turns of a roller, commencing below the knee and extending up to it; then place a compress above the patella, and secure it there by a few figure-of-eight turns over that bone; pass one or two circular turns above to secure the strips there; and lastly, tie the opposite ends of the strips together. This will tend to keep the fragments in apposition. Then, taking a long splint that will extend from the upper part of the thigh as low down as the malleolus, place it on the posterior part of the leg, and secure it there by a roller passed from below, upward, making a few figure-of-eight turns at the knee. The limb is then put on a pillow with the heel elevated, so as to relax 184 FRACTURES OF THE BONES OF THE LEG. the rectus muscle; and iri the after treatment, the same rules are to be followed, as have been inculcated elsewhere. Inflammation must be combatted, and anchylosis may be prevented, by occa- sionally moving the joint. The treatment of longitudinal fractures of the patella avi'II be a far less difficult undertaking. The leg should be placed in the extended position, a compress applied on each side of the patella, secured by a figure-of-eight bandage, and a splint adjusted posteriorly, exactly as in transverse fractures. We go on in the next place to consider Fractures of the Bones of the Leg. They may take place high up in the neighborhood of the joint; but, as the treatment in such cases is precisely the same as that of fracture through the condyles of the femur, I shall not stop to make any remarks upon such cases. If only one bone is frac- tured, the other, acting as a splint, prevents there being much displacement. Consequently, there will be but little deformity in such a fracture. When both bones are broken, there will be no difficulty in the diagnosis. The finger passed along the surface of the bone, will at once detect the point of the fracture, or it may be easily discovered by bending the bones upon themselves, as though you would bring the ends together, thus causing them to form an angle at the fractured point. In the treatment you may adopt either the semiflexed or the extended position. You may employ any of the apparatus used for fractures of the thigh; the apparatus of junks, if you choose, or the short splints of Liston, or hollow carved splints, and you may use the many tailed bandage, or the common roller. In ordinary country practice, the simplest and most convenient plan of treatment is that by the apparatus of junks, put on precisely as in fracture of the thigh. When this has been applied, you may allow the patient to place the limb in any convenient position, as over a double inclined plane, for example. But, as I said before, a very good apparatus is afforded us by Liston's short splint. When you are desirous of using this, place two strips of bandage longitudinally, on the inner side of the knee, having first applied lateral cushions; secure the strips by a few turns of a roller, and passing the ends through the mortice, tie them there. This forms a point for counter-extension. Then, hav- ing split one extremity of the roller, knot the ends together so as to form a loop, and hitch this over the notch in the lower end of the splint. Next, place a compress over the foot; and then carry FRACTURES OF THE BONES OF THE LEG. 185 the bandage obliquely over the instep, behind the heel, through the notch in the lower end of the splint, and so on. Thus extension is produced. Finally, secure the whole by spiral turns of a roller passing up to the knee. You will find this a very convenient ex- temporaneous apparatus in country practice; and should you de- sire additional security, you may add another splint on the outer side of the leg. In the treatment of these fractures, I may also mention the apparatus of Mayor. It is a simple, comfortable, and efficacious method of adjustment. There is one kind of fracture of the leg, which, although at first glance it appears slight, is yet of so much importance, that I must invite your attention particularly to it. I allude to a fracture of the fibula at its lower extremity, associated or not with disloca- tion. It is very apt to be followed by great deformity. The peronei muscles draw the foot forcibly outwards, and tilt the sole up, so that though you may flatter yourself that every thing is going on well, after you take off the apparatus, and the patient attempts to walk, you find the foot constantly tend- ing to cant outward and upwards. I have seen so much deformity resulting from errors in the management of this fracture, that I must urge on you the necessity of bearing constantly in mind the indications connected with its treatment. I must point out to you the principles involved, the original explanation of which we owe to the celebrated Baron Dupuytren. The great difficulty arises from the action of the peroneus longus and peroneus brevis muscles. The great indication, then, is simply to antagonize the action of these muscles. Place a thick compress on the inner side of the leg, leaving the lower end doubled under, and do not let it extend below the malleolus. Over this apply a splint, designed to act as a lever, and secure it above by a roller passing downward; and then draw the outer, margin of the foot downward, so as to turn it in towards the splint, and secure it there by a roller passing in the form of a figure-of-eight, over the instep and around the splint. Thus, you perceive, the action of the peronei muscles is completely antagonized, and the fragments are approximated. This is the plan to be adopted, and I wish you to bear it particularly in mind, for if you treat this fracture in the ordinary method of treating fractures of the leg, you will be very lucky if your patient comes out without considerable deformity. Sometimes the outer malleolus is fractured transversely, though the portion of its extent which is covered, on its inner side, by 186 TARSAL AND META-TARSAL BONES. cartilage and synovial membrane. Unless great caution be used in these cases, too, you may fail to obtain bony union. Again; a fracture may sometimes take place through the lower portion of the tibia, or even through the malleolus. The best method of treating this I apprehend, is, by the ordinary immoveable apparatus; which is constructed in the following manner. After the proper adjustment is effected, a roller bandage is applied, and its outer surface is painted over with a solution of starch : then, over this, is placed paste-board splints, cut into proper shape, which are also covered with starch : then another roller is applied, which is again to be starched ; and this process is to be repeated, till the apparatus has attained the requsite degree of thickness. The starch drying, a thick, firm encasement is formed for the limb ; and this is what is called the immoveable apparatus. It should never be applied, until after all inflammatory action has been sub- dued. Some surgeons make use of it in the treatment of all those fractures to which we have already alluded : and when all inflam- mation has been subdued, and proper care has been taken in its application, I have no doubt that it may be made a very efficacious method of treatment. While, however, I thus speak in praise of this apparatus in the treatment of fractures, I should be guilty of a dereliction from my duty, if I did not at the same time say to you, that it is as yet an unusual remedy; and among the common peo- ple, if any accident arises, the surgeon is very apt to be blamed. I should also state, that unexpected tumefaction may take place, particularly when the injury is in the neighborhood of a joint, and irreparable injury may result. Already, indeed, have cases oc- curred, in which surgeons have been called upon to pay damages for mal-practice in this respect, even when the utmost precaution had been observed. Be circumspect, then, in the adoption of this method. Watch carefully the progress of your patient; and dis- tinguish those cases which may be correctly treated by this "im- moveable apparatus," from those in which its employment should be wrong. As regards Fractures through the Tarsal and Mcta-Tarsal Bones, We have no remarks to make, except with respect to those occur- ring to the astragalus and os calcis. Fractures of the astragalus may be of a very serious nature. COMPLICATED FRACTURES. 187 Possessing the recuperative power in but a very small degree, this bone when broken is remarkably apt to fall into necrosis. This gives rise to a continued suppuration, and renders relief impossible, until either the dead part, or the whole bone is removed. The irri- tation increasing, and the inflammation extending, even amputa- tion may become necessary. In several cases, I have taken out portions of the astragalus by cutting into the joint, and removing the necrosed portions with the forceps. When the whole bone is removed, the tibia settles down upon the calcis, and the patient may walk very well, the shortening of the limb not being as much as you might suppose. With'regard to fractures of the os calcis I may say, that they require no particular remarks, except when occurring through its posterior part. In these cases, the utmost care is to be observed in keeping the fragments together. It is very necessary to keep the foot extended and the upper fragment drawn down. For the accomplishment of this end, you may use the starch bandage, with some of the apparatus given in the books for the treatment of rupture of the tendo Achillis. Here, however, you may use your own ingenuity, keeping in mind, that the main objects to be ful- filled are the perfect extension of the foot, and the counteracting the power of the gastrocnemius and soleus muscles. A very good plan is, to use a common slipper, tacking a piece of tape to the heel of it, and attaching this posteriorly to a band passed around the upper part of the leg. LECTURE XXIV. COMPLICATED FRACTURES--COMPOUND FRACTURES--COMMINUTED FRACTURES--COMPOUND COMMINUTED FRACTURE-- TREATMENT--FALSE JOINTS--TREATMENT. I would observe, gentlemen, that our remarks, heretofore, were designed only to apply to imple fractures, those not accompanied by any serious injury to ;he surrounding soft parts. Wherever the soft parts are lacerated, and the bone protrudes, we applied to the case, as you will recollect, the term of compound fracture. In other instances, the bone may be crushed; and then we are pre- 188 COMPOUND FRACTURE. sented with a case of comminuted fracture : or these two may be combined • and then we have what we call a compound comminuted fracture. When you are presented with a case of compound fracture, the important duty to be performed is, after having adjusted the bones, to draw the external edges of the wound as neatly as possible to- gether, and to secure them by adhesive strips, or, if necessary, by suture. The object is to secure union of the soft parts as soon as possible, and thus convert a compound into a simple fracture. For this purpose it has been recommended—and by no less an authority than that of Sir Ashley Cooper—to apply a pledget of lint, moistened with the blood of the wound, over the external sur- face of the injury. A neater method, I apprehend, would be to moisten the lint with collodion, provided the injury be not of very great extent, for applied to a large surface this substance might create too much irritation. And in this connection I would remark, that when there is great laceration, accompanied by inflammation and suppuration, you must be exceedingly cautious how you apply the ordinary fracture apparatus. Carelessness in this respect may even result in the loss of the limb. It will always be better in serious injuries, to place the limb in an easy position on pillows, until, by the ordinary antiphlogistic treatment, the inflammation is subdued. As soon as this is done, or as soon as the excess of in- flammatory action has subsided, when the slough, if there is one, has separated, and granulations are springing up, it will then be time enough to put on your apparatus, and treat the injury as a simple fracture. On account of the discharges, it will be neces- sary, in these cases, to dress the wound at least once a day. Con- sequently, when dealing with the lower limb, the apparatus of junks will be found very convenient, having to remove only the strips which are soiled, and not being obliged, in doing so, to lift the limb, sjnce the clean strip may be attached to one end of the foul one, and thus be drawn into its position by the removal of the lat- ter. Compound fractures are always serious accidents, as they give rise to great constitutional derangement; and against this it is that your therapeutical agents should be particularly directed. You must not, however, because there is a great degree of inflam- mation, urge your antiphlogistic treatment too far; for under the influence of this very inflammation, the constitution may rapidly yield, the vital powers become debilitated, and, sooner than you COMPOUND COMMINUTED FRACTURE, 189 expect it, you may be called upon to support the patient with stimulants. When you have a Compound Comminuted Fracture To deal with, it is important that you should examine the spicules of bone with care. But in this respect, let me urge upon you one particular cau*.ion. Be not over-anxious to remove all of these spiculas; be circumspect; and save as much of the bone as possible, for the more you thus preserve, the less work will na- ture have to perform. If the spiculas are loose and detached from the periosteum, it then becomes necessary to remove them; but if the}1, are not thus separated, then endeavor to place them as nearly as possible in their natural position, and thus preserve as much as you can of the structure. You will sometimes meet with cases of compound comminuted fractures, in which it becomes a problem for you to solve, whether it will be in your power to preserve the limb without risking the life of the patient. In other words, the question of amputation will arise. To solve this problem, you will sometimes find an exceedingly difficult matter. In forming your decision, you must consider,— first, the extent of the injury; secondly, the parts involved; thirdly, the constitutional powers of your patient; and fourthly, the condition of the subject, or those circumstances under which the treatmentisto be conducted. If the injury is extensive, the prin- cipal vessels lacerated, and the nerves torn asunder; and if the vitality of the parts cannot be supported, then it would be madness to attempt to save the limb; for, by so doing, you would endanger the life of your patient, which risk might have been avoided by a timely resort to amputation. If the constitution is impaired, or broken down by bad habits, and the circumstances surrounding the individual operate in an unfavorable manner upon those pro- cesses by which nature effects the union of parts, amputation again becomes necessary. Great danger would accompany the attempt to save the limb under such unfavorable auspices; though I would not have you infer from this, that you should hastily resort to amputation. Be careful, and do not run into this extreme; always consider carefully the circumstances of each case; and form your judgments only after due reflection upon them. There is, again, a great difference in the results attending these fractures, depending upon the location of the accident. 190 COMPLICATED FRACTURE. Whenever you have a compound fracture involving any of the large joints, particularly those of the lower limb, and the articula- tion is much injured, very frequently, the only chance for your patient will consist in the amputation of the limb. Few constitu- tions can stand the inflammation, which is almost necessarily the result of such an injury. Still, however, be careful in forming your decision, and in every case fortify that decision by a careful consideration of all the circumstances of which I have already spoken. Another complication, which is frequently engrafted on these accidents, is tetanus. It therefore becomes highly important that you should keep down the susceptibility of the nervous system, and take every precaution to prevent the supervention of so terrible a result. Here we are met by the question, whether or not this terrible malady can be checked by resorting to amputation immediately after its symptoms have been developed. Generally it is consid- ered as unavailing; and this impression appears to be confirmed by universal experience. Little, indeed, can any treatment avail. The disease will run its course, and all that we can do is, to resort to the ordinary remedies and stimulants appealed to in such cases. Opium and its compounds, cannabis Indica, brandy, ether, chloro- form, &c.,&c, should be tried. There is still another serious complication which will some- times present itself in these cases. The sharp edges of bone, or some of the spiculas, may lacerate some important vessel, and give rise to an alarming, and even dangerous hemorrhage. Of course, the first indication here, I need scarcely say, is to arrest this hemorrhage as soon as possible. As a temporary means, we may resort to the tourniquet; or, as a permanent recourse, we may use the ligature at once, if it is possible to find the orifice of the lacer- ated vessel. But this is often impossible, and, consequently, it becomes necessary, if the vessel be large, to cut down and tie the main artery at some point above the seat of injury, in the same manner as when this operation is performed for other purposes. I have deemed it necessary, before leaving this subject, to make these remarks on compound and complicated fractures; and let me repeat, that a compound fracture must always be regarded as a serious accident, and a compound comminuted one as still more important. There are still one or two other particulars relating to fractures in general, which deserve some special remarks. It will some- FALSE JOINTS. 191 times happen, that, either in consequence of some fault in the con- stitution _of the patient, or error in the adjustment, no bony union will be found to have taken place, and there is still some motion at the seat of fracture. This is a very unfortunate circumstance ; and when the condition has existed for some time, it gives rise to what is denominated a False Joint. A change lakes place in the ends of the bone : their earthy mat- ter is absorbed ; and union is effected only by a dense, ligamentous substance. Sometimes, when the limb is much used, even a kind of synovial membrane is formed between the broken ends of the bone, and a regular artificial joint is established. The principal inconvenience, in such a case, consists in the pa- tient's possessing a greater number of joints than he is entitled to, and more than is convenient for the ordinary purposes of life : and it becomes a question of importance to inquire—what are the cir- cumstances most likely to produce this result ? Sometimes we find it existing when we can find no fault in the constitution of the patient. When this is the case, I apprehend that the want of bony union depends on one of two causes : either your apparatus has not been properly adjusted, and the fault rests consequently with yourself; or the patient has disobeyed you, and prevented the union, by permitting motion in the part. But in another class of cases, the want of bony union is to be attributed, as already said, to a fault in the constitution. When this is the case, in addition to the ordinary local treatment, it will be the duty of the surgeon to study the cause, and if possible to remove it. If it reside in some peculiar diathesis, he must resort to the treatment proper for the removal of that diathesis ; or if the patient is weak, it becomes necessary to resort to tonics, stimulants, &c, and in this connec- tion I would remark, that it was formerly thought that the defect consisted in a want of phosphate of lime. Hence, this was given as a remedy to supply the supposed deficiency : but I apprehend that very little good is done by it in this way; though it may be useful in strengthening the constitutional powers of the patient. A more important point, however, remains still to be discussed. When all our efforts have failed to obtain a bony union, and an artificial joint is formed, the question arises—how are we to relieve the patient of this condition ? One of the best and most simple means which we can resort to is friction. You should frequently remove the dressing and press the ends of the bone together, rubbing them against each other, and then re-apply the dressing in such a man- 192 TREATMENT OF FALSE JOINTS. ner, as to prevent all motion. This method, however, is only ap- plicable to recent cases : in such I have several times seen it prove efficacious. Another expedient of a simple kind, especially where the bone is superficial, is to establish an issue directly over the injury, in order to excite sufficient inflammatory action at the seat of the accident to effect union. This will sometimes succeed in causing the deposition of bony matter; but a vastly more certain ex- pedient than either of these, is that recommended by Dr. Physick. It consists in passing a seton between the ends of the bone, and leaving it there for a sufficient length of time to give rise to that chain of actions, which shall result in deposition of bony matter. This remedy is perhaps more efficient, and applicable to a greater number of cases, than any other, though it too will sometimes fail. When you determine to use the seton, you must never regard the inconvenience caused by it, but continue it for some time : indeed it may even be necessary to persist in its use for months. For it to succeed, it is necessary that the ends of bone should not be very far apart. Another expedient which has been resorted to, and which was first proposed by Prof. Dieffenbach, of Berlin, is to make an incision directly through the soft parts, down to the fragments; then to drill, or bore with an ordinary gimblet, several holes in the fragments, two thirds through them; and to plug these up with ivory pegs. The ivory being an animal substance will be absorbed; but, acting at the same time as a foreign body, it will cause suffi- cient inflammation to effect the desired result; when, if the plugs have not fallen out, they may be removed with the forceps. This is an ingenious plan, and may succeed. We sometimes, however, meet with cases, in which all of these methods fail; and under these circumstances, there is yet one plan, by the adoption of which you may obtain bony union. It consists in exposing the ends of the bone, and sawing offa portion of each; when, by shortening the limb a little, the ends are brought together, and union is ob- tained by the use of an ordinary fracture apparatus. There are still other expedients which may be resorted to, but which are by far less important than those already alluded to. One, which I may mention is, to pass a wire through the articulation, then re- turn it, and bringing the end through, leave it to cut its way out by ulceration. This is inconvenient, however, and frequently fails to produce the desired effect. You will frequently find it necessary to vary your plan of treat- ment in these cases, and to resort to one method after the other, until success crowns your efforts. DISLOCATIONS. 193 LECTURE XXV. DISLOCATIONS--GENERALLY CONSIDERED--OF INFERIOR MAXILLARY. We design this morning, gentlemen, to enter upon the subject of dislocations. The meaning of this term is sufficiently under- stood by you all, and therefore, perhaps, needs no particular defi- nition from me. I would merely remark, that by the dislocation of a bone, we mean that state in which one of its articulating sur- faces is removed from its normal position. In speaking of dislocation, we find it necessary to recognize sev- eral varieties, and to divide the subject accordingly. And, first, when the head of a bone is driven by any violence from its proper position, we divide the dislocation into two varieties: primitive, and secondary, or consecutive. To illustrate, let us suppose a disloca- tion of the humerus. Here there are only two points at which the bone can, in the first instance, be dislocated. These are, first, downwards and forwards, and secondly, backwards and upwards. These are the primitive dislocations. But if we suppose the head dislocated downwards and forwards, and then moved from this position, and carried under the clavicle, or under the pectoral muscle, we have an example of secondary or consecutive disloca- tion. The one results from the direct cause of the dislocation, the other generally from muscular action. Again : having reference to the manner in which the displace- ment is produced, we have accidental and spontaneous dislocation; the first resulting from direct violence, aided generally by undue and involuntary action of the muscles; and the second, either from gradual changes morbidly going on in or about the joint, (as hy- drarthrosis, or an accumulation of water in the joint, for example,) or by muscular action alone. We have also, simple and compound dislocation. In the first, there is only a displacement of the head of the bone, accompanied, of course, by more or less laceration of the ligaments, and contu- sion of the surrounding parts; while, in the second, we have, asso- ciated with the dislocation, a laceration of, and an opening through, the surrounding soft parts, as in compound fracture. We may have dislocation, simple and complicated; the first, as already described ; the second, where there is, in addition, some fracture, laceration of the vessels or nerves, or some other compli- cation. Sometimes there is so much laceration and injury of the M 194 DISLOCATIONS. surrounding parts, as to give rise to inflammation, sloughing, sup- puration, necrosis, &c; and we may even be compelled to resort to amputation. This kind of dislocation, then, may vary exceed- ingly, both in character and result. Having thus pointed out the varieties of dislocation, let us, in the next place, briefly consider what are its causes. At first view, we might be disposed to attribute dislocation to external violence alone; but when we consider it philosophically, we find that, though this is the chief cause, therp are others which are some- times of great importance. They all may be comprehended under the two heads of predisposing and exciting causes. The first are of comparatively little importance, and I would only remark, that individuals differ exceedingly in the degree of their liability to dislocation. In some, great force is required; in others, very little. I would also remark that one dislocation predisposes strongly to others at the same joint; so much so, that muscular action, aided by position only, will sometimes suffice to reproduce the disloca- tion of a bone which has once already been in that condition. This is particularly the case in the lower jaw, where the simple act of yawning will suffice, in such cases, to throw the head of the bone from its cavity. But, for obvious reasons, it is not necessary to dwell longer upon this division of the subject. The exciting causes I may sum up in a few words. They consist of external violence, combined with muscular contraction, though direct vio- lence is often of itself sufficient. It is necessary that I should state to you, as another element of importance in this discussion, that the number of collateral cir- cumstances, or coincident accidents, are various. As a general rule, there is, in the first place, a contusion of the surrounding parts; in the second place, a greater or less laceration of the capsular, and other ligaments of the joint; and thirdly, an implication of sur- rounding organs, laceration of blood-vessels, nerves, $*c. The extent of these complications will be various in different cases. In consequence of the laceration of blood-vessels, we will have an extravasation of blood into the joint and the cellular tissue, and the force may be sometimes so great as entirely to destroy the vitality of the part; and thus, from the violent contusion alone, sloughing may take place, and, as a consequence, extensive trau- matic hemorrhage be produced, which may even result in death. Pain always accompanies this injury. It may sometimes be so great as even to throw the patient into a state of collapse. This TREATMENT OF DISLOCATIONS. 195 may pass off in a few moments, or, where the injury is great, and the nerves weak, may sometimes continue so long as to cause rea- sonable fears for the life of the patient. It is, for the most part, however, followed sooner or later by reaction. Sickness of the stomach, flushed face, &c, will come on; and finally irritative fever may set in, varying in degree of severity, according to the extent of the injury. These are the constitutional results of dislo- cation. But when the bone is allowed to remain in its abnormal position, a series of local changes of the greatest importance takes place. The coagulum of blood is absorbed, and its place is occu- pied by lymph, which both fills up the cavity of the joint, and in- filtrates itself into the surrounding parts. A gradual organization of this plasma follows; and, after some time, we find a new articu- lation formed for the head of the bone in its abnormal position. In process of time, the organization of plasma will gradually give rise to the formation of an adventitious capsular ligament, and some degree of motion may obtain in the part, restoring to the patient, in some measure, the use of his limb. In dislocation of the hu- merus downwards into the axilla, adhesions may form to vital parts, and exceedingly dangerous results may accrue from any attempt at reduction. It is important that you should bear this in mind. Such attempts have been followed, on the one hand, by extensively diffused traumatic aneurism, and, on the other, by paralysis, from injury to the nerves. On the present occasion, I merely mention this important circumstance, and now pass on to consider the symptoms of dislocation. To enter into details con- cerning these, would be obviously unnecessary at this part of our subject, as it would be again requisite to do so. when we come to speak of the particular dislocations. It will suffice here, for me to say, that we have a greater or less extent of deformity, or displace- ment, and more or less inability to use the part. We now come to the most important division of our subject— the consideration of the treatment of dislocations. The main indi- cation to be fulfilled is evident. The bone having been removed by some force from its natural position, must be restored to the same. This is to be done by force, applied in a proper manner; and in fulfilling this main indication, we should, in the first place, see that the force be applied in the proper manner, and in the proper direction; and, in the second place, we should bear in mind the obstacles to be overcome by that force, aided by other means. As regards the application of force, I may in general terms remark, 196 TREATMENT OF DISLOCATIONS. [hat it is to be conducted in precisely the same manner as in frac- tures; by extension and counter-extension—the first being applied to the periphery, the second to the body. The direction in which these are to be applied will depend on various circumstances, which can be considered only when we pass in review the individ- ual cases of dislocation. Prominent among the obstacles to be overcome in the reduction of dislocation, we must remember rigidity of the muscles. Hence the means for producing relaxation, constitute an important part of our treatment. Sometimes other obstacles to the return of the bone will present themselves. In the shoulder joint, for example, the capsular ligament may be so torn, or slit, as to encircle, con- strict, or gird the bone in such a manner as to oppose its return; and in the phalanges, the tendons of the muscles may get hitched over the rounded protuberances on the face of these bones, and thus constitute an obstacle to their reduction. Again : when the bone has been long removed from its natural position, adhesion to the neighboring parts may have taken place; and these, it becomes necessary to break up, by imparting a certain rotatory direction to the force employed. The means of overcoming muscular action, as I have already said, constitute an important part of our treatment. These are, mostly, already known to you. They are blood-letting, nauseating agents, and anaesthetics. You all know that the stoutest man will grow pale and weak, and that all his muscles will be relaxed, under the influence of the first of these means. Sit your patient then erect; tie up his arm; bleed him ad deliquium, and then apply your force. You are all acquainted with the debilitating and prostrating effect of nausea. If necessary, produce this state, and tobacco will be here found a powerful agent in those not ac- customed to its use ; though I apprehend, that in our country, few such will be found. Fortunately for humanity, we are in modern times supplied with agents, which are far more powerful and safe than either of these. I mean, as you no doubt understand, those agents, chloroform, ether, &c, which not only place the patient entirely under our control, but at the same time render him uncon- scious of pain. Our only misfortune is, that in all instances these agents cannot be used ; as in cases of affection of the brain, heart, or lungs. Still, these agents are applicable to so great a number of cases, that the human race owes a debt of gratitude to the inven- tors, for which it can never repay them. TREATMENT OF DISLOCATIONS. 197 When you determine to use the anaesthetic agents, you should induce their full effect. Y'our patient will thus be relieved from all suffering; and you will also have gained another important point: all motion on the part of the patient, by which the opera- tions of the surgeon are opposed, almost involuntarily, are put an end to. And I may here remark, that when it is inadvisable to use these agents, this last object may be obtained by so diverting the patient's attention, and, as it were, taking him by surprise, as to accomplish your object before he is aware of what you are about. The degree of force to be used in the reduction of a dislocation is, of course, very variable. Sometimes the mere manual exertions of the surgeon will suffice; or the assistance of one, two, or more individuals may be required : while sometimes it will be necessary to resort to instrumental assistance, such as the compound pulley, and other means which will be shown to you at another time. In this connection there is still one point of importance which remains to be discussed. When a dislocation has remained for a certain time unreduced, it becomes inadvisable to attempt to restore the part to its natural position, on account of the changes already described as taking place under these circumstances; and this im- portant question presents itself for our determination—how long after the accident can the. attempt at reduction be made with safety to the patient, and reasonable hopes of success ? If we refer to books and reports on the subject, we find that dislocation of the shoulder has been said to have been reduced after six months, and that of the hip after four. As regards the shoulder, if you will recall what I have said, you will perceive, that after such a time has elapsed, the danger to the axillary nerves and vessels must be very great from the application of much force. As I have al- ready stated, evil has frequently been the result of such measures. The axillary nerves have been torn out by their roots from the. spinal cord, and the axillary artery torn across. Be chary, then, in your at tempts at reducing the shoulder joints after a long time has elapsed. Three months for the humerus, and six weeks for the femur, may be set down as the utmost limits, within which an attempt at reduc- tion should be made. Should you even succeed in removing the bone from its abnormal position, after such a period has elapsed, you may find the natural cavity filled up by adventitious deposits. After reduction has been accomplished, it may be necessary, as in fracture, to make use of some retentive apparatus, splints, ban- 198 DISLOCATION OF THE LOWER JAW. dages, &c, such as will be suggested to you by each individual case. In the time that still remains to us, gentlemen, I propose to com- mence the more particular discussion of our subject, by calling your attention to the Dislocation of the Lower Jaw. Its articulation, as most of you are aware, is an example of the ginglemoid or hinge joint; and if you examine the parts, you will perceive, that the only direction in which this bone can be dis- placed, is forwards, the chin being thrown downwards. When the dislocation takes place on both sides, the chin will project most, and the patient be totally unable to close his mouth. If it is limited to one side, the chin will fall down and be inclined to one side. You might suppose, at first, that the reduction of this dislocation would be very easy ; but we are sometimes disappointed in our attempts: and you may even fracture the bone, if you apply force, as in old times, directly to the chin. If, however, we reflect on the indica- tions to be fulfilled, and on the anatomical arrangement of the parts, the reduction becomes more simple. If, instead of applying force directly to the chin, we use this as the arm of a lever, the fulcrum of which is formed by our thumb passed into the mouth and pressed on the angle of the bone behind, and raise the chin up, pressing down, at the same time, with the thumb, the action of the muscles themselves will throw the head of the bone into its glenoid cavity with some degree of force. If you wish to avoid the risk of being bitten, you may protect your thumbs by means of lint. Some have used pieces of cork, placed behind the teeth, instead of the thumbs. I have never, however, experienced any injury from this source. The four-tailed bandage should be applied after the reduc- tion, and be worn for two or three days. This should be particu- larly enjoined on your patient, as some liability to spontaneous dis- location will be produced by a repetition of the accident. We will continue the subject of dislocation at our next meeting. DISLOCATIONS OF THE CLAVICLE. 199 LECTURE XXVI. DISLOCATION CONTINUED--OF CLAVICLE--HUMERUS--TWO BONES OF FORE-ARM TOGETHER--RADIUS AND ULNA SEPARATELY. When we examine the claviculo-sternal articulation, we are struck by the fact, that the articulating surfaces merely rest in con- tact with each other. These surfaces, then, must oppose but little if any resistance to forces tending to separate them; and were it not for the strong ligaments which bind them in their places, espe- cially the costo-clavicular ligament, dislocation of the clavicle would be very common indeed; whereas, in reality, it cannot take place without the rupture of some of these ligaments. We meet with three dislocations at this joint. The head of the bone may, in the first place, be thiown upwards; in which case the shoulder will be thrown forwards : secondly, it may be dislocated forwards; and here the shoulder will fall down and a depression will be perceived where the head of the clavicle should be, a prominence being also perceived on the sternum : and thirdly, we may have the bone dis- placed directly backwards ; though this latter is of very rare occur- rence. In this case the shoulder will be thrown forwards, and the head of the clavicle, going backwards, will encroach on the trachea, throw it out of place, and impede respiration by narrowing its ca- pacity; and, by pressure on the jugular vein, it may also impede the return of blood from the head. In all of these cases, there will be no difficulty in recognizing the nature of the accident; and the reduction will be easily accom- plished, by carrying the shoulder upwards and backwards, and placing the bone in its proper position. The main difficulty will be, to retain it adjusted; for, as soon as you let it go, the weight of the shoulder will throw it out again, if the apparatus for retention be not properly adjusted. I think that the best plan to be adopted in 'such a case is, to reduce the dislocation as already explained, place a conical pad in the axilla, as in fracture, and secure it by Dessaults' bandage; which, having already shown to you, I need not demon- strate again. This will tend to carry the shoulder backwards, and at the same time to keep it up. A compress should be placed over the seat of injury; and the arm should be kept motionless for sev- eral months, and be then used with great caution. The acromial end of this bone is also but feebly articulated with the scapula. The ligaments of the joint, however, are so disposed, 200 DISLOCATIONS OF THE HUMERUS. as to make a dislocation here an accident of very rare occurrence, especially in an upward direction ; for, to produce a displacement of the bone upward, the conoid and trapezoid ligament must be ruptured. A force sufficient to do this, would usually fracture the bone. If the dislocation is downward, the acromioclavicular liga- ments must be ruptured. This may be produced by a force applied directly to the end of the bone. If the dislocation is upwards, the end of the clavicle will be found riding over the acromion, upwards and backwards; if downwards, a depression will be perceived in its natural position, and the end of the bone will be felt below. The reduction is to be accomplished by raising the shoulder, and, by careful manipulation, placing the head of the bone in its nat- ural position, as in the preceding case. Here, too, the same diffi- culty will be met with in retaining the parts in their normal rela- tion to each other. This is to be obviated in the same manner, and by the same means, viz : Dessaults' apparatus. We pass, in the next place, to a displacement of far greater fre- quency, and therefore demanding particular consideration. I refer, as you may rightly suppose, to the Dislocations of the Humerus. If you study carefully the anatomical relations of the va- rious parts at this articulation, the capsular ligament, muscles, &c, you will find that there are but two points of escape for the rounded head of the humerus, the socket in other directions being strongly fortified against its passage. First, it may be dis- located downwards and slightly forwards, the head resting in the axilla: secondly, it can escape upwards and backwards, the head resting on the dorsum of the scapula. Y'ou might suppose, from a casual glance, that it may also take place directly downwards; but if the arrangement of the long head of the triceps be taken into consideration, you will see that such a dislocation is impossible. These two, then, are the only points of escape for the head of the humerus. But, starting from these points, it may subsequently be moved in various directions; for we must remember, that from these primitive dislocation, consecutive or secondary ones may arise, as already explained in a general manner. The dislocation downward and forward into the axilla, is by far the most frequent; and from this primitive dislocation, various secondary displacements may result. The bone may be so acted on, by the force producing the accident, by muscular contraction, REDUCTION OF DISLOCATIONS OF THE HUMERUS. 201 &c, as to be carried beneath the pectoral muscle, on the ribs, between them and the scapula, or beneath the clavicle; and there are cases on record, in which the head of the humerus has even been driven into the thoracic cavity, through one of the intercostal spaces. Hence, although there are but two leading dislocations at this joint, we divide them into various other kinds : as, first, that into the axilla; second, that under the pectoralis major; third,^ that beneath the clavicle, &c, &c. In the dislocation upwards and backwards, on the dorsum of the scapula, the bone is so bound down in this position, that there is seldom much secondary dis- placement Let us now consider the symptoms presented by a dislocation at this joint. First, when the displacement is downwards and for- wards, we find a depression at the joint, and we can sometimes feel the empty glenoid cavity; and then, examining the axilla when the arm is raised, the rounded head of the bone will, as a general rule, be found there. It is important also to attend to the direction of the axis of the limb. It will have an inclination some- what out from the side. And, in addition to this, we may have an- other deformity; for when the head of the bone is placed under the great pectoral muscle, the arm may be directed obliquely back- wards. I should state here, that there are other accidents in which a depression may be found at the joint; and in which, also, the change of direction in the arm may occur. In fracture through the neck of the humerus, we may have both of these symptoms. But as soon as you move the arm, you find, in a case of fracture, that you can reduce it at once, while in a case of dislocation con- siderable force is required ; and, if it is a fracture, the deformity will recur soon, after it has been reduced; while, on the other hand, the parts will remain in their natural position, if a dislocation has been reduced. In fracture of the neck of the scapula, the same symptoms may present themselves, but the same difference will serve to point out the true state of the parts. In a dislocation backwards and upwards, there can be no mistake. The axis of the arm will be inclined obliquely forwards and outwards, and the head of the bone will be felt on the dorsum of the scapula. All the plans of treatment adopted in cases of dislocation at this joint are founded on one and the same principle, but are modified to suit each case. If the head of the bone is thrown forwards and downwards, there are two, and I may say three, methods by which it can be 202 REDUCTION OF DISLOCATIONS OF THE HUMERUS. restored to its position, and generally with ease, particularly if you avail yourself of some of the means of relaxation spoken of at our last meeting. A very simple plan will be, to place the patient on a bed, a sofa, or on the floor, and, drawing your boot, place your heel in his axilla, seize his wrist with your hands, and make extension steadily, carrying the arm at the same time towards the ^ide. In a great number of cases, the head of the bone will slip into the glenoid cavity, and success will be the result of this sim- ple method. Another equally simple plan is, to place the patient in an ordi- nary chair; to take your position behind him, with your foot placed on the edge of the chair, so that your knee will be immediately beneath the axilla of the injured side ; and, having caused the arm to be extended from the side and traction to be made in that direc- tion by means of assistants, to press the member down on your knee as a fulcrum, using the patient's arm as a lever. By this plan, also, we frequently succeed in reducing this dislocation. When both of these fail, I have often succeeded by the following method. Place the patient on his back on the floor, and yourself above his head ; press your foot against the acromion process of the scapula, and, taking his hand, draw his arm directly up, con- tinuing the pressure with your foot. I bring to your notice all of these plans, because, in many cases, you will find that one suc- ceeds when the others have failed. They should, therefore, be tried in succession. If in either the first or the last plan, you find that you cannot ex- ercise sufficient strength yourself, you may secure a cord to the arm by means of a roller bandage, or a towel, and place it in the hands of an assistant. Some recommend that counter-extension should be made, by causing the assistant to seize the opposite wrist, and make traction in a direction at right angle with the body, while the surgeon is at the other side. The opposing forces operate through the trapezii muscles. When extension is made directly on the injured side, it will be well for the surgeon to place his knee under the humerus, so as to be able to force the head up. A very good way of doing this also, is for the surgeon to pass a band over his neck, and beneath the afflicted arm, by which means he can command a very good leverage on the head of the humerus by raising his shoulders up. In many cases, however, these methods of applying the force will fail. You then should take a sheet, table-cloth, or band of some kind, and, passing it obliquely DISLOCATION AT THE ELBOW JOINT. 203 under the axilla of the affected side, carry it round the body, and attach it to a post, or stay of some kind. This is for counter- extension. Then, take another band, (and in applying this take care to protect the skin,) and secure it above the elbow joint, though some say that this should be applied to the wrist. I pre- fer that it should be secured above the elbow, as then the fore-arm can be flexed, and used as a lever for rotation. This band is for the purpose of extension ; and with that object it is placed in the hands of assistants, who are by means of it, to apply a steady trac- tion, at right angle with the body, and in a direction exactly op- posite to the counter-extension band. The surgeon then, by means of his knee, or the strap round his neck, throws the head of the bone into its place. If all these plans fail, it will be necessary to resort to the compound pulley. When the accident, however, is of recent date, and adhesions have formed, I need not again remind you of the great danger that threatens the axillary nerves and vessels from the application of too much force; and if the sub- ject is much debilitated, and there is reason to suspect that the bones are fragile, 1 would also advise you not to apply too much ieverage power on the humerus, for fear of producing a fracture. After the reduction, all that will be necessary is to carry the arm for a short time in a sling, and, sometimes, to prevent motion, it may be advisable to apply a bandage. We have said that the direction of the forces used in reducing dislocation at this joint, should be modified in accordance with the nature of the dislocation. If the head of the bone be thrown backwards and upwards, on the dorsum of the scapula, which, if you recollect, was stated to be the only other primitive dislocation that could occur, the counter-extension should be made, as above, from beneath the axilla, and round the thorax ; and the extension should be directed outward, and slightly forward, and should be steadily continued until the head of the humerus is sufficiently disengaged from its new position, when the lower part of the arm should be suddenly moved backward, so as to throw the upper portion forward, into its natural position. When the dislocation is very far forwards, a like method should be pursued, but in the opposite direction. We pass now to consider Dislocation at the Elbow Joint. As you are aware, this is an example of the hinge joint, and is formed by the ends of three bones. 204 REDUCTION OF DISLOCATIONS AT THE ELBOW. We find it convenient, therefore, to consider dislocation here, first, as it involves both bones of the fore-arm, and secondly, as it is confined to one of them. So far as a dislocation of both bones is concerned, we find that there are but three directions in which they can be displaced. The first of these is directly backwards; in which case, the coronoid process of the ulna will be lodged in the fossa magna of the humerus, the olecranon process will be prominent on the back of the arm, and the fore-arm will be slightly flexed. The second and the third points, at which the dislocation of the two bones can occur, are, respectively, to the inner and to the outer sides; in which cases, the displacement is never complete, except in some rare instances, in which the soft parts are very much torn, and the diagnosis will be rendered a matter of little difficulty, by the prominence on one side or the other, as the case may be. In the reduction of the dislocation backwards, different plans have been recommended by different surgeons. Some advise simple extension and counter-extension in the direction of the axis of the arm, assist- ants performing counter-extension at the shoulder, while the surgeon extends from the wrist. If you bear in mind the fact that the coronoid process is, as it were, hooked into the fossa magna, and bound there by tendons, you must at once perceive that this plan is founded upon erroneous principles, and that the reduction had better be conducted in a far different manner. Place yourself on the side of the patient, who may be on a chair or bed; take his arm in one hand and his fore-arm in the other, and place your knee in the angle of his elbow. Then flex his fore-arm, or wrench it, as it were, across your knee, and the reduction may easily be accomplished. Another plan is to place the patient near the bed- post, and flex the arm directly around it. The post acts as the knee does in the first mentioned plan. There is still another method, proposed by Professor Dugas, in which the muscles are made to act the principal part in the reduction. This method causes the olecranon process to act as a fulcrum in lifting the coronoid process out of the fossa magna. The arm is placed on a hard table, so that the fore-arm may project; and the fore-arm is then seized, and pressed directly down in extension till the coro- noid process is disengaged, when the action of the brachialis anti- cus muscle draws it directly to its normal position. I have never been under the necessity of resorting to this plan, as I have never met with a case in which I could not succeed by flexing the arm across my knee. In one case three months had elapsed, and ad- hesions had formed. There will be no difficulty in the reduction DISLOCATION OF THE RADIUS AT THE ELBOW. 205 of the lateral dislocations. Simple extension, counter-extension, and pressure out or in, as the case may be, will generally succeed. The two bones, as I have said already, cannot be dislocated for- ward, without fracture of the olecranon process: nor can the ulna be o\\s\oc&teo\ forward without the same complication; and if it be dislocated backward, the appearance, symptoms, and treatment will be the same as if both bones were dislocated in that direction. The radius may be displaced either forward or backward; and the question presents itself—how can these two accidents be dis- tinguished, the one from the other? If it is displaced forward, there will be a depression where the head of the bone should be; and this depression will be especially evident, when the arm is in a semi-flexed position; beyond which it can be flexed no more, from the obstacle presented by rounded head of the radius coming in contact with the humerus. This limitation of motion constitutes another symptom. The hand will be placed in supination. If the dislocation is backward, the hand will be pronated, and supination cannot be fully accomplished. There will also be a depression in the place naturally occupied by the radius, and its rounded head may be detected behind. In either case I do not think the reduc- tion will be found a difficult matter. We place the patient in such a position, that his arm can rest on a table, and his fore-arm extend over its edge. The arm is to rest on the inner condyle, and it is to be held firmly to the table by the assistants, and kept resting on the inner condyle. The surgeon then takes hold by the wrist, and using the whole of the ulna as a lever, he makes exten- sion and counter-extension ; when, having by this means brought the radius to a proper level, he presses it either forwards or back- wards, as the case may be. Having effected the reduction, the fore-arm is to be flexed on the arm, and a paste-board splint is to be put on to prevent motion, and be worn for some time. 206 DISLOCATIONS OF THE PHALANGES. LECTURE XXVII. DISLOCATIONS CONTINUED--AT WRIST JOINT--OF PHALANGES OF THUMB AND FINGERS--AT HIP JOINT. I have already mentioned, incidentally, that dislocation at the wrist joint was an accident of very rare occurrence. I endeavored at the same time to impress upon you the fact, as I believe it to be, that many fractures at the lower end of the radius, have been treated for dislocation of the carpus. If you examine the parts you will readily perceive how difficult it would be for the accident to occur. Laterally, the styloid processes of the radius and ulna are situated, and must in most instances be fractured, before the wrist can be displaced to either side. The anterior excavation is filled up by strong tendons, fortifying the joint in that direction, and almost preventing entirely a dislocation in that quarter. Behind we have a similar arrangement, and it is almost impossible for it to occur in that direction. So it is evident, that dislocation, either forward or backward, must be of rare occurrence. Yet in your books you will find the two dislocations laid down as common accidents. If a case of the kind should come under your care, a careful examination of the joint will reveal its nature to you. If the dislocation is backwards, the radius will project into the palm and the carpal bones form a prominence on the back of the hand ; if it is forward, the reverse will be the condition of the parts, the radius will project behind, and the carpal bones form a prominence in front. The reduction will be easily accomplished. If the dis- placement of the carpus is forward, the hand should be extended and bent backwards, and the end of the radius pressed into its position; if it is backward, the same extension should be made, but the hand should be bent forward, and the end of the radius, as before, pressed into place. If the displacement should be lateral, extension and lateral pressure will restore the parts to their normal relations. Dislocations of the Phalanges of the Thumb and Fingers, Frequently give a good deal of trouble to the young practitioner; and even the most experienced surgeons may sometimes be baffled in their endeavors at reducing them. I shall therefore explain to you the cause of the difficulty. If the thumb, for example, is DISLOCATIONS AT THE HIP. 207 dislocated at the first phalanx, the tendons of the flexor brevis pol- licis, adductor pollicis, abductor pollicis, #c, and the lateral liga- ments of the joint become hitched over the rounded protuberances at the base of the first phalangeal bone, and the more we extend and counter-extend the thumb, the more they are stretched, and the tighter are they hitched. Thus they oppose the extending force, and create a difficulty in the reduction, which is sometimes almost insurmountable to those attempting it by simple extension and counter-extension. The re- laxing of these ligaments and tendons, should be your object; and this may be accomplished by flexing the thumb still more, when, by applying your extension and counter-extension not exactly in the axis of the thumb, and gradually bringing the bone up and back to its place, the reduction may be accomplished. This refers to a dislocation forwards. If it is backwards, instead, in the first instance, of flexing the thumb, it should be extended, and then gradually brought to its position. It has been proposed by some to cut these ligaments, but I do not know that you will ever be under the necessity of doing this. The same difficulty will be met with in all of the phalangeal bones, and it should always be met in the same way. We will now pass to the dislocations of the lower extremity, and commence with Dislocation at the Hip. As in the case of the humerus, the femur can escape from its articulation with the os innominatum at but two points, upwards and backwards, and downwards and forwards. These are the prim. itive dislocations, though this bone is also liable to be drawn more or less from the place to which it originally escaped. The first mentioned accident is the most frequent. The head of the bone rests on the dorsum of the ilium; the foot is turned in, and the limb is short- ened to the extent of two or three inches. The trochanter major is turned forwards, and the foot, turned inwards, as just stated rests upon the meta-tarsal bone of the great toe of the opposite side. In this dislocation the head of the femur may be sometimes drawn into the greater ischiatic notch; in which case, the toes of the injured side will rest upon the articulation of the meta-tarsal with the first phalangeal bone of the great toe of the opposite foot, and the trochanter major will lodge against the edge of the acetabulum. 208 REDUCTION OF THE DISLOCATIONS AT THE HIP. Some contend that there will be shortening, others affirming that there will not. If you examine the relative position of the parts, you will find that the head of the bone, when in this place, rests a little higher than the acetabulum, and therefore slight shortening must be the result of the displacement. This injury may be mis- taken for a fracture, but the difficulty of motion should enable you to distinguish it from that accident. When the second of the two primitive dislocations occurs, the bone may also occupy one of two positions, downwards and forwards into the foramen thyroideum, or directly forwards on the ramus of the pubis, where the head may be perceived under Poupart's ligament, and the hip will appear somewhat flattened. If the bone occupies the first of these posi- tions the limb will be rotated outward, and it will be impossible to bring it in towards the sound one. If the bone lies on the ramus of the pubis, the character of the deformity, as above mentioned, together with the appearance of the head under Poupart's ligament, will satisfy you of the nature of the accident. It has been said that the femur has been dislocated directly downwards on the ischium, but I apprehend from the anatomy of the part, that this is very improbable. The accident, if it should occur, would be characterized by the unnatural length of the limb. In attempting the reduction of dislocation at this joint, it is a matter of the highest importance that you should bear in mind the muscular influence which is brought to bear on the bone. From the immense force of the muscles which exercise this influence, it sel- dom happens that mere manual power is sufficient to overcome their action. I shall explain the methods followed generally in the reduction of dislocations of the femur; premising, however, that I do not consider them founded upon correct principles, and that I prefer the plans which I shall afterwards explain. This plan makes use of the muscles themselves, and causes them to assist in effecting the reduction, instead of overpowering them by mere force. In the dislocation upwards and backwards on the dorsum ilii the direction of the extension (which is performed by means of an extension and a counter-extension apparatus, such as you see here the first secured above the knee, and the second passing under the tuber ischii, a compound pully being generally used) is oblique, and it is continued until the muscles are exhausted by the steady traction. The thigh being flexed towards the abdomen by the REDUCTION OF DISLOCATIONS AT THE HIP. 209 forward obliquity of the extension, the surgeon continues rotating it quickly, and when the bone is sufficiently brought down, by means of a strap, he lifts the thigh so as to let it slip into place. If the apparatus which you see here, is not at hand, you may make use of a sheet folded cravat-like, and extend, by means of a roller bandage, always taking care—and the same caution may be given in reference to any apparatus—not to injure the skin in its applica- tion. In the other dislocation backwards, that into the greater ischiatic notch, the same plan is followed. In the dislocations/or^arrfs on the ramus of the pubis, or into the thyroid foramen, extension and counter-extension of the axis of the limb, are of no use. The pelvis of the patient is secured, and ex- tension is made laterally, by means of a strap passed round the thigh, and attached to a compound pulley. The surgeon in the meanwhile holds the foot in, and carries it also towards the other limb. These are the ordinary means, but I here show you the ap- paratus of Jarvis, as it is called; an ingenious, but complicated affair. The piece like the letter U, with the cushion at the open end, is for counter-extension. By winding the instrument up we obtain extension and counter-extension at the same time; and, by means of the lever we force the bone out. By certain modifications of the instrument we may use it for other dislocations. As I have already stated, however, I prefer the plan which I will now proceed to explain; and in which the muscles are made instrumental in the reduction. In the first place, in the disloca- tion upwards and backwards, on the dorsum of the ilium, the rota- tor muscles are put on the stretch. Bearing this in mind, let us consider what would be effected by flexing the thigh on the body, and the legs on the thigh. If you recollect the origins of these muscles, and their common insertion into the digital fossa, you will readily perceive, that by the flexed position of the femur, their influence is brought to bear upon the upper extremity of the bone in a more perpendiculardirection towards its axis, and,consequently is exerted to much greater effect. In fact, with so much effect is it exerted, as to draw the head of the bone down towards the acetabu- lum • and vou accomplish the reduction, then, by simply raising the head up to clear its edge, at the same time applying a rotatory motion. Thus, without any compound pulley, or any complicated apparatus, you may succeed by taking advantage of the very mus- cular action, for overcoming which these apparatus are employed. The method is not a new one, but is a century old; and yet you N 210 DISLOCATIONS OF THE PATELLA. can hardly take up a medical or surgical journal, without seeing some allusion to the "new method of reducing dislocation of the femur upwards and backwards."* You merely strap the patient's pelvis to a table, and standing over him, flex his thigh upon his abdomen, and extend upwards as you stand. In the other dislo- cations at the hip, it has lately been proposed to place the patient on his back, and make extension and counter-extension latterly by means of a strap passed under the thigh, the pelvis being secured; and that the surgeon should take the foot, and draw it across to the opposite one, rotating the limb at the same time. But as I am encroaching upon your time, I shall not tax your patience any longer. At our next meeting, I shall pass on to the other disloca- tions of the lower extremity. LECTURE XXVIII. DISLOCATION CONTINUED--OF PATELLA--AT KNEE--AT ANKLE JOINT-- OF ASTRAGALUS--OF PHALANGEAL BOXES OF TOES--COMPOUND DISLO- CATION--DISLOCATION CONCLUDED--AFFECTIONS OF, AND INJURIEIS TO, JOINTS--WOUNDS OF JOINTS--INFLAMMATION OF JOINTS. It sometimes happens that the patella is displaced from its natural position, where it plays over the joint, and thrown to the inner, or the outer side of the middle line. Where the axis of the limb is much changed from a straight line, as in those commonly called "bow- legged," there may be a considerable pre-disposition to this acci- dent. The diagnosis of such an injury will be a matter of no diffi- culty. There will be considerable pain; and a tumor of the form of the patella will be seen on the inner, or the outer side of the knee, according to the direction of the dislocation. A depression will be evident in the natural position of the bone; and there will be inability, on the part of the individual, to extend the leg. An important indication to be fulfilled, in accomplishing the reduction, will be, as you may readily suppose, to relax the large extensor muscles of the front of the thigh, which have their common inser- tion into this bone. This may be readily accomplished by simply flexing the thigh on the abdomen, and extending the leg on the * This method has been taught in the Lectures, annually, for eighteen years. DISLOCATIONS AT THE ANKLE. 211 thigh; and, having thus relaxed these muscles—or, as they are together called, the quadriceps extensor femoris—there will be no difficulty in pressing the bone with the thumb, over the condyle, into its position. It will be advisable to make those who are sub- ject to this accident wear a laced knee cap. Dislocation at the Knee May take place in any direction, but will hardly ever be complete, on account of the extent of the articulating surfaces. If, for exam- ple, the dislocation is inwards, the lower end of the femur will rest on the outer fossa of the tibia. There will be no dislocation with- out considerable laceration of the strong ligaments of the joint; and in consequence of this, the great obstacle to the reduction is removed. All that is necessary in such a case is, to apply slight extension and counter-extension, and press laterally, in or out, as the case may be. It is always rendered a serious accident on ac- count of the laceration of the ligaments, the extent of the injury to the synovial membrane, and the consequent inflammation of the same. W7e go on, in the next place, to the Dislocation at the Ankle Joint. Lateral displacement cannot occur without fracture of the in- ternal or external malleolus—an accident, I may remark, of not at all uncommon occurrence. The only dislocations, then, that can occur without fracture, are those backwards and forwards. In either case, there will be no difficulty in forming the diagnosis. When the lower ends of the bones of the leg are thrown forwards, on the anterior tarsal bones, the foot will appear shorter, and the heel longer than natural; and when, on the other hand, they are thrown backwards, the foot will appear elongated, and the heel shortened. In neither case will there be much difficulty in effect- ing the reduction. Should the tibia be thrown forwards, the sur- geon, with the palm of his right hand on the heel of the patient, and his left hand on the instep and toes, extends the limb till the surfaces of articulation are in a line with each other. Assistants, in the meanwhile, keep up counter-extension at the knee; and then the surgeon elevates the toes and depresses the heel, forc- ino- the bone back at the same time. In dislocation backwards, the same plan should be followed, with the exception, that the heel should be carried in the opposite direction. Dislocation of the Astragalus. It sometimes happens, that, from great violence, the astragalus 212 COMPOUND DISLOCATION. is thrown to the inner or the outer side of the other bones of the tarsus; and you may, in some cases, find it exceedingly difficult, or even impossible, to reduce it. If there is not much laceration of ligaments, the bone will be tilted up, so as to receive, on one edge, the whole weight of the tibia. All that we can do in such a case, is, to make extension from the foot, with counter-extension from the leg, and to endeavor to press the bone into its place.- But some- times, as I have said, this will be impossible; and then all that can be done, after having made such attempts, is'to keep the patient quiet, until he is strong enough to walk. When the astragalus is dislocated from the naviculare, the nature of the accident will be readily perceived. Its reduction can be easily accomplished by slight extension, counter-extension, and pressure; and it will be well, in these cases, to put on the immovable apparatus, consist- ing, as has already been explained, of repeated layers of starched bandages. In Dislocations of the Phalanges of the Toes, The same difficulty will be encountered as in those of the fingers; and the same method should be followed in overcoming it. The toe should be first flexed, or extended, as the displacement is for- ward or backward—in order to relax the tendons and ligaments which are hitched around the tuberosities at the heads of the pha- langeal bones; and in short, precisely the same treatment is to be adopted, as in the like accident to the phalanges of the fingers. Compound Dislocation. In all dislocations, where the accident assumes those characters which I have mentioned as constituting a case of compound dislo- cation, you have a serious injury to deal with. The tissues of the joints invariably take on an intense grade of inflammation ; and tetanus may, in some cases, supervene. Amongst these accidents, none are more serious than those which occur at the ankle joint; and when you meet with cases of this kind, it will always be a question of great importance to be determined before you begin the treatment, to decide whether, in attempting to save the limb of your patient, you may not jeopardize his life. In forming your deter- mination on this important point, all the circumstances of each case should be carefully weighed. The extent of the accident; the age and constitution of the patient; the circumstances under which he is placed, as regards the atmospherical influences; the kind of nursing he is likely to receive, &c; his habits and state of health, WOUNDS OF JOINTS. 213 are all to be carefully investigated, and allowed to exercise due weight in directing the course you should pursue. If the injury is of considerable extent, the patient old, or of bad constitution, and the other circumstances unfavorable, you should not attempt to save the limb, but proceed to the operation of amputation, as soon as re-action has taken place. If, however, the reverse obtains—if the patient is young and of good health, and has the advantages of good nursing, it will be your duty to attempt to save the limb. When you determine upon this course, the dislocation should be reduced ; the wound in the soft parts neatly brought together, and united by adhesive strips or sutures if necessary ; and the antiphlogistic treat- ment rigidly enforced, in order to combat the inflammatory action. With regard to the other complications which may accompany dislo- cation, we shall have more to say at some future period, and there- fore pass them by for the present. By a natural step we proceed, in the next place, to consider some of the DISEASES AND INJURIES OF THE JOINTS. Any injury or disease involving a joint, is rendered a complex subject for consideration from the number of structures, which, sooner or later, are implicated. First, we have the vascular heads of the bones; and secondly, the articular cartilages, devoid of blood vessels, but capable of undergoing changes, and of taking on dis- eased conditions. Thirdly, we have, surrounding these parts, the synovial membranes; and lastly, as appendages of the joints, we also have the ligaments, and the tendons of the muscles, with their bursae mucosae, sacs precisely similar to the synovial membranes. In order to investigate the pathological conditions of the joints, we must understand the nature of all these structures; for, owing to their intimate union, it is almost impossible for diseased action to be confined to one of them. Hence arises the great difficulty in understanding the subject. In considering the subject, an antomical division would be the most natural; but it would involve too much repetition, and occupy too much time; to avoid which, we will go on in the order of the injuries and diseases, commencing with the more simple. To begin, we will take up the consideration of Wounds of the Joints. It is important, in the first place, to divide these into—those which penetrate into the joint, and those which do not, as the prognosis 214 TREATMENT OF WOUNDS OF JOINTS. will materially differ in the two cases. Where a simple incised wound is inflicted over the knee, and it does not penetrate the joint, it will be followed by no more unpleasant symptoms, than the same injury any where else; and all that we have to do, is merely to bring the edges together, and unite them. In this connection, how- ever, there is one point in the diagnosis^ to which I desire to call your special attention. It is the fact, that synovial fluid, or rather I should say, a fluid precisely similar to that secreted by the syno- vial membranes, may be seen issuing from the lips of the wound; and this may lead you to suppose that the joint has been penetra- ted, when perhaps the synovial sac is untouched. In such cases, the fluid comes from one or more of the bursas mucosae in the neigh- borhood of the joint. This is an important point to be borne in mind ; for you may form hastily, and communicate to your patient, a greatly exaggerated opinion of the nature of the wound; since, if you were convinced that the synovial membrane had been en- tered, you would reasonably consider the injury as of a very serious character. When this is the case, violent inflammatory action is apt to come on, even, in some cases, after several days have elapsed. The limb being kept quiet, and the patient suffering no pain from it for some days, he begins to use it, and no sooner is the friction set up on the surfaces of the synovial membrane, than inflammation is engendered thereon, of a violent character, and soon followed by pain, diffused inflammation in the surrounding parts, delirium, and even death, if the inflammatory action is not checked. Hence it becomes a matter of the highest importance, in the treat- ment of injuries of this kind, that you should be extremely careful, always bearing in mind, that even at a late period, violent inflam- matory action may come on. The edges of the wound should be carefully brought together as soon as possible, (I here refer more particularly to simple incised, or punctured wounds,) and the limb should be kept in a perfectly quiet state; which latter direction should be particularly enjoined on the patient. If you have not a perfect confidence that he will carry out this important injunction to the letter, you had better ap- ply to the limb a splint of sufficient stiffness, to prevent the slight- est motion of the joint, and thus avoid the consequent friction of the synovial membranes, a slight degree of which may serve to induce inflammatory action, which perhaps might not otherwise have arisen. As regards the other treatment demanded, I may, in general terms, remark, that the antiphlogistic plan should be car- ried out, to a greater or less degree according to the symptoms which INFLAMMATION OF THE SYNOVIAL MEMBRANES. 215 present themselves. It may be necessary, in some cases, to resort to venesection, and even to repeat that operation again and again; and in most cases leeches should be freely applied. The bowels should be kept open ; the function of the skin should be kept up ; and anodynes must be used to ensure rest. If the injury is extensive, the head of the bone comminuted, the soft parts lacerated and contused, &c, it becomes a question, as I have already said, whether you would not hazard the life of the patient, if you attempted to save the limb. If the joint is one of the larger ones, and there is extensive injury to the parts, the at- tempt would be hazardous, particularly if the patient's constitution be bad, and other circumstances are unfavorable. In such cases, you should resort to amputation, as soon as reaction has taken place. I have seen cases in which, in twenty-four hours, all hope of saving the patient's life was lost. Let us in the next place, turn our attention to those accidents of the joints, which may result from spontaneous or internal causes,— from diseases which may naturally attack the joint. And in the first place, we will consider Inflammation of the Synovial Membrane. This, as you know, is a closed sac, secreting an unctuous fluid. When inflammatory action is set up in any portion of this sac, it diffuses itself with great rapidity over the whole surface. When we trace this inflammation, and investigate the consequences which result from it, we find them of extremely different characters. One of the first changes noticed in the part is an increase of vascularity. Then, we may have a modification of the secretion effected. Instead of the natural synovial fluid, plasma, or coagulable lymph, is thrown out by the vessels. This, when not mixed with much synovial fluid, may soon coagulate, gradually go through the pro- cesses resulting in organization, and form an adventitious layer over the membrane. Or it may organize in shreds, or form a strong band of adhesion. Sometimes it may fill up the cavity of the sac j and, when the organization is allowed to go on, it may limit, or entirely destroy, the motion of the joint, and thus form what is called soft anchylosis. When it goes on a still greater length of time, bony deposit may take place; and what we denominate per- fect, hard, or solid anchylosis will be the result. The extrayasated fluid, however, may be partly synovial, and partly lymph; and we will have swelling, and distention of the capsular ligament of the 216 INFLAMMATION OF THE SYNOVIAL MEMBRANES. joint; or sometimes, the plasma maybe very deficient, and the distention may be caused by a purely serous fluid. The plasma may sometimes be found floating in shreds, or flocculi through the fluid. Upon opening into the joint small bodies are let out, partly organized, yet totally disconnected with any Jiving part, and float- ing in the fluid; and our curiosity is aroused to account for their organization. The plasma, being originally thrown out by the membrane, was, at one time, attached to it, and while thus in connection with the body, its organization was being effected ; but, hanging loosely in the joint, by the motion of the fluid, or of the joint itself, it must have been detached in pieces, which then floated freely in the cavity of the joint. By some modification of the diseased action, in inflammation of the synovial membrane, instead of the synovial secretion, or the extravasation of plasma, pus may be eliminated. Generally, how- ever, this is mixed with some synovia. It distends the capsular liga- ment; which suppurates, if the distension is continued, and the mat- ter is discharged. But, worse than this, it may involve in the suppu- rative process, the cartilages of the joint; and the mischief may even extend to the osseous structures adjacent. The term "hydrarthro- sis," is applied to that species of effusion, in which the fluid is transparent. When the part is smooth, pale, and flabby, it is called " white swelling." But such names are apt to mislead. This very condition, called white swelling, is not of one constant character, but involves several changes. This is a subject, however, of so much importance, that I shall take it up in the next lecture; when I shall continue my remarks on it, and consider its treatment. SYMPTOMS OF INFLAMMATION OF THE JOINTS. 217 LECTURE XXIX. INFLAMMATION OF JOINTS CONTINUED--OTHER PATHOLOGICAL CONDI- TIONS OF JOINTS, AND THEIR TREATMENT. We remarked to you yesterday, gentlemen, that, in consequence of the close connection existing between the structures forming the joints, it was almost impossible for any pathological condition to effect one of these structures, without sooner or later extending itself to some, or all of the others. Inflammation, for example, of the synovial membrane, may soon pass to the cartilage, and even through it, to the head of the bone ; or, first attacking the cancellous struc- ture of the head of the bone, it may, in a short time, involve the cartilage; and the synovial membrane may ultimately be effected. Having traced, in the last lecture, the pathological anatomy of inflammation of the synovial membrane, before passing farther, it will be convenient to point out the means for detecting such a con- dition. When we have an acute synovitis, the whole capsule, in the first place, will become distended, and the joint will conse- quently be swollen; and, if sufficient pressure be exerted with the fingers, fluctuation may be perceived. In the case of the knee joint, this will be most distinct when the leg is flexed on the thigh, as the pressure exerted by the tendons of the quadriceps extensor femoris on the synovial sac, will tend to press the fluids laterally, and thus cause a bulging on each side. In the same manner, in the elbow joint, the fluids would be pressed laterally by the tendon of the triceps, and the detection of fluctuation will be thus rendered less difficult. By these means, then, we can easily detect the ac- cumulation of fluid in a joint. Commensurate with these changes in the configuration of the joint, we have pain of a local character, sometimes acute, and sometimes increasing in severty towards night-fall, and less acute during the day. In some instances, where the attack is not of a very acute character, you will find that your patient, when he gets up in the morning, complains that the joint is stiff, and painful. But, after walking, or moving for some little while, he will tell you that all uneasiness has disappeared ; and he congratulates himself for being well again. After remaining quiet for some time, how- ever, he will tell you that the stiffness and pain have returned, per- haps with greater severity. This may occur again ; and if the patient be not restrained, an acute synovitis may be brought about, 218 TREATMFNT OF INFLAMMATION OF THE JOINTS. for every motion of the part will tend to increase the inflammation. In many cases in which there are these changes going on in the joint, there may be no alteration perceived on the surface of the skin. Both its heat and color may be not at all increased. The part may even be of a pale, glossy color. Sometimes, however, the morbid action may extend outward, and it may be swollen and red. These changes are different in different joints, and at different stages of the inflammation. In these cases—turning our attention now to the treatment—the limb should be kept in the most perfect state of rest; the semi- flexed position should be chosen; and even the involuntary action of the muscles should be prevented; as the slightest motion will tend to exasperate the inflammation. You should next determine which of the antiphlogistic remedies to adopt, blood-letting of course being placed at their head. But whether you resort to this locally, or generally, should be determined by the circumstances of each case. If the patient be strong and healthy, and the inflammation run high, you should bleed him freely, and repeat the venesection if necessary. If the constitutional powers of the patient are low, or the inflammatory fever is not so great, and the symptoms are not so urgent, you should resort to relays of leeches applied around the joint, bleeding from the bites of which may be encouraged by fomen- tation ; or you may use the scarificator and cups. While you employ these means locally, you should not neglect the internal, or constitu- tional treatment. A due combination of mercurials, antimonials, and opiates should be resorted to; the bowels should always be kept open, or even purged, if the case is urgent. Concerning the pur- gative treatment, however, there is one thing which must be remem- bered, and which constitutes an objection to its adoption. The mo- tion necessary in resorting so frequently to the close stool, will greatly tend to increase the inflammatory action in the joint, and should as much as possible be avoided by the use of a bed pan, whenever this can be obtained. You may next resort to the use of blisters, applied on the inner, or outer side of the joint, or even in front. I know that in recommending these I am in opposition to high authority; hut I have found such great benefit to result from this treatment, that I do not hesitate to affirm, that its adoption by you will be found beneficial to your patients. To fulfil our expec- tations properly, the blistering must be kept up for some time. To the same head, we must refer the stimulating applications in vogue. Of these there are a great variety. Antimonial ointment, mercu- TREATMENT OF INFLAMMATION OF THE JOINTS. 219 rial ointment, olive oil and aqua ammoniae in combination, or iodine with lard, may, any of them, be used. Many use a liniment long employed, and known as " Brodie's liniment." It is a combination of olive oil, turpentine, and strong sulphuric acid, in equal parts; and it is to be rubbed on several times a day. A sense of heat, and a slight redness follow its application, succeeded, in a day or two, by desquamation. It is an excellect application, and superior to the ordinary ammoniacal liniment. Its use should be kept up for some time. When the affection is of the character of rheumatism, or it is associated with a rheumatic diathesis, it will be well to combine with these remedies, such others as are appropriate to that diathesis. The iodide of potassium, with mercurials, alternated with colchi- cum, should be used. Whatever be the character of the inflammation, however, you will be able to do but little for your patient, unless you can secure per- fect rest for the inflamed part. Few patients will be found able to bear the constraint necessary to obtain this; and hence mechan- ical means of support should be resorted to. As a splint may produce too much pressure, on the part, the roller bandage may be used, and it is often found to be very advantageous. The con- striction, applied thus evenly, is found of great benefit. It prevents a determination of blood to the part, affords it considerable sup- port, promotes absorption, and prevents motion by compressing the muscles. But when the case is one of a more chronic charac- ter, and changes have occurred which involve considerable injury to the parts, though bandages may give great support, I would not rely exclusively on them, but would use paste-board splints, care- fully adjusted. Before they are put on, the joint should be anointed with some stimulating application. Camphorated mercurial oint- ment, or camphorated spirits may be used. Over this should be placed a layer of soft lint, and then your apparatus should be ad- justed. This may be a splint, or the starch bandage. But when you resort to this, or in fact to any plan, you should, from time to time, remove your apparatus, and examine the condition of the parts beneath. A variety of splints may be employed. You may use such as are carved and grooved to fit the limb, or such as may be flexed as you desire. In some cases of inflammation of the elbow, »r knee-joint, the angular screw splint exhibited when we were discussing fractures of the arm, so arranged, that by turn- ing the screw we may break up adhesions at the joint, may be used with great convenience. 220 THICKENING OF THE SYNOVIAL MEMBRANE. In these measures, then, will consist the treatment of the slighter cases of inflammation of the joints. Some of them also appertain to the treatment of the more serious cases, of which I shall presently speak. But in this connection a question arises, to which I should call your attention. It has been gravely pro- posed, that when the capsular ligament is much distended, it should be punctured, and the fluid drawn off. Now, when we con- sider the serious character of a wound thus penetrating the joint, and the proneness of the parts to take on inflammatory action, I apprehend that it will be far better to let the fluid remain, and to trust to proper treatment to procure its absorption. I would be very reluctant, in ordinary synovitis, when the fluid is synovia, with or without a little plasma, to adopt this plan. With the same views, I would also condemn the treatment lately recommended, of puncturing, drawing off the fluid, and injecting with a solution of iodine, or some other stimulating fluid. In some cases of bursal tumors, unconnected with the joint, you may resort to this method. You may inject a solution of iodine and water, in equal parts, which will soon be absorbed, and a cure will be effected. But where the joint is concerned, if you resort to this plan, I would prefer your being guided by other authority than mine. In my general remarks of yesterday I stated to you, that in the more serious affections of the joint, the disease was not confined to any one of the component structures of the part, but soon ex- tended to most, if not all of them. Before I go on to these, how- ever, I would mention one other pathological condition, which is confined, at first, to the synovial membrane. The membrane slowly thickens, gradually fills up the cavity, and, extending to the sides, gives rise to a spongy-feeling tumor. Here there is no increase in the synovial fluid, but a fungoid degeneracy of the membrane, which gives rise to the soft, spongy feeling. When, in the case of the knee-joint, it progresses backwards and over- lies the popliteal artery, so as to receive the impulses of its pulsa- tions, it may be—and, indeed, has been—mistaken for a popliteal aneurism. Where this spongy condition of the synovial membrane exists, as might reasonably be supposed, the cartilage, in process of time, is apt to become involved. It may even, after a while, be entirely absorbed; and, upon cutting into the joint, we may find no vestige of it remaining. The diseased mass may thus lie in direct contact with the heads of the bones, which may then become involved; and ultimately such extensive changes of structure may take place as to create the necessity of amputation. TREATMENT OF DISEASED JOINTS. 221 In some cases, however, and especially in those of a scrofulous dia- thesis, we find the changes taking place, first, in the cancellous struc- ture of the head of the bone. When, in such cases, we have had the opportunity of an early examination, we find that the first change consists in a deposit of tubercles in the cancellous structure of the bone. Gradually the whole of it becomes involved, and the disease encroaches on the cartilage; which is then affected, not by a tuber- cular deposit, but by a destructive process of absorption, which may soon remove it entirely. The diseased action then extends to the synovial membrane, and gives rise there to similar changes to those which have already been described as resulting when it arises primarily in that tissue. Tubercular deposit here, under- goes the same changes as in the lungs. It may remain dormant for some time; or inflammatory action may, by its presence, be excited in the surrounding parts, and ulceration results; the tuber- cles in the meantime going through the stages of softening, and producing suppuration and caries. I have been under the neces- sity of amputating above the knee joint, when the whole disease arose from the head of the femur or tibia, and affected all of the surrounding parts. As I intimated, during the lecture of yesterday, the term ''white swelling" has been applied to this chronic affection, when the parts present a white and smooth glossy aspect. It is an unmeaning expression; for this condition, instead of being a simple disease, is in reality the result of a number of affections of the joints. In what- ever structure the disease begins, you may always rest assured, that you have a serious affection to deal with. There is always a dis- position to the gradual destruction of the part, until either the patient is worn out by the disease, or you come to his assistance by amputation, or by cutting off the heads of the bones, provided the limits of the disease warrant the hope of saving the limb. As regards the treatment of these chronic affections, I have to refer you, for the general rules, to what I have already said. One essential rule is, that you should obtain perfect repose. This is so important, that I take the liberty of repeating it here, although I have already mentioned it as the leading indication, and alluded to the means for fulfilling it. Here venesection is unsafe, and even local blood-letting, in cases of long standing, or where the patient is weak, may be inadmissible. Buc, at first, or when the inflamma- tion is high, a small number of leeches, successively applied, will often be found of benefit. It is in these cases especially useful 222 TREATMENT OF DISEASED JOINTS. to keep up a gentle degree of pressure, by means of the proper apparatus, so applied as to be capable of easy removal and re-ad- justment from time to time. You may use carved splints; or you may use the immovable apparatus, but so applied as to be removable. You should leave the anterior part open, by cutting it through longitudinally with a pair of scissors, and thus converting it info a kind of trough. I have often resorted to this expedient, in affec- tions not only of the knee and elbow, but also where the hip was the part involved, and when the disease had extended even to the pelvis. In such cases, the opening to admit of its removal, should be in the side. You will find this suggestion very useful, not only in securing compression, but also in restraining the mo- tion of the parts involved. It is preferable to the carved splints, both on account of its greater convenience, and its being less expensive. In addition to these measures, it has been strongly recommended, in the inception of these diseases, to bring the patient gradually under the influence of mercury. I think, however, that great dis- crimination should be used in resorting to this plan of treatment. It unfortunately happens, in a great number of these cases, that the disease is engrafted on a scrofulous diathesis; and the admin- istration o( mercury, under such circumstances, would be highly injurious. This medicine seems, in such constitutions, to depress. or lessen the vital forces of the system. Where the constitution is good, when we have no reason to suspect a scrofulous diathesis, and when the disease is in its inception, a slight mercurial course, combined with anodynes, will be of service: but it should never be pushed to ptyalism. There are, in this connection, still some other important considerations, which we will be obliged to defer to our next lecture. HIP JOINT DISEASE. 223 LECTURE XXX. DISEASES OF JOINTS CONTINUED--HIP JOINT DISEASE--ANCHYLOSIS-- TREATMENT OF ANCHYLOSIS. In our preceding lecture, gentlemen, we endeavored to portray the leading pathological conditions of the articulations. You will remember how we explained to you, that whenever the parts of a joint become affected by disease, the consequences were variable, in accordance with the number of tissues it involved, and its extent; that, in most cases, the diseased action is not confined to one structure, but extends from the synovial membrane to the cartilages, from the cartilages to the bones, and vice versa, spread- ing in various directions, and sometimes involving the surrounding cellular tissue, and other neighboring structures; and that, the remedies, in these various conditions, were very nearly the same, it only being necessary to modify the treatment according to the acuteness, or the stage of the disease. But, while we intend these general remarks to apply to diseases of all the joints, the subject is one of such importance, that there are some specialities in refer- ence to particular joints, to which we must call your attention, before we leave the subject. I allude more particularly to the hip joint, and we will now consider some of the circumstances refera- ble to this particular part. Here, diseased action almost always involves serious consequences. It is a matter of importance to con- sider, not only the pathalogical conditions of the joint, but also those changes in the relation of parts, which are apt to result from such conditions. As regards the changes of structure, I need not add to what I have already said in reference to joints in general, but will suppose these changes to have occurred. WTe find the patient complaining of a pain in the joint, which differs greatly according to circumstances. It is modified by the state of the atmosphere, and it is relieved after exercise, but returns with greater violence after rest. And so the disease goes on, step by step, ob- scure at first, but gradually obtruding itself upon the notice of the individual. In process of time, a notable change takes place in the outer conformation of the hip. Its breadth will be found to be increased, as may be evinced by ascertaining the fact, that a line drawn from the symphysis pubis or the spine of the sacrum to the trochanter major of the affected side, will be longer than a similar one, drawn on the sound half of the body. Accompanying this 224 HIP JOINT DISEASE. change there will also be an evident lengthening of the affected limb. This can be seen by placing the malleoli side by side; though in thus determining the fact, there is one circumstance which must be attended to, in order to avoid a mistake. The axis of the body should be made to correspond to that of the limb, or you may fail to detect the lengthening, and may even think that the opposite con- dition obtains. This is owing to the fact, that the constant effect of the disease is to tilt the affected side of the pelvis up, thus producing an appearance of shortening. A line, drawn from the superior spinous process on the injured side to the malleolus, will be found to be longer than one, similarly drawn, on the opposite side. We find that this change of conformation in the limb and pelvis, has resulted from changes which have already taken place in the joint itself, and which tend to protrude the head of the thigh bone from its natural position in the acetabulum. These changes have been variously explained; or, more properly, the reason of the changes in the position of the head of the femur, has been variously interpreted. Some ascribe it to a gradual thickening of the syno- vial membrane, others to the same change occurring in the cartilag- inous structure. It is very probable, that, in certain cases, all of the oauses which have been assigned may concur in producing the result. But there is one element in the production of the protru- sion, which is of great importance. We find that, while there may be important changes taking place in the joint, changes also occur in the head of the femur itself. They generally commence with a tuberculous deposit. The bone becomes more and more distended by this deposit, and gradually increases in size, until it is no longer capable of being retained in the cavity of the acetabulum, when it is thrown out; and then by the action of the muscles it is drawn to the dorsum of the ilium, thus occupying one of the positions of dislo- cation. In estimating the causes of this deformity, we must take all of the changes at the articulation into due consideration. There are still other circumstances to be considered in reference to this important subject; and to do these justice, we will follow the disease as it progresses, step by step. The first phase of the affec- tion, is that from its first appearance to the period in which the mor- bid changes have resulted in dislocation of the head of the femur. Within this limit, then, we will include the first stage of mobus coxarius, or hip disease. As_ soon as the dislocation has occurred, owing to the action of the internal iliac and psoas magnus muscles, the limb will be flexed ; the knee will be drawn in ; and, of course, TREATMENT OF HIP DISEASE. 225 the gait of the patient becomes considerably altered. These symp- toms will evince the termination of the first stage; but when we trace that stage from its commencement, from day to day, we find the limb gradually to increase in length, and the thigh to become more and more flexed. These changes progressively advance, until in process of time the head of the bone is protruded from its artic- ular cavity, and is lodged on the dorsum of the ilium. Now, instead of finding the limb lengthened, we will discover that shortening has occurred; and the foot will be found to be inverted (by the action of the iliacus intermus, and psoas magnus muscles,) on the thigh. The thigh of the affected side will be drawn in over the other, and will be flexed slightly; while the patient will be. able to walk only on his toes. Thus, there is a change in the axis of the limb ; and, to accommodate the centre of gravity to this change, a curve takes place in the vertebral column. These are the phenomena pre- sented by the second stage of the affection. The mischief daily extends; and ulceration and suppuration supervenes, the bone being often carious even prior to the dislocation. The surrounding cellular tissue, and other structures, ultimately become involved, and burrowing abscesses are formed. These last changes consti- tute the third stage. Sometimes, either by the conservative forces of nature, or by the aid of art, the affection may be arrested before extensive suppuration has occurred; but we cannot expect the parts to return to their natural conditions, and the patient, though he may recover finally, will be permanently deformed, to a greater or less degree. Thus, I have endeavored to exhibit the leading changes pre- sented for our consideration, by this most distressing disease. It is one which requires to be continually watched, and in the man- agement of which we are often doomed to fail in our most carefully directed endeavors to benefit the condition of the unfortunate pa- tient. As regards the treatment to be adopted, I may in general terms state, that it consists of a modification of that laid down for the management of diseases of the joints in general. In the early stages, leeches should be applied around the joint; and afterwards revulsives should be resorted to. Stimulating liniments, the moxa or actual cautery, setons, or issues may be employed. Blisters may be used in process of time, particularly when the constitution is weak. Irritative fever, or chills, followed by more or less febrile action and sweating, are apt to supervene; and they so exhaust the system as to require a relinquishment of the antiphlogistic o 226 TREATMENT OF HIP DISEASE. treatment, and to render it necessary to resort to tonics, and a healthy, invigorating diet. There is one point to which I would call your especial attention. As soon as you find a disposition for the bone to escape from the cavity, you should put on some appa- ratus, by which you may keep up a slight degree of extension and counter-extension, and which will also assist in keeping the patient quiet. Hagerdorn's fracture apparatus may be used. This con- sists, as already explained, of a long splint to be applied to the sound side of the body, and a foot board with a mortice through it, to which the foot is to be secured. These having been adjusted, the foot of the injured side is brought alongside of the opposite one, and secured to the foot-board. Should there be any objection to Hagerdorn's apparatus, you may use a long wooden splint, to ex- tend from the crest of the ilium to the foot, carved so as to fit the ine- qualities of the limb, and made of material as light and soft as pos- sible. To this the limb may be strapped, through its entire length. Or, you may use a kind of immovable apparatus constructed of starch bandages and paste-board, filling up the inequalities with soft lint, and extending it from the crest of the ilium to the heel. Apply first a roller bandage the whole length, (protecting the parts by some soft material) and extending alsooverthe pelvis: on this, lay strips of paste-board, and then a layer of starch; then apply a bandage again; and so on, as often as is necessary. The limb should then be placed in a proper position, and all motion must be prevented until the starch has hardened. But as it is a matter of importance to remove the apparatus from time to time, you should remember to apply no paste-board on the inner side of the limb; so that, when the starch has hardened, with a pair of scissors you may cut up to the nates, and turn the apparatus off, as you would the bark from a tree. Thus, the apparatus may be removed and replaced, as often as may be necessary. It is to be secured to the leg and pelvis by means of straps. There is still, in this connection, one collateral circumstance to which I would call your attention. I have stated that, as a o-eneral rule, notwithstanding the high authority against me, I am opposed to puncturing a joint when it is distended by an inordinate accumulation of synovial fluid. But the question arises whether it would not be well to do so, if the accumulation be of a purulent character. I am free to confess, that under such circumstances, I would unhesitatingly puncture, and evacuate the pus; and even if the accumulation again took place, I would re- TREATMENT OF HIP DISEASE. 227 peat the operation. A purulent collection, whether located in the neighboring tissues, or in those comprised within the joint proper, should always be evacuated. You should remember, however, that the constitution, previously but little if at all affected by the local disease, may soon become, so, from the admission of atmos- phere into the cavity of one of the larger joints. If it should be- come expedient to puncture such a joint, you should, therefore, be ready to support your patient, and to fortify his constitutional powers by the use of an invigorating diet, and the judicious ad- ministration of tonics, or even stimulants, according to the exi- gences of the case.* *The operation of excision of the diseased portions of bone in hip disease has been advocated, of late years, with considerable zeal by some, and with equal caution by others. Erichsen limits the operation to those cases in which the head of the bone is removed from its socket, and is carious and irritating- to the parts in which it lodges, or to the general system, through the constant discharge from the absceses and sinuses which it gives rise to. Skey says: "This opera- tion is rarely justifiable, or, when performed, answers any good purpose. In strumous disease of the joint, followed by spontaneous disarticulation, the disease appears to have reached its crisis, and the morbid actions subside. The operation of excision is only indicated in disease of long standing, in which the parts are much attenuated, and when abscesses form about the joint or around the head of the bone. Under these circumstances the removal of the head may be occasionally justifiable." An indiscriminate condemnation of this operation is certainly incorrect, Recent statistics seem to show that it is by no means so fatal when resorted to in appropriate cases, as it was formerly thought to be. It is even questionable whether some cases would have survived, if it had not been resorted to. The subject is well discussed by a recent writer, Dr. R. A. Kinloch, in the Charleston Medical Journal and Review for May, 1S57. Dr. K. has here published a table of forty cases. Sixteen of these are reported as having recovered, with various degrees of usefulness in the limb; eight are re- ported as in a favorable condition; thirteen died before recovering from the opera- tion—three of these, however, dying from the supervention of other diseases, in one case eight years after the operation—two are represented to be in an unfavor- able condition; and the result in one case is unmentioned by the original reporter. In the words of the writer, this record "proves the mortality to be much less than can be shown for amputation at the joint; and so far as it pronounces upon the utility of the limb after excision, the verdict is satisfactory." We should say then, in conclusion, that the operation maybe performed for the removal of the diseased head, and as much of the acetabulum as may be diseased and removable, whenever we apprehend that the affection has progressed to such a decree that a spontaneous cure is to be despaired of; or whenever the head of the bone is removed from the socket, and is still in a carious condition, and so irritating to the parts around as to react upon the constitution; provided always, that the patient still possesses so much strength as to afford us a reasonable prob- ability (we can never be certain) of his ability to stand the shock. In such circum- stances we conceive that the operation affords, the best chance for recovery ; and the surgeon is bound to give his patient the benefit of that which his judgment 228 TREATMENT OF HIP DISEASE. I will not, however, dwell longer on this point, but pass on in the consideration of our subject. I have already stated, that, owing to diseases of the joints, a certain condition may obtain which is accompanied by a loss of motion in the part, and which is called anchylosis. This is divided into true and false anchylosis. False anchylosis is restricted by some to mean that impairment, or destruction of motion caused by disease of the tissues extraneous to the articulation. By others, it is made to include all cases in which but slight motion is per- mitted; true anchylosis being by these latter considered as that condition in which all motion is destroyed. I would prefer re- suggests as most likely to afford a favorable result, even though in doing so his reputation may run some risk. In all cases in which the operation should be per- formed, it will be found that the ligaments of the joint are more or less diseased, or absorbed. But little difficulty will, therefore, be experienced in dislodging the head, and protruding it sufficiently into the incision to admit of its removal by means of the chain saw. Some surgeons advise an angular incision, some a T shaped, and some a semilunar one. By the first plan, an incision maybe "made longitudinally to the extent of about three inches over the trochanter major, and a second incision carried backwards, of sufficient length to expose the neck up to the head. For this purpose the leg must be carried over the opposite limb with some force, in order to facilitate the exposure of the head of the bone, and to bring it within the grasp of the operator. The ligamentum teres being absorbed, the head may be drawn from the acetab- ulum, if yet retained within it, and the neck divided with a fine saw." This is the description given by Skey, in his "Operative Surgery," American edition, page 374-i. Prof. Erichsen adopts the T shaped incision, and we will quote his de- scription of the operation as performed by this plan. ''The operation itself is not difficult of performance; the carious head of the femur, lying at the bottom of an abscess or of sinuses, may readily be exposed by a T shaped incision over it. When it is exposed it may be turned out by drawing the limb over the opposite thigh, and rotating it outwards, when it may be cut off through the neck or tro- chanter by means of an ordinary saw. In planniug the incision, care must of course be taken not to cut too far forwards, lest the anterior crural nerve be wounded, or too freely backwards, lest a gluteral artery be injured. After the op- eration, the wound must be dressed in a simple manner, and a long splint applied. Mr. Fergusson recommends that the extension by means of the perineal band should be made from the opposite thigh, round the upper part of which a laced stocking is fixed, to which the band is attached. In such cases as these, much advantage, I should imagine, would be derived by the use of the bracket thigh- splint," &c. Sedillot's operation is performed by means of a semilunar incision, commencing a little in front of the trochanter, carried upwards and backwards, and then back- wards and downwards, so as to expose the joint. A strip is then run beneath the neck of the femur, and the chain saw is passed along this, and the bone divided. In all of these plans of procedure, the patient is to be turned over on the sound side, and supported there.—Ed. TREATMENT OF ANCHYLOSIS. 229 striding the term true anchylosis, to that condition of parts in which solid and immovable union has taken place between the articulat- ing surfaces by the deposition of osseous matter. The results of anchylosis will differ, in accordance with the joint affected ; and the amount of inconvenience to the patient will vary, therefore, according to the seat of the disease. When the loss of motion is a matter of great inconvenience to the patient, it becomes an in- quiry of importance, whether surgical science can do any thing to relieve this condition of the part. Now, in cases of recent origin, and in those cases in which the union is of a soft or incomplete character, simple motion of the joint, often repeated, and the adop- tion of an antiphlogistic treatment, will often succeed in restoring the parts to their natural state of mobility. When the adhesion is still more firm, but yet soft, it may be necessary to resort to an operation of more importance. And here modern surgery has achieved a great triumph. In many cases, which, for a long time, were considered beyond the reach of art, the experience of later years has shown, that we may tear up the bonds of union with im- punity, and succeed in improving the motion of the joint, and even, sometimes, in entirely relieving the condition of the patient. It was formerly considered dangerous to disturb the joint, but in modern times it has been demonstrated that we may, without risk, tear adhesions apart, and place the limb in any desirable position. Louvier accomplishes this by means of a screw apparatus. It is not necessary for me to describe this apparatus particularly to you. You can best understand its mode of operation by inspecting it yourself. In operating with it, there is violent pressure exerted on several parts of the limb, at the straps, and at the pad. So much is this the case, that the skin is often violently contused, and sometimes even excoriation and ulceration may result. This apparatus I consider as generally unnecessary, though in some cases it may be employed with advantage. As a general rule, instead of adopting this method of Louvier, 1 would advise that you should merely employ your own muscular power. Let us suppose a case of soft anchylosis at the knee joint, in which the leg is too much flexed on the thigh. At first you might suppose, that I would directly extend the limb. I would adopt exactly the opposite course. Seize the thigh and the ankle, and wrench the latter gradually back. The leg will thus be car- ried still more into flexion. This will break up the adhesions. The limb should then be extended as far as is desirable, and 230 TREATMENT OF ANCHYLOSIS. placed in an immovable apparatus; and the antiphlogistic treat- ment must be enforced. In difficult cases of angular anchylosis, for example at the knee joint, it may be necssary, before proceed- ing to break up the adhesions, to divide the tendons of the flexor muscle, and also that of the rectus funoris, by tenotony. Chloro- form should be freely used, to prevent pain, and secure relaxation. This operation should never be attempted, when there is much inflammation, or after suppuration, tuberculosis, or caries of the bone. I would not trespass so much upon your time, gentlemen, but there is still one point to which I would call your attention—the treatment of solid anchylosis. When this has taken place, with the limb in an inconvenient position, modern surgery has suc- ceeded so far as to restore the limb to a more comfortable state; and, in some instances, even the motion of the part has been re- gained. Barton and Rogers, two American surgeons, have at- tempted to produce artificial joints in these cases. The operation of Barton was simply, in anchylosis of the femur to the innomina- tum, for example to cut down to the bone—below the trochanter major, saw through it, bring the limb straight, and prevent union by occasional motion of the part. The operation of Rogers was of a similar kind. If the anchylosis takes place in an inconvenient position, we can, at any rate, restore the limb to a more comfortable one. Let us take, for example, a case of the disease at the knee, in which the leg is too much flexed. Here it is not necessary to make an arti- ficial joint, as the patient will be able to walk very well without it, if the leg were only bent at a right angle. In such a case, we may saw out a wedge-shaped piece of bone from the anterior por- tion of the femur: so that, when the posterior part is fractured, the opposing surfaces may come into contact, and the leg be nearly straight. It should afterwards be treated as a case of fracture, retaining, throughout the treatment, the slightly flexed position of the leg. Upon the same principles, we may treat anchylosis at any of the other joints, choosing the most convenient position for each limb. This is an important advantage gained by modern surgery; for which it, and humanity in general, are greatly in- debted to Dr. Rhea Barton, who first performed the operation on a native of this city, a professional brother, who I believe still walks with a considerable degree of facility. OSTEITIS. 231 LECTURE XXXI. PATHOLOGY OF OSSEOUS STRUCTURES--INFLAMMATION OF BONE, OR OSTEITIS, ACUTE AND CHRONIC, COMMON AND SPECIFIC, ETC.-- RESULTS OF OSTEITIS--OSTEO-SPONGIOSIS--OSTEO-SCLEROSIS --EX- OSTOSIS--OSTEO-PHYTA--ATROPHY OF BONE--OSTEO-PYOSIS-- MEDULLARY ABSCESS--CARIES, OR OSTEO-ELKOSIS--NECROSIS-- TUMORS FROM BONE. I propose this morning, gentlemen, to pass in brief review the various pathological conditions of bone, involving changes of struc- ture. When we contemplate this part of the organization in its dry state, we are apt to infer that its vital endowments are of such a character as to exempt it, in a great degree, if not entirely, from the pathological conditions of the other structures of the human body. Such an inference is by no means in accordance with the truth. There are few structures in which pathological changes are of more frequent occurrence. Its diseases are precisely the same as those of the soft parts; as I will endeavor, in the course of my remarks, to point out to you. In the discussion of this subject we find it convenient to adopt the same course as in our consideration of the diseases of the soft parts; commencing with inflammation, and tracing it to its various results and terminations. Osteitis, like inflammatory action in general, may be divided into Acute and Chronic, Common and Specific, &c, as in our gen- eral discussion of the subject of inflammation. The inflammation may arise in the osseous structure itself, or in the fibrous perios- teum ; and it may extend from the one to the other. In consider- ing our subject, let us investigate, in order, the phenomena it pre- sents, its symptoms, and the consequences that follow, or its results. Whenever a bone is exposed to the circumstances which cause inflammation in other parts, we find an increased flow of blood, a retardation of the flow, an increased accumulation of blood in the part, a heightened degree of vascularity, &c, as in inflammation elsewhere, acompanied, also, by an exudation of the same charac- ter as that poured out in any other inflamed part. But here there is one collateral element in the consideration, which it is important to bear in mind. We find, that as soon as active inflammation is set up in a bone, and exudation, with changes in the blood begins, the calcareous portion of the bone is gradually 232 EXOSTOSIS. absorbed, so that, in some cases, there is a notable softening of the bone. These are some of the local derangements in the vital processes, when inflammation is kindled in any portion of the osseous tissue. I have already stated, that at some period of the morbid train of actions, as in the soft parts, an exudation takes place. This con- sists of the same material as that extravasated in inflammation elsewhere. At first, it is serous; then, as the inflammation pro- gresses, plasma is thrown out, and this undergoes various changes, and gives rise to a variety of results. Under the most simple conditions, we find that this plastic material produces organic cells; which, grouping together, give rise, in turn, to organized struc- tures, either on the surface of the bone, or within its areolae. Once the process has reached this point, we find that this new material, as yet soft and pliable, becomes the seat of a new deposit, of an earthy character; which, if the whole be not absorbed, will give rise to a great variety of modifications in the shape, consistency, volume, and weight of the bone. If the whole is removed by ab- sorption, the inflammatory action has terminated by "resolution." If it is not absorbed, we find that the bone, under the operation of this law of organization, may, in the first place, be considerably increased as to volume, either with or without a change in its con- sistency. Where no expansion takes place, its consistency will be increased; and the bone will be more solid and compact. Where the opposite condition obtains, it will become more spongy and porous. Thus, you perceive, there may be several pathological conditions. First, there may be an augmentation of size, ivith an increase of consistency; and this condition will necessarily be ac- companied by an increase of weight. To this condition we may apply the term osteosclerosis. Again, while the volume is aug- mented, the consistence may be diminished; and the bone, though larger, may be no heavier. It is, as it were, expanded, like a sponge. Hence this condition is called osteo-spongiosis. The bone is traversed by pores. It is a pathological condition of great impor- tance. These are changes produced merely by a modification of the nutritive functions of the part; but it sometimes happens that the inflammation, instead of acting in this manner, is confined within smaller limits; and then it gives rise to bony tumors, which will be very variable, as to size, configuration, consistence, &c; but which have this in common—that they all arise from a process of inflam- OSTEO-PYOSIS. 233 mation, however obscure the evidences of that inflammation may have been. Now, when we have such a tumor arising from a bone, we apply to it the term exostosis—bone growing out of bone. These bony tumors differ, as I have stated, not only in size and form, but also in texture. Sometimes they are of the nature of the bone from which they spring; sometimes they are softer; and sometimes they are more compact. I have seen such tumors so compact and hard, as to resemble ivory; though by the aid of the microscope, the bony structure could still be observed. These tu- mors may, again, assume another modification. They may resemble very much lifeless projections standing up from the surface of the bone,which is, as it were, studded with vegetable growths; and hence this condition of the surface may be called osteo-phyta. The size of the bone is considerably increased, and the soft parts are some- times so much irritated, as even to lead to a necessity for amputa- tion. Sometimes the disease may consist of a number of minute spines. Such a condition may frequently be detected at the base of obstinate skin ulcers. In these cases, the periosteum is also affected. But inflammatory action may occasion effects diametrically op- posite to these that we have been thus far considering. It may give rise to a diminution of size; or, if the volume be unchanged, it may, at any rate, produce a diminution of consistency—a loss in the substance of the bone—without a loss of volume, from absorp- tion of its earthy matter. This is atrophy of bone, and is precisely analogous to the same condition in the soft parts. You have an excellent specimen of atrophy of bone in this tibia I hold in my hand, which you will find to be so light, that it will float, like cork, upon the water. This deprivation of the bone in its earthy components, if not the result of inflammation, may be caused by some disturbance in the functions of nutrition, which causes the absorbents to act with peculiar energy upon its calcareous portion. Pus globules may also be formed as the result of inflammation of this structure. Blood may become exuded, and undergo those changes which result in suppuration, which is obedient to the same laws as elsewhere. At first, the corpuscles may be merely infil- trated through the meshes of the tissue; but as they increase in number, they accumulate, and become circumscribed; force aside the softened bony texture; and present all the characters of an abscess. This constitutes osteo-pyosis, or circumscribed abscess in the substance of the bone itself. Here, there is one point which 234 EXFOLIATION OF BONE. I must bring to your mind in this connection. When we saw open any one of the long bones, we find in its centre, a space, hollow, as regards the dried specimen, but which, in the living state of the bone, is occupied by a peculiar substance, the medullary matter. This "medullary canal" is lined by a medullary membrane, which also divides the space into a number of minute cells, filled with adipose matter. Now, my reason for calling your attention to this medullary canal, and its contents, is, that pus may first form in these medullary cells, instead of in the tissue of the bone itself. This canal may be the first point of the disease; which may be prevented from extending, as in other parts, by plastic exudation around it: and thus may be formed a medullary abscess. Suppuration, then, and its termination in an abscess, is one of the results of inflammation in the osseous tissue. Wherever this abscess is formed, it is surrounded by such circumstances, that it is interesting to trace the processes by which nature relieves her- self of the accumulation. This process, again, is precisely similar to what occurs under like circumstances in the soft parts. Absorp- tion (first of the earthy matter, and then of the soft portion of the bone,) removes gradually the structures interposed between the abscess and the surface ; and thus, the cavity may be emptied by the unassisted powers of nature. We have before us many inter- esting specimens illustrating this principle, in which even medul- lary abscesses have discharged themselves, through small, round openings, made by absorption. In all of these cases the matter may be discharged, as in the soft parts, by the conservative powers of nature. But this is not all. We have, in the next place, to call your attention to a state precisely similar to ulceration of the soft parts, and known as caries, or osteo-elkosis. Now, you may remem- ber that we stated to you, that we attributed ulceration, in the soft parts, to a species of mollecular death. This is precisely what takes place in caries of bone. It dies by particles : some of which are thrown off by way of the discharges, and some are taken up by absorption, and carried out of the system in the various secretions. Sometimes the bone, by this means, is completely riddled, and made much lighter than natural. Often small fragments or scales will become detached, and fall off. This is termed exfoliation of bone, differing from ulceration only in the fact, that the death takes place in small masses, instead of particles ; though, indeed, this difference is more apparent than real, for if you examine ulcera- tion in the soft parts, especially in what are called sloughing ulcers, OSTEO-CHONDROSIS. 235 you will find that at times small masses become detached, and slough off. This is precisely what take place in exfoliation; small portions at a time become deprived of their life, and are detached. This condition of bone may result from a variety of causes. The scrofulous cachexy, and many of the other diathesis, may be its origin. But of all the causes which tend to its production, there is none of so wide spread an influence, as the combined force of the syphilitic virus, and the mercurial action. Mercury, it is well known, may be absorbed into the system, and may accumulate, to a con- siderable extent, in the osseous tissue. Globules of it have been shaken from specimens of deceased bone. Again; tracing this pathological process, we find that the diseased action may take another turn, and, instead of a mo- lecular death, extensive portions may lose their vitality at once; and we have "necrosis;" this being a death of a more or less extensive portion of bone at a time. This is the. exact coun- terpart of gangrene, or mortification in the soft parts. Now, this "necrosis" will give rise to very different results, accord- ing to the part affected, and the extent of the disease. When near the surface, and not very extensive, it becomes detached, and is cast off, as a slough is in the soft parts. But when it is deeply seated, and more extensive, and it not only becomes de- tached, by its absorption, from the adjacent parts, but other changes of great importance take place in these parts. While the dead portion is being separated, plasma is thrown out around it; which becomes organized, and transformed into bone, thus forming a kind of casement surrounding it. To this, pathologists have applied the name of "involucrum." The interior, enclosed dead bone, they call the "sequestrum." The involucrum is some- times perforated by outlets, which are called " cloatree." These are accompanied by corresponding openings in the soft parts, through which the matter escapes. Besides these results of the inflammation of bone, we have a variety of other consequences, corresponding to the homoioclyte and heteroclyte productions in the soft parts. Sometimes a fibrous tumor may result, and sometimes one that bears a resemblance to cartilage; when the affection is called osteo-chondrosis. This may be of such a size, and so situated, as materially to disturb the neighboring parts, or prevent the motion of a joint, some- times even rendering the removal of parts necessary. It some- times occurs in the internal portion of the bone. Those tu- 236 ANIMALCULAR COLLECTIONS IN BONE. mors of a fibrous character may also form in the interior of the bone; and sometimes one may be found perforating the osse- ous substance in canals. When abnormal deposits of this charac- ter are diffused through the bony texture, pathologists have long been in the habit of applying to the parts thus affected, the epithet of " osteosarcoma," bony flesh. I should state to you, that this term is a very inaccurate one, as it is applied to various different con- ditions. Were it applied only to those cases, in which the cells of the bone are filled with an organized fibrous structure, it would be definite enough ; but often the new matter bears no resemblance whatever to flesh, and sometimes it consists of living animals. It is sometimes of an encephaloid, or medullary character; and, unfor- tunately, a malignant deposit often takes place, which has no pro- totype in the organization, and which possesses this peculiarity, that, though it may remain a long time dormant, it springs, under certain circumstances, into vigorous action, and progresses with a fearful rapidity, which soon leads to fatal results. This is cancer, medullary, encephaloid, orotherwise. I repeat, then, that this term, osteosarcoma, is a very loose and inaccurate one. The animalcular collections, sometimes found in bone, are hydatids, being composed of simple cysts. In some cases, a projecting point may be discovered, forming a kind of head; while in other cases, they consist simply of a membranous cyst, filled with a watery fluid. In both instances, they possess the power of multiplying themselves; and by this means, they encroach upon the surrounding bony structure. Such, gentlemen, are, in a general point of view, the pathologi- cal conditions to which the osseous system is liable; and if you have followed me in this imperfect sketch of the diseases of the bony tissue, you will see, that from the first, I have been explain- ing a series of changes precisely similar to those taking place in the other structures of the body. Commencing with inflammation, we have followed it, step by step, in its various mortifications, to its various consequences and results, to ulceration, mortification or necrosis, abnormal productions, &c. I have considered the subject more in an anatomico-pathological point of view, and before we can understand its surgical bearing, we must comprehend its patholog- ical relations with other parts. To this point, we will call your attention at our next meeting. PERIOSTITIS. 237 LECTURE XXXII. PERIOSTITIS--ITS VARIETIES--NODES, ETC.--RESULTS OF PERIOSTITIS-- TREATMENT--OF OSTEITIS, PERIOSTITIS, NECROSIS, ETC. I incidentally mentioned yesterday, that when inflammatory ac- tion seized either upon the bone or its investing membrane,\it was very seldom confined to the tissue in which it originated. In the general tenor of my remarks, however, I confined myself almost exclusively to the pathological changes of the bone proper, and, before I go on to speak of the treatment of the disease, 1 deem it expedient to make a few remarks on inflammation of the periosteum, or periostitis. We divide periostitis into several varieties. When arising from causes common also to inflammation elsewhere, as from a blow, a burn, &c, we have simple periostitis. It is liable to be produced by any cause from which inflammation in any other tissue may arise. But when we examine the subject in all its connections, we find—and it is a somewhat peculiar fact—that of all the tissuesof the body, the periosteum is most liable to take on that species of inflammatory action which is the result of certain special causes, traceable to some peculiar diathesis or disease. It becomes highly important, then, that the surgeon should understand the nature of these causes, and the probable results to which they lead. Hence, too, we may have several other varieties of periostitis. One of the most prominent is the rheumatic periostitis, for rheumatism is often at the bottom of periosteal inflammation ; which fact, if it be not understood, will very much embarrass the practitioner in car- rying out any plan of treatment. You will frequently find that periostitis will be a concomitant of the rheumatic attack. But this is not all. If you examine a number of cases of the gouty diathesis, you will find that gout, like rheumatism, is very apt to give rise to periostitis, as also to inflammation of the other fibrous textures. And again, in considering these diathesis, relatively to the development of periostitis and inflammation of the bone proper, we find one of very wide spread influence in the scrofulous habit. Cases of scrofulous deposit in bone, (such as have been already spoken of, in discussing the diseases of the joints) are very apt to be accompanied by inflammation of the periosteum. 238 PERIOSTITIS. But, passing from that arising from peculiar diathesis, let us next turn our attention to the inflammation resulting from particu- lar causes, as the introduction into the system, for example, of the venereal poison. Universal experience proves, that if the vene- real virus is not eradicated, and its action on the system checked, after a certain time the morbid train of action produced by this poison, has a notable tendency to seize upon the periosteum, and also the bone itself. Thickening of the membrane will be the first evidence of its becoming affected, and these conditions are termed " syphilitic nodes." This species of inflammation exer- cises so wide spread an influence, that we find that no part of the fibrous system is capable of escaping. In process of time, if the train of action is not checked, it may completely riddle the bone, and entirely destroy the periosteum. Other similar causes might be stated. But not to dwell here, let us go on to consider the pathalogico anatomical results of inflammation of these parts. In the first place we have determination of blood to the part, followed, as in the soft parts, by an exudation of precisely the same character. Coincident with these processes, if we examine the periosteum itself, we find that great changes are taking place in it. In a case of highly acute periostitis, this membrane becomes so soft, as to be easily torn and broken. As the disease progresses, this exuded material, lying partly within the texture of the membrane itself, partly on its surface and partly in the line of union between it and the bone, is converted into an organized substance, and once it becomes such, it may go on through a variety of changes. It may become con- verted into a kind of cartilage, similar to adventitious cartilage in other parts of the body; or it may become the nidus for a deposit of phosphate of lime, and an osseous structure may thus be super- added to the bone. A specimen illustrating this result, I here present. Under the peculiar power which modifies morbid growths, the exuded plasma has assumed the form of an osseus deposit on the surface of the bone. All the specimens which I here present, have been the result of periostitis. Again : precisely as happens in other structures, the inflamma- tion may assume another form. Purulent matter may be produced and it may collect together, presenting precisely the same appear- ance as abscesses in other parts. Sometimes it may accumulate on the surface of the membrane, and sometimes between it and the bone, giving rise to an abscess in that situation. Under a different modification of action this periostitis may TREATMENT OF PERIOSTITIS. 239 again, result in death of the periosteum—may cause xdceration of it—or it may give rise to the death of the periosteum and bone to- gether. These parts are also liable to the various heteroclyte, and, in short, to all those malignant deposits which affect other struc- tures of the body. When you bear in mind the great variety in the local changes incident to these affections, you will not be surprised to learn that the external indications of periostitis are very various in their character. I shall not dwell upon them, as it would be an unne- cessary waste of time. When the inflammation is first coming on, the changes are slow and the symptoms very obscure; but when it has arrived at a certain point, the patient begins to suffer a dull, constant pain, of a character resembling that of rheumatism, and this may go on for some time without the constitution be- coming affected. Soon, however, a symptomatic fever will arise, and the patient's sufferings will go on from day to day, with little if any intermission, inflicting perpetual torment, until either he is relieved spontaneously or by art, or the disease goes on to the exhaustion of mind and body, and the powers of life can resist it no longer. And so in the chronic form of the disease, these symptoms go on slowly until the patient is borne down by fatigue and distress. In cases of acute periostitis and osteitis, we judge of the nature of the affection by a process of reasoning by exclusion. For ex- ample, if the tibia is attacked, and the skin is bound immovably to the bone, we can say, by exclusion, that inflammation of the periosteum and bone is present. When we have a constant ach- ing pain, and hectic symptoms, we have reason to say that pus has formed in the medullary canal; and when this is the case, the disease will progress until an opening having been formed, we find either an abscess merely, or an abscess associated with necrosis. Again: when ulceration has taken place, as there are dead parts within, and it is necessary for these dead parts to escape we make a puncture, and find caries or ulceration of the bone. Thus you see that the subject is an extensive one, and it is impossible, in the short time to which I am limited, for me to o/ive minutely all of the symptoms peculiar to each condition. W7e now pass, by a natural transition, to the treatment of these affections en masse. And first, as to simple periostitis resulting from common causes. I may dismiss this part of my subject by saying, that this, as inflammation elsewhere, is to be treated by 240 TREATMENT OF PERIOSTITIS. carrying out the antiphlogistic plan, with a due regard to the intensity and extent of the inflammatory action. But, as I men- tioned before, there is in very many cases a particular diathesis, or diseased condition of the system at large, which has produced, and may keep up, the local disease. In such cases, I need not say it becomes necessary to modify our plan of treatment, in accord- ance with that condition of the constitution. The peculiar dia- thesis must always be borne in mind, and your treatment is mainly to be directed towards Us cure, or its alleviation if it is incurable. The peculiar treatment of each diathesis would be too extensive a subject to occupy our attention at this time; but I would, in general terms, exemplify my remarks by supposing a case of the inflammation arising from rheumatism. Your patient spends sleepless nights from the violence of the pain; his constitution is vigorous; and you have seen him at the earlier stage of the attack. In addition to the other depletive measures, I would recommend under these circumstances, in the first place, that you should tie up his arm and bleed him; and, if necessary, repeat the venesection again and again. If, however, he is weak, his constitution bad, or some other circumstance obtains, by which you deem it best to avoid general blood-Jetting, you should apply cups, or leeches, or both, and encourage their bleeding with warm fomentations. But, under these circumstances, the constitutional treatment is by far the most important. Here there is one circumstance to be borne in mind. Though there is a considerable resemblance between rheumatism and gout, there is still this essential difference : that, when the rheumatic diathesis exists, it is essentially a blood dis- ease. This being the case, it is important, that in all our applica- tions of remedies, this blood disease should be remembered. Let us see, then, what should be done. On examining the urine, we find such a deposit as shows the blood to be in a deranged condi- tion ; and, starting from this point, let us see if we have any agents capable of eliminating these poisonous elements from the constitution; which give a peculiarity to the disease, and change the character of the fluids. Have we any agents by which we can restore the blood to its natural state ? Fortunately for humanity, we have many such. At their head, I would place the iodide of potassium. It must be given freely. Five grains may be admin- istered, three times a day; and if it is borne well, the dose may gradually be increased, always, however, being careful to watch its effect. The modus operandi of this agent, it is difficult to ex- TREATMENT OF CARIES. 241 plain ; but be this as it may, you will find that in acute or chronic periostitis, or ostitis, from rheumatism, as soon as the patient feels its effects, a very great amelioration in the symptoms will follow. Another agent is the nitrate of potash, or common saltpetre; which, if given in large doses, will be found, like the iodide of potassium, very efficacious in the rheumatic diathesis. To be at all useful, it must be employed in large doses. At least half an ounce should be taken in the course of the day, bearing in mind, however, that it is liable to affect the stomaoh in such doses.' Again, we have the different preparations of colchicum. These may be given alone, or in combination; and should be adhered to for a long time, but with great caution, as they are powerful agents. Allied to colchicum, is aconite, a virulent poison; which though useful, must be employed with exceeding caution. It may be used internally, or externally. When applied externally, it is followed by a sensation of pricking, and often, after a time, by diminution of the pain. Another powerful agent is mercury, under different forms. It is very appropriate, but must be used cau- tiously and slowly, giving it in small doses. Calomel and blue pill, but more especially the iodide and the bichloride of mercury, or corro- sive sublimate, and the other preparations, in small doses, will, any of them, be found useful. Again, we have in the various narcotics another class of remedies applicable to, and, in fact, never to be omitted in these cases. At the very head of this class, I would place opium and its preparations. It is especially important to diminish that susceptibility of the constitution, which, if the dis- ease be not checked, will expose the patient to constant torture. Belladonna, hyosciamus, and various other narcotics, are also use- ful in producing this immunity from suffering. You may, also, in these cases, adopt some one of the various diet drinks; and some of the many compounds of sarsaparilla are also applicable here if you have any confidence in them. 1 have none. They are fit only to fill the pockets of the apothecaries, and to delude your patient. In caries of a bone, after we have opened the abscess, our main attention should be directed towards supporting the constitution of the patient. A generous diet should be allowed him, and even wine or brandy may be added to his bill of fare. Tonics also should be employed. Bark, the various vegetable bitters, iron &c, may all find a place in your treatment during some stage of the disease. Some of the older writers have regarded assafcetida 242 TREATMENT OF NECROSIS. as a specific in these cases. I have no confidence in it, and can- not see how it can act beneficially, except by its stimulant prop- erty. Nor have I any more confidence in the remedial powers of the phosphate of lime, in such cases. Nature is perfectly compe- tent to extract this substance from the materials in combination with which it is presented to her; and if it is stuffed in by medi- cation, she is unable to use it. But in necrosis, the surgeon has other duties to perform. After opening the abscess, it becomes a question how the sequestrum is to be removed; which, as you may remember, may be exceedingly various in extent. Now, where it is only on the surface of the bone, and there is no involucrum, all that it is requisite for us to do is, to remove the dead portion with a pair of forceps; but when it lies beneath an extensive involucrum, it becomes necessary to resort to other expedients. And here one circumstance presents itself, which is so admirably exemplified by this beautiful specimen in my hand, that I must call your attention to it. You will observe, on comparing this diseased femur with a sound one, that the axis of the limb to which the former belonged, must have been changed materially from its natural direction. You perceive that this has produced such a change in the relative situation of the sequestrum, that it is thrown out of the axis of the bone. Now, in conse- quence of this change in the axis of the sequestrum, and its oblique position, it often happens, that, on cutting down to the cloacae, you may seize the dead portion of the bone with the for- ceps, and succeed in drawing it out; and, indeed, it sometimes happens, that, owing to this same change, nature herself is ena- bled to effect the relief. Unfortunately, however, this result can- not always be attained, the sequestrum being sometimes held so firmly as to render it necessary to resort to the performance of an operation to remove it. The parts should first be attentively examined, before we proceed to lay the sequestrum open to view. We may find it loose and movable. In such a case, we should pass a pair of forceps through the opening, and strive to extract it by pulling it in different directions. If we fail in this, we must resort to other means. We may break it, by means of the bone shears, into fragments, and take it away piece-meal. But even this will not always succeed • and then it becomes necessary to make an incision down to the involucrum, as long as the diseased portion, dis- sect back the flaps, lay bare the involucrum, and open through TREATMENT OF BONE ABSCESSES. 243 it, either with a Hey's saw, a trephine, or a mallet and gouge, according to your convenience, and the position of the disease. Having cut through the involucrum, and removed the seques- trum, all you have to do, is to fill the cavity with lint, and let it heal by granulation from below. But I have still a word to say in this connection. I have re- marked that abscesses may be formed in the substance of the bone. In such a case, a cure cannot be effected until the matter has been drawn off. When, then, you discover the existence of a medullary abscess, you must cut down, as in necrosis; lay bare the bone, and open the wall of the abscess with a trephine, saw, or gouge. As this is generally accompanied by more or less of necrosis, which it may be impossible to extract by the opening you have made, I would ad- vise, as a more expeditious plan, and not a more painful one, that you should take a common carpenter's gouge, and chip away the bone over the abscess. This is the practice I pursue in cases of necrosis, osteo-pyosis, &c. When you use the saw, you will save time by first making two or three perforations, and then sawing into them with a Hey's saw. But a great deal of time, and conse- quently of suffering, may. be saved, by using, as I have stated, a mallet and gouge. You may perform the operation in one-tenth the time; and you also gain the advantage of having it in your power to remove easily any portions of the dead bone, which you may find at the bottom of the abscess. 244 CASES REQUIRING AMPUTATION. ESSAY No. 5* GENERALITIES OF AMPUTATION--CASES WHICH REQUIRE AMPUTA- TION--PERIOD MOST FAVORABLE FOR AMPUTATING--MOST ELIGIBLE POINT FOR AMPUTATING--COMPARATIVE ADVANTAGES OF AMPUTAT- ING THROUGH THE CONTINUITY AND IN THE CONTIGUITY OF THE BONES--APPARATUS AND INSTRUMENTS TO BE PROVIDED--MEANS OF COMMANDING THE HEMORRHAGE--DIFFERENT METHODS OF OPER- ATING--AFTER TREATMENT. Amputation may justly be considered one of the most desperate resources of the surgeon. In most other cases, the numerous means furnished by his art enable him to restore the suffering organs to health; but in the conditions requiring amputation, there is either such an injury of the living structures, or such an ag- gression committed upon the vital powers, as to render it indis- pensable to sacrifice the diseased member. It therefore becomes a matter of the utmost consequence to distinguish, as far as prac- ticable, those cases which call for this appalling and desperate resort. In the present state of our knowledge, all that we can do, in considering the cases which require amputation, will be to lay down certain general principles, to which many exceptions must of course arise, in particular cases, and under peculiar circum- stances. With regard to the precise cases which call for the sacrifice of a member, there has ever existed considerable difference of opin- ion; some restricting the operation to so small a circle of cases as almost to exclude it from the resources of4 the surgeon, while others, swayed by false judgment, or actuated by an overweening desire to enjoy the eclat of operating, have often resorted to it unnecessarily. The following may be considered as a fair expression of the indications which require amputation. When an individual is affected with a disease or injury of a member, which, in the pres- ent state of the science, is incurable, or which is rendered so, either by the fault of his constitution, or the circumstances in which he *This Essay is entirely composed of extracts from Frof. Geddings' article on amputation, in the American Cyclopaedia of Medicine and Surgery, which fact the reader is requested to bear in mind, especially when the personal pronouns are made use of. S. L. PERIOD MOST FAVORABLE FOR AMPUTATING. 245 is placed, and which at the same time endangers his safety, or will, by its nature, render him a cripple for life, the removal of the part, by an operation, will be called for. Such are, in general terms, the exigencies which justify a resort to the operation of amputation. We pass now to another point involved in the general consider- ation of our subject, viz : the period most favorable for amputating. There is no point in the discussion more important to determine, and few unfortunately have given origin to so much diversity of opinion. The importance of the question relates more especially to those cases in which the operation becomes necessary on ac- count of external violence, and those in which it is demanded for the removal of a limb affected with gangrene, though it is not un- important in cases of a chronic character. In the first set of cases it is called primitive amputation where the operation is performed on the spot, or within a short period after the receipt of the in- jury, and consecutive, where it is not practiced until after the ex- piration of several days, or subsequent to the subsidence, of the disturbance which follows the accident. These are the points upon which the discussion has mainly turned—one party advo- cating immediate amputation, while the other has as strenuously insisted upon the propriety of delaying it until the tumult of the system, aroused by the injury, has entirely subsided. If a candid appeal be made to the results of experience, espe- cially to that of the army and navy surgeons, whose opportunities of observation are the most extensive, and if all the facts are taken into consideration, the question so long agitated maybe considered as fairly settled in favor of primary amputation, and the practice recommended by Faure and LeConte, is proved not only to be erroneous, but fraught with dangerous consequences. The principal arguments which have been urged by those who condemn immediate amputation, have reference to the condition of the patient, and the chance that limbs may be sacrificed, which, by delaying the operation, might be preserved. It is well known to all surgeons who are conversant with the phenomena of gun-shot and other violent wounds, that these acci- dents frequently inflict an alarming shock upon the individual, and sometimes occasion a temporary prostration or a suspension of the vital powers. This state of the system has been very justly urcred by the advocates of consecutive amputation against the propriety of performing the operation immediately. But what 246 PERIOD MOST FAVORABLE FOR AMPUTATING. sensible surgeon would ever think of removing a limb in such a state of the system? There is always a period intervening be- tween the receipt of the injury and the development of the inflam- matory symptoms, at which the operation should be performed. Until the patient is aroused from the stupor occasioned by the shock, the operation will be hazardous, and it should always he a rule to delay, until the powers of animation are resuscitated, whether that event take place in one or twenty-four hours. When, however, circumstances render it impracticable to resort to primary amputation, and the inflammatory symptoms have already made their appearance, all our hopes of success must rest upon our ability to conduct the patient safely through the stage of excitement, fever, and suppuration, and bring him to the period recommended by Faure as the most favorable for the operation. Amputation must not be thought of while the whole system is in this tumultuous condition, except it should be demanded by the rapid progress of gangrene, in which case the removal of the limb ought not to be delayed. Here it would be dangerous to wait for the development of a well-defined limit between the dead and the living parts : death will ensue before such an occurrence can take place; and the concurrent experience of most modern surgeons of extensive observation, has confirmed the correctness of the prac- tice so ably inculcated by Larrey, of immediate amputation in cases of spreading traumatic gangrene. Should this necessity for amputation during the persistence of the inflammation not exist, the surgeon must content himself with such treatment as will be calculated to bring about a calm in the conflicting acts of the living organism; and when that is induced, which will generally be within a period varying from fifteen to twenty-five or thirty-days, the member may be removed with much greater probability of success than at any other moment, except that which has been designated as the most advantageous for pri- mary amputation. Here, however, much must depend upon the constitution of the individual, the condition of the limb, and the state of the internal organs. The patient is too frequently exhaus- ted by profuse suppuration and hectic, or becomes affected with a formidable lesion of some of the important viscera. But if the removal of the limb has been necessary from the commencement, and there is now no possibility of preserving it, amputation must be regarded as the "unicum remcdiirm," and should be practiced, although the chances of success be unpromising. There are, never- MOST ELIGIBLE POINT FOR AMPUTATION. 247 theless, some circumstances which will render the operation alto- gether hopeless. These consist, for the most part, in the existence of a dangerous or incurable disease in some part or organ essen- tial to life; and extreme debility may also constitute a counter- indication to the operation. Yet experience has demonstrated, that in many cases where the debility is considerable, the removal of the violent and exhausting irritation kept up by the diseased limb, is soon followed by a speedy restoration to health. Concerning the most eligible point for the performance of ampu- tation, there is far less difference of opinion at the present day, than in former times. Many of the ancients recommended the incision to be always made through the mortified parts, and though Celsus prescribed a different procedure, their advice was generally fol- lowed, until its impropriety was exposed by Wiseman. Since his time, it has been the established practice to cut through the living parts, either at, or a little above the line of demarcation by which they are separated from the dead. As regards the precise part of the member upon which the opera- tion should be performed, it must be determined by the necessities of the case. The operation may be performed either through the substance of the bone, or through the articulation—through the continuity, or through the contiguity of the bones. In fixing upon the point at which it should be executed, we have what is called the point of election, and that of necessity ; but in many'cases the first is entirely wanting, in consequence of the disease being so situated as to leave us no alternative but to amputate at a particular place. It may be laid down as a general rule, that the member should be removed at that point which will ensure the effectual extirpa- tion of the disease, and the preservation of the greatest possible quantity of the limb. In cases of gangrene, when the destructive process is still progressive, the incision should be made sufficiently remote from the seat of disease to insure its passage through parts which are healthy; and this precaution should also be ob- served where the member is affected with any specific form of dis- ease which would be liable to recur, as well as when the affection of the bone extends higher up than that of the soft parts. It has been recommended not to amputate in the vicinity of a large joint, and as a general rule, this precept should be observed. There are, nevertheless, cases in which it ought to be departed from. Should a disease or injury of the leg or arm, be situated so high up as to 248 AMPUTATION AT THE JOINTS. leave no alternative but to amputate, in the vicinity of the knee or elbow, or above these articulations, the former procedure must be adopted, inasmuch as those joints are so useful to the individual, that they ought not to be sacrificed, except from absolute necessity. It is also desirable to perform the operation upon that portion of the limb which is capable of affording the best flap or covering for the stump. To secure these advantages, however, too much must not be sacrificed. Amputations generally do well in the tendinous parts of the leg and arm, and as it is important to save as much of the member as possible, when the disease or the injury is situated low enough down to admit of the operation being performed at these points, this object can never constitute a sufficient reason for unne- cessarily sacrificing a member which may be useful to the indi- vidual. There is one point of practice to which I am anxious to advert. It has been the practice with many surgeons, when the humerus or femur has been shattered in the immediate vicinity of their artic- ulations, either by musket or cannon shot, and when the soft parts have been extensively contused or lacerated ; or when necrosis of these bones occupies the same situation, to resort to amputation at the shoulder or hip joint. This conduct is exceedingly improper. The operation may, in a majority of such cases, be successfully performed through the continuity of the bone, and the individual will thus be saved the pain and hazard of an amputation through the articulation. Since the time of Brasdor and Larrey. who revived in modern times the method of amputating, in certain cases, in the contiguity of the bones, repeated experience has shown that many of the fears which were formerly entertained relative to cutting into an articu- lation, were for the most part groundless, and if it is not safe to amputate through the large hinge joints, this operation can be more advantageously performed through some of smaller magni- tude, than at any other point. It will be generally observed, that the hazard attending amputa- tion at the articulations will be always in ratio with their extent, and the complicated character of their arrangement. The hip and shoulder joints, those of the phalanges of the fingers and toes, of the meta-tarsus and meta-carpus, wrist, &c, present a less extent of surface, and are more simple in their arrangement, than those of the knee and elbow. Hence it has been found by repeated obser- INSTRUMENTS NECESSARY IN AMPUTATION. 249 vation, that amputation may be safely performed at those joints, whereas, at the elbow and knee, especially at the latter, though sometimes successful, it is by far a more hazardous operation. There is, besides, another fact to be taken into account in deter- mining upon the comparative advantages of the two methods. The cartilages take on less readily the adhesive form of inflammation than the bones themselves, and when a large extent of such a sur- face is exposed, it sometimes happens, that, although the flaps unite as under ordinary circumstances, a cavity remains in rela- tion with the central part of the stump, in which tedious suppura- tions take place, and retard the cure. Influenced by these and other principles, surgeons of the present day seldom amputate at any but the smaller and more simple ar- ticulations, and more rarely at the ankle, knee, or elbow. The apparatus and instruments necessary in amputation vary according to the kind of operation adopted, and the point at which it is to performed. It will be proper, however, to enumerate all that will be requisite in the execution of the operation upon any part of the body. There should be two good tourniquets, or, in cases of emergency, where this instrument is not at hand, a strong bandage, or a hand- kerchief, may be tied around the member, and rendered sufficiently tight by inserting beneath it the end of a stick, the hilt of a sword, or any convenient thing which may be at hand, with two or three turns of which the band may be twisted until it is rendered tight enough to command the circulation. For the same purpose there should be provided a key or boot-hook, with the end wrapped with lint or old linen, for the purpose of compressing the artery. Knives of different configurations and dimensions are employed, according to the kind of operation that is to be performed. They should always be of a length proportionate to the volume of the member. Those for the hip joint should be about twelve inches long, and three fourths of an inch broad near the handle. For the shoulder, the instrument need not be more than eiffht inches in length. A catlin of smaller dimensions will be more convenient for the ampu- tation of the arm, fore-arm, elbow, wrist, carpus, tarsus, &c, the size being always regulated by the dimensions of the part. There should also be one or more large convex scalpels, sharp pointed bistouries, a retractor of soft leather or strong cloth, with two or three tails, according to circumstances; a good amputating saw with an extra blade, a meta-carpal saw, bone forceps, one or 250 MEANS OF COMMANDING THE HEMORRHAGE. two tenaculums, a pair of artery forceps with a slide or spring, and several curved needles armed with ligatures. In dressing the stump it will be necessary to have a sufficient supply of silk or animal ligatures, of different sizes, and properly waxed ; adhesive plaster spread and cut into strips; lint made into pledgets and spread with cerate; compresses; a roller bandage of coarse muslin three inches wide, and three or four yards in length; sponges, and warm and cold water; bottles filled with hot water, or a chafing dish with burning charcoal to warm the adhesive plasters; towels, &c, &c. I employ a saw about three inches longer than that in common use, the handle of which is so attached as to form an obtuse angle within the blade. In consequence of this arrangement much more force is thrown upon the teeth of the instrument at each propulsive effort, than when the handle is placed on the same line with the blade, and it cuts through the bone in nearly one half the time. The teeth should always be widely set, so as to form a furrow of sufficient dimensions to prevent the. pinching of the instrument, which is always embarrassing, and sometimes causes the bone to be splintered before it is divided. The best retractors are made of kid skin, or chamois leather, but when these are not at hand, coarse muslin will answer very well. For the thigh, a piece eight inches wide, and fourteen inches long, should be divided lengthwise, from one end to the middle, and the end of the slit should be rounded out so as to adapt it to the con- tour of the bone. For the leg or fore-arm, the retractor must be divided into three tails, one of which must be passed through the interosseous space. All these implements should be arranged upon a table or tray, in the order in which they will be required, and covered with a towel until the operation is commenced. The patient is generally placed on a table covered with a mattrass or several folded blankets, and with his head and should- ers elevated. When, however, the operation is to be performed at the shoulder joint, upon any part of the arm, the hand or foot, the sitting posture will either be necessary or may be adopted from choice. In the larger amputations, several assistants will be requisite. Each one has his particular duties to perform, and they should all be so disposed as not to embarrass each other or be in the way of the operator. DIFFERENT METHODS OF OPERATING. 251 The means of commanding the hemorrhage during the operation, demand the attention of a reliable assistant, whether the tourniquet or simple compression be employed. Although the tourniquet of Petit, improved and variously modified, is generally used by mod- ern surgeons, and is, under all the circumstances where it is ap- plicable, the safest means of commanding the hemorrhage, it can- not be applied in amputation at the hip and shoulder joints, or in the immediate vicinity of these articulations, and is liable to serious objections even under the circumstances to which it is applicable; as the pain it occasions; the impediment to the verous circulation which it produces, and which causes the blood to accumulate, and as soon as the first incision is made, a profuse gush of that fluid takes place—a circumstance often of great importance in debili- tated subjects—and the unequal contraction of the muscles which takes place when the instrument is removed, and renders the face of the stump irregular and uneven. These considerations have induced many distinguished surgeons to abandon the tourniquet, and rely upon the simple compression of the artery, either with the thumb or fingers of an assistant, or the extremity of a common key or boot-hook, wrapped with old linen or soft cloth. The tourniquet, however, is safer, and for that reason should be adopted where a reliable assistant is not at hand. When operating, it becomes an object to secure a sufficient flap of soft parts to cover the bone when the stump is dressed; and hence in speaking of amputations we divide them, in the first place, into those by the double and those by the single circular incisions. When we operate by the double circular incision, we cut first through the skin and sub-cutaneous cellular tissue by a circular incision; dissect back and turn over the soft parts, as we would the cuff of a sleeve; and then make the second incision to the bone. When we operate by a single circular incision, the difference is that the knife is carried by one incision as near as possible to the bone. Again, we have the double and the single flap operations. In forming these flaps we may either transfix the limb and cut out- wards or cut from the surface to the bone. A limb may be amputa- ted with facility by either of these methods. There is still a very great difference of opinion among surgeons as to their relative ad- vantages. Tt is but a matter of taste, however. So far as the safety of the patient is concerned there is no difference whatever. Each surgeon must select that plan which is to him the least diffi- 252 CIRCULAR OPERATION. cult, and which he can quickest perform. For my own part, I prefer the flap operation, as occupying less time, and being less painful and more easily performed. In amputating by the circular method, a great many different plans of conducting the various steps of the operation are pursued. But after all, these diversified modifications are of much less im- portance than might be inferred from the numerous disquisitions to which they have given origin. The following will perhaps be found the most convenient and expeditious method of securing all the objects proposed. The patient being conveniently placed and every thing properly disposed, the.operator, by a single circular sweep, carried steadily round the limb, divides the integuments fairly down to the mus- cles. The assistant still drawing these upwards, he next with a few strokes with the. point of his knife, or a common scalpel, di- vides the connecting bands of cellular tissue, until a sufficiency is saved to cover the face of the stump. The extent of this dissection should of course be regulated by the diameter of the limb. In the thigh three or four inches will be required, but in the leg,- arm, &c, a smaller quantity will suffice. The integuments need not be reversed, as is advised by some, for no advantage can accrue from thus contusing and injuring the soft parts. Inserting his knife a second time, on a line with the margin of the retracted parts, and with the edge directed obliquely upwards, the assistant still grasp- ing the member with both hands, and retracting the structures, he makes a second circular cut through the muscles down to the bone, or at least so deep as to allow the more superficial to be drawn upwards. A third cut is next made in the same manner, inserting the edge of the knife, held upon the base of the small cone formed by those muscles which are deepest seated, which is to be carried fairly down to the bone all around its circumference. Where the member contains two bones, the point of the knife should be made to glide in the interspace, while it is describing the circular evolution, as advised by Lisfranc; or if the operator is not expert, the structures which are situated between the bones may be divided with a common catlin, after the completion of the circular incision. The periosteum is next to be divided, in order that it may not become entangled in the teeth of the saw, and the retractor is to be applied. The operator then fixes the thumb-nail of his left hand upon the bone at the point at which it is to be di- vided, to guide the saw, the heel of which he fixes upon the bone, FLAP OPERATION. 253 and then making a slight pressure on the instrument, he draws it slowly and steadily towards him from heel to point, so as to form a superficial groove, the depth of which is increased by two or three light and steady alternate sweeps backwards and forwards. Hav- ing thus established a channel of sufficient depth to prevent the saw from slipping, he may conduct his strokes with greater rapid- ity and force, always making them long and free, and taking care, when the bone is nearly divided, to saw slower, so that it may not be splintered. The assistant, who supports the limb, should also be particular, during this step of the operation, not to allow any flexure which can pinch the saw, or fracture the bone. When there are two bones, the saw should be first made to play upon one of them until it forms for itself a groove, after which, by de- pressing or elevating the handle, it should be brought to bear upon both. The smaller of the two, however, must be cut through first. Should any spiculse remain after the section of the bone, they must be removed by the bone-nippers or a scalpel. But the flap operation, as already stated, is the one which we pre- fer. The operation may be performed with either a single or with two or more flaps. The cases to which the first method is applicable will be designated in connection with the particular operations. The latter plan is more extensively applicable, and is more gener- ally preferred. It has been differently executed, according to the object proposed, or the predilection of the surgeon. All flap opera- tions, however, are performed either by cutting from without inwards, or by plunging the knife through the thick part of the member, and bringing it out so as to form a flap of the proper dimensions. The first of these methods, though somewhat more tedious than the second, is preferred by many operators, because of the greater facility afforded by it in regulating the form and dimensions of the flap. The other procedure, however, is infinitely more prompt, and consequently less painful. The operation of cutting from without inwards may be performed so as either to make the flaps of the integuments alone, or of them and the muscles together. It is more frequently practiced, how- ever, without dissecting the integuments from the muscles, they beino- merely divided by the first incision and retracted; which done, a second incision is made upon a line with their margin, through the muscles, and down to the bone. This procedure should always be preferred when the parts are incised from with- out inwards, inasmuch as a better tegumentary covering will be 254 OBLIQUE OR OVAL METHOD. thus preserved, than when the skin, cellular tissue, and muscles, are all divided by a single sweep of the knife. The method of forming the flaps by extending an incision obliquely from the sur- face to the bone, is preferred by some. Chelius forms the first flap in this way, and then transfixing the member on the other side of the bone, by introducing the knife at the angle of the first inci- sion, he forms the second flap by cutting from within outwards; and Ravaton, LeDran, and B. Bell, divide the integuments and muscles by a circular incision, and then make a longitudinal cut upon the external and internal part of the member, the inferior extremities of which fall upon the circular incision. Nearly all others, who prefer the flap amputation, execute the operation by thrusting a long narrow catlin through the member, first on one, and then on the other side of the bone, and cutting from thence towards the circumference. After the flaps are formed and held back, the muscles which adhere to the bone are divided by a cir- cular incision. As a general rule, the length of each flap, where two are formed, should be a little more than one half the diameter of the mem- ber, and it is advised by most surgeons to make both as near as possible of the same shape and dimensions. We are inclined, both from reason and experience, to prefer the flap operation in a large majority of cases, and we are pleased to observe that the members of the profession are ever)- day becom- ing more sensible of its advantages. There are cases, however, in which the circular operation should be preferred, and as both methods will succeed very well, it should be left to the operator to select that which is best adapted to each individual case. Amputation by the oblique or oval method has been applied by Guthrie to the amputation at the shoulder joint, and by others to the removal of the bones of the carpus and tarsus, to which it is well adapted. The chief peculiarity of the method is, that the incision is made from without inwards, and is carried obliquely around the member so as to represent the letter V inverted, the acute angle being directed upwards, and the obtuse portion down- wards. It is sometimes performed by two cuts, one dividing the integuments completely round, and the other extending to the bone. Some operators, however, accomplish the division of the whole of the soft parts by the first cut. The former method should be preferred at the shoulder, or wherever the member is a large one. TREATMENT AFTER AMPUTATION. 255 Whichever method be adopted, the upper part of the incision should extend a little above the point at which the bone is to be sawed, and ought, as a general rule, to occupy the part of the member upon which the soft parts present the least thickness. After Treatment.—The first object that claims the attention of the surgeon, after the removal of the member, is the hemorrhage. The ligature is the most appropriate, and, indeed, the only means that can be securely relied on, for commanding the hemorrhage from large arteries. A single thread of fine silk should be used for the smaller arteries, but for the principal trunks, a ligature composed of two or more threads must be employed. One end should always be cut close to the knot, and when several ligatures are applied, the remaining ends should be brought out at the nearest angle of the wound; or if one or more of them be placed in the centre of the stump, they may be brought out at the nearest point between the adhesive strips. To draw out the extremity of the bleeding vessel some surgeons prefer the tenaculum of Bromfield, while others employ the artery forceps. We have generally found the former the most conve- nient instrument. The point ought to be very sharp, and well polished. The end of the vessel should be cautiously transfixed, without including any of the adjacent structures, and then slightly drawn out, so as to permit the assistant to fix the loop of the liga- ture upon it. When this is accomplished, the two ends are to be cautiously drawn, while with the point of the index finger, the slip of the loop is pressed down upon the vessel. It should always be secured by a double knot, and particular care be taken not to include the vein or the accompanying nerves. The principal artery being secured, those of smaller size are to be sought by gently sponging away the blood and slacking the tourniquet or diminishing the com- pression. Every vessel that bleeds must be secured, for although it is a bad practice to apply too many ligatures, it is still more so, to be obliged, after the stump has been dressed, to open it on account of secondary hemorrhage, or to expose the patient to the irritation and suppuration likely to arise from an accumulation and confine- ment of grumous blood. Sometimes considerable venous hemorrhage takes place, which is difficult to control. The tying of the vein with the artery has been adopted, but sometimes this produces an alarming phlebitis, and the plan should never be resorted to, except from urgent neces- sity. Very alarming effects have also resulted from including the nerve in the ligature, and in some cases it has given rise to tetanus. 256 ARRESTING THE HEMORRHAGE. WThen, as is sometimes the case, considerable hemorrhage takes place from the nutritious artery of the bone, it should be arrested by the introduction of a small plug of wax or soft wood, by a lint compress, or, what will generally be effectual, by twisting or lace- rating the mouth of the vessel with the point of the forceps. When merely a slight oozing continues after the arteries have been tied, the stump should be soaked with cold water. Astringents ought never to be employed under such circumstances. They irritate the wound, excite inflammation, and create an obstacle to immediate union. If a small vessel bleed, it should be secured, and time must be allowed for re-action : for it frequently happens that then many vessels bleed for the first time, and render it necessary to open the stump. To obviate this, some surgeons, as Parrish, Klein, Dupuy- tren, Lisfranc, and others, have proposed to leave the stump open for some time after the operation : a practice which we have seen adopted with advantage, not only as a precautionary means against hemorrhage, but likewise, as we are inclined to think, in facilita- ting union by the first intention. Other means of arresting hemorrhage have been proposed. One of these is torsion of the extremity of the vessel. This practice, since 1S2W, has been practiced to a considerable extent, and although it has been found successful, the result has proved that it possesses no advantages over the ligature, and that it is much less safe. It ought never to be confided in where the vessel is large, and should, if employed at all, be confined to vessels of small calibre. To accomplish the torsion, the divided end of the vessel is to be seized and drawn out with a pair of forceps, furnished with a slide or spring, taking care to have it separated from the other structures. A second pair of forceps is then to be fixed on the vessel in the bottom of the wound, so as to grasp it in a transverse direction, with which it is to be supported, while seven or eight turns are made upon its extremity with the first instrument; or the artery may be held between the nails of the index finger and thumb while torsion is made with the thumb. The latter method, recom- mended by Velpeau, is the simplest, and is equally effectual. Contusing or lacerating the cut end of the small vessels with the tenaculum or forceps, will often be found sufficient to stop them from discharging blood. But this procedure should never be relied on, except for such branches as are too small to require the liga- ture, and which merely give rise to a slight oozing. When the artery is so profoundly imbedded in the soft parts as to render it impossible to isolate it and draw it out sufficiently to TREATMENT AFTER AMPUTATION. 257 apply the ligature, a common curved needle armed with three, or four threads of silk should be introduced into the soft parts first on one, and then on the other side of the vessel, and the ligature drawn so as to include a portion of them, together with the artery. Should the artery be so ossified as to be incapable of sustaining the liga- ture applied in the usual manner, a cone of soft buckskin large enough to fill its cavity may be passed into its orifice, and there secured by a soft flat ligature of the same substance, tied around the vessel in the usual manner. The plan proposed by Velpeau, of reverting the extremity of the artery, and thrusting it into the soft parts, is unsafe, and as it secures no advantage, ought never to be employed, except for very small vessels. After all the vessels have been secured, and the oozing has ceased, the next thing to be done is to dress the stump. All coagula of blood should be carefully sponged away, and the parts wiped dry with a soft towel; and the surgeon should then assort the ligatures, and place them in the situation he wishes them to occupy, arranging those which are nearest the circumference so that they may be placed in the angles of the wound, and bringing out the others in the centre. If the surgeon desires to obtain union by the first intention, it is important that the corresponding surfaces of the flaps should now be brought in accurate contact, and that no foreign substance be interposed. If the silk ligatures be used, one end should be cut close to the knot, and if chamois leather or buckskin, nothing but the knot itself should be left. Coagula of blood must also be care- full^ removed; for if suffered to remain, they always excite much irritation, and not unfrequently give rise to suppuration. The edges of the skin, being neatly approximated in a line correspond- ing to the direction of the flaps, when the operation is performed in that manner, are to be confined with strips of adhesive plaster, which are to be brought over the end of the stump, and placed so as to leave sufficient space between each for the escape of the discharges. It was formerly the practice to use sutures for this purpose; and although they have been abandoned by most modern surgeons, there are still some who continue to employ them. They are never necessary, and they may do considerable mischief. After the adhesive strips have been applied, a piece of lint spread with simple cerate should be laid over the face of the stump. To Q 258 TREATMENT AFTER AMPUTATION. furnish additional support, a roller bandage must next be applied, by laying one end longitudinally upon the limb, and carrying the bandage, by reversing it in opposite directions over the face of the stump, so as to form a cross, and ascending with it by spiral turns some distance up the member. By some it is recommended to make the first turns upon the trunk, and thence carry the band- age downwards to the base of the stump, with the view of bring- ing the muscles more completely over the face of the bone. The wound must be kept cool, and should be as little encumbered as possible, and the more simple the dressings, provided they serve to keep the edges of the wound together, the better. The stump being dressed, the patient must be put to bed, and the member placed upon a pillow in such a manner that the parts remote from the wound shall bear the greater part of the pressure. A mattrass should be preferred to a feather bed, and when it is desirous to keep the stump wet, the pillow may be covered with soft oiled silk. When union by the second intention is desired, the best method will be that practiced by Dr. Physic, and recommended by Dor- sey, of merely interposing a pledget of lint between the edges of the wound, so as to prevent the skin from adhering, and then con- fining the parts in the manner directed above. Few questions relating to surgical practice have given rise to more discussion than that of the comparative advantage of imme- diate and consecutive union after amputation. From a faithful survey of the whole grounds, we would Jay it down as a rule, that immediate union should be attempted in all cases where the struc- tures are healthy. We are not sensible of any bad effects that can possibly result from it. We may sometimes fail in accom- plishing it; but even then we lose nothing by the attempt; for we shall have as many facilities for accomplishing union by the second intention, as we would if we had sought it from the first. Even when the parts are not entirely healthy, they ought to be placed as nearly as possible in apposition, taking care not to con- strict them with the strips and bandages; and if we should merely succeed in obtaining union to a limited extent, the advantage will be considerable, as the part to be healed by granulation will be thereby diminished. The second dressing should, under ordinary circumstances, be deferred to the fifth or sixth day. But in some instances, where con- ACCIDENTS AFTER AMPUTATION. 259 siderable oozing of blood takes place, it becomes confined within the bottom of the wound, and renders it necessary to remove the first dressing at an earlier period. As the first dressings are generally very firmly agglutinated with each other, great care must be taken in their removal, not to tear up any adhesions of the edges of the wound, and to avoid inflict- ing unnecessary pain. To facilitate their detachment, they should be carefully softened by throwing a gentle stream of tepid water upon them, until they will separate easily^ and while the surgeon removes them, an assistant should carefully support the stump, making a gentle pressure against its sides, to prevent the edges from separating. If the stump is large, it will be advisable to remove only one ad- hesive strip at a time, supplying its place with a new one, before the next is detached, thus obviating the necessity of suddenly de- priving the stump of all its support. After the stump has been cleansed with a soft sponge, and wiped dry with soft linen, the ad- hesive strips must be applied as before. Over them should be laid a pledget of lint spread with cerate, or spermacity ointment, and the whole confined by a roller, as in the first dressing. The subsequent dressings must be managed upon the same principles, and should be renewed as often as the circumstances of the case may require. The ligatures of the small arteries generally be- come loose about the fifth or sixth day, and those of the principal trunks about the tenth or twelfth. Sometimes, however, they are retained for several weeks, and keep up more or less suppuration in the vicinity. After sufficient time has elapsed for them to become detached, very gentle traction should be made at each dressing, taking care never to use sufficient violence to tear them away. Should they not become loose in the course of two or three weeks, they may be cut away by means of a small beaked knife, having a slight notch or groove upon the beak to direct it along the course of the thread. There are some accidents consecutive to amputation, which may require special treatment. Hemorrhage, at various periods and from various causes, may occur. Sometimes it occurs soon after the dressings are applied, either because too little time has been allowed for reaction, or from the slipping of a ligature or a division of the tunics of the vessel by the same, in consequence of their diseased condition ; and it sometimes also happens that a kind of vital erethism is excited in the stump, which disposes the capilla- 260 CONSECUTIVE HEMORRHAGE. ries to bleed to a considerable extent. The veins may also pour out blood, in consequence of the bandages being applied so tightly upon the limb as to interrupt the free return of the blood. From whichever of these causes the hemorrhage proceeds, we should never open the stump, except where the necessity is abso- lute. That operation is always productive of extreme pain, and is regarded by the patient with horror. In most cases where the bleeding is not profuse, it will merely be necessary to remove the roller and compresses, to slightly elevate the stump and expose it freely to the cool air, or to keep it wet with cold water, or covered with ice. If the hemorrhage is venous, the simple removal of the bandage will generally be sufficient. Should these means not prove efficient, pressure must be made upon the course of the principal artery, and when the hemorrhage is more profuse and cannot be commanded by any of these means, the stump must be opened. If the accident occur shortly after the operation, it will be easy to secure the bleeding vessel. But if this cannot be done it may sometimes be commanded by means of a piece of soft sponge or agaric, confined for some time upon the extremity of the artery. Hemorrhage sometimes takes place from the stump at a much later period, and proceeds from a very different cause. From a want of a proper degree of plastic power in its tunics, the vessels take on ulceration at the point at which they are included in the ligature, or they become affected by a kind of sloughing process, by which the ligature is thrown off before obliteration can be ac- complished. Consecutive hemorrhage from these causes seldom occurs before the tenth or twelfth day, and frequently after the third week. It is always a formidable accident, and difficult of management. The ligature to the orifice of the bleeding vessel is no longer practicable, except by including a portion of the soft parts. A piece of sponge or agaric may sometimes be advanta- geously bound upon the part, by means of a compress and roller, properly adjusted upon the limb ; and it will also be proper to apply compression upon the course of the artery. Should all these means fail, the only recourse left for the surgeon is, to cut down on and tie the main arterial trunk some distance above the stump, as in the treatment of aneurism. Even this, in some instances, has failed to arrest the flow of blood, this being kept up by the anastomosing vessels. There is another form of consecutive hemorrhage produced by CARIES AND NECROSIS OF THE END OF THE BONE. 261 the necrosis of the end of the bone. At each dressing there is an oozing of blood between the dead and the living parts, which can- not be arrested except by the resection of the dead parts. Phlebitis and purulent deposits in the various organs sometimes follow the operation of amputation, and these cases do not differ from those produced by other causes. The abscesses and sinuses which sometimes form in the stump are also similar to those which are ordinarily developed under other circumstances. Sometimes the edges of the flaps unite, while the bottom of the wound suppurates, and the matter accu- mulates so as to form an abscess. Caries or necrosis of the bone, the irritating influence of the ligatures, &c, also conspire to favor the development of these abscesses. Sometimes the matter travels along the limb in the interstices of the muscles, or in the course of the synovial sheaths, and thus occasions extensive burrowing si- nuses. The latter accident is more apt to occur after amputation at the wrist, or through the articulations of the tarsus, and in many instances it is necessary to make numerous incisions to give exit to the matter. This should always be done as soon as an abscess has formed in a stump, whether it be small or large, and if the pus has a free outlet, there need not be much apprehension entertained by its retarding the cure, unless there be some local cause to keep up the irritation. Caries and necrosis of the end of the bone after amputation may result from several causes. The injury inflicted upon the bone itself will sometimes so far impair its vital power as to render it incapable of sustaining the integrity of its structure. A laceration or detachment of the periosteum, an insufficient covering of soft parts, either from the first or after cicatrization in consequence of retraction of the integuments, and ulceration of the cicatrix from pressure against the end of the bone; an inflammation of the medullary membrane, and sometimes, after amputation of the leg below the knee, the weight of the soft parts of the calf of the leg dragging so forcibly upon the skin at the angle of the tibia as to cause it to slough, may all cause the bone to fall into the condi- tion of caries or necrosis. All these causes must be avoided as much as possible. The retraction of the integuments may be generally prevented by the application of a bandage, which should be so adjusted as to coun- teract the contraction of the muscle; and when the caries or ne- crosis does take place, the surgeon must secure a free exit for the 262 CONICAL STUMP. discharges, and pick away the pieces of detached bone. It will not be necessary to saw through the bone higher up, except where the protrusion is so considerable as to expose a great extent of its surface, and thus render it impracticable to cover it with the soft parts after the dead portion is detached. In some instances, how- ever, this painful operation will become necessary, and in execu- ting it, great care should be taken to detach the muscles from the bone to a sufficient extent to furnish an adequate covering for the latter. A conical stump was an accident of frequent occurrence irt the hands of the older surgeons; but the practice of healing the stump by the first intention has greatly diminished the number of such cases, and if proper precaution be observed in executing the operation, and conducting the subsequent dressings, it cannot take place except as a consequence of an extensive sloughing of the muscles and integu- ments. W7here the protrusion of bone is slight, it may be safely left to nature, the surgeon contenting himself with the removal of the carious or dead bone, as soon as it becomes detached ; but secondary amputation will in some cases be necessary here as in the previous case, and under the same conditions. This operation will also be necessary in some cases of extensive gangrene and sloughing of the soft parts, which occasionally take place after amputation, especially where the parts are not healthy or the patient is of feeble constitution, or has been addicted to habits of intemperance. Various other accidents sometimes supervene upon amputation, which, however, it will not be necessary to describe, as they must be treated upon general principles. AMPUTATION OF THE FINGERS. 263 LECTURE XXXIII. SPECIAL AMPUTATIONS--OF THE PHALANGES OF THE FINGERS--OF THE META-CARPAL BONE OF THE THUMB--OF THE WRIST--OF THE FORE-ARM--AT THE ELBOW--AMPUTATION OF THE ARM--AT THE SHOULDER JOINT--AMPUTATION AT THE META-TARSAL JOINTS. I propose on the present occasion, gentlemen, to commence the consideration of the special amputations, and to demonstrate the methods of performing the particular operations. We will com- mence with the Amputation of the Fingers, An operation apparently very simple ; and simple indeed, if you understand it, but not so simple if you do not. Suppose, for ex- ample, that you would remove the last phalanx of one of the fin- gers. This amputation should be performed by the single flap method. Seize the first phalanx between the finger and thumb; flex it; place the knife two lines in front of a line which you will perceive on the palmar surface, and carry the incision over the dorsum of the finger, convexing it slightly forwards, and forming your flap from the palmar surface. Unless you bear in mind the rule in reference to the position of the incision, you will fall on the bone instead of the joint, and be somewhat embarrassed in exe- cuting this apparently trifling operation. Where you wish to re- move two phalanges, the operation is equally simple, if performed properly. Turning your attention again to the transverse fold on the palmar surface, you will find that it is directly in a line with the articulation. Your incision, then, must be made directly in a line with it; and, as before, your flap must be made from the palmar surface. I would stale, however, that these operations are sometimes performed in a different manner: namely—by forming the flap first, by transfixing the finger just beneath the joint on the palmar surface, and cutting outwards to a sufficient extent, after which the joint is opened into as before. It sometimes becomes necessary to remove the first phalanx from the meta-carpus. To do this there are two methods, both of which will do very well. By one a double flap is formed, in such a manner, that when the finger is removed there remains a V shaped flap wound ; and the other method is what is known as the oval operation. The first plan is very simple. Seizing the 264 AMPUTATION AT THE WRIST JOINT. finger in the left hand, and causing an assistant to draw aside the other fingers, place the knife on the fold of skin between them, and carry it directly back to the articulation ; pass through it, and bring out the knife on the opposite side; then bring the two neigh- boring fingers together, and heal by the first intention. To pro- mote the approximation of the fingers, the head of the meta-carpal bone is sometimes removed, by sawing it through obliquely. Where all of the phalanges are to be amputated, they may be removed by a single sweep of the knife. Having flexed the fin- gers, insert the knife, draw it simultaneously through the four articulations, and then form a flap from the palmar surface. It is sometimes necessary to amputate the Meta-carpal Bone of the Thumb, At its carpal articulation. Here it is necessary to form the flap from the flesh on the outer side of the thumb. Having placed the hand in pronation, draw the thumb out, insert the knife at the commissure, cut freely, and grazing the bone, reach the joint; pass through it, and form as large a flap as possible, by bringing the knife out opposite the meta-carpal articulation, grazing the bone the whole way. The oval method is as follows—If operating on the left hand, supinate it, and make an incision from one line above the carpal joint to the inner side of the first phalanx of the thumb; then pronate the hand, and continue the incision along the dorsal surface, until it reaches the point where it commenced, at an angle of about thirty degrees; divide the muscles adhering to the bone ; open the joint from the dorsal surface ; and dislocate the meta-tarsal bone outwards, and detach it from the flesh. You may adopt either of these methods. Amputation at Wrist Joint. Where you have to amputate at the wrist joint, your guides will be the styloid processes of the radius and of the ulna. The joint forms a curve between these, and in amputating here there are two methods. The first is, by placing palm to palm, with the thumb on one styloid process, and the index finger on the other, to flex the hand slightly; place the knife on one process, and, re- membering that the articulation forms a curve, whose convexity is upwards, sweep round to the other; then to open the articulation, and form a flap from the palmar surface. The other method con- AMPUTATION AT THE ELBOW JOINT. 265 sists merely in transfixing the limb upon its palmar surface, in cutting outwards, and in making the flap as before, opening the articulation in front. Amputation of the Fore-arm. As regards amputation of the fore-arm, it has been recommended to perform the operation in the upper third; but I would remark that the choice of the site of the operation must be governed very much by the circumstances of the patient. If he is in easy cir- cumstances you should save as much of the limb as possible, and therefore, should cut low down; under other circumstances you should operate at the point of selection, the upper third. You may operate here by single or double flap, by double or single circular incision, &c; but you must remember that you have here two bones, with an interosseous membrane between them; and that this membrane must be divided. If you amputate by the double flap, the easiest method is the following—Stand on the inner side of the arm, and pronate it; then transfix it, and cut the flap from within outwardly. Next supinate it, transfix it, and cut outwards ; and then, by a circular incision around, the knife entering the interosseous space and dividing the ligament, cut to the bone. In these operations a retractor should always be used to protect the soft parts; and where there are two bones the re- tractor should consist of three strips. Amputation at Elbow Joint. In some cases it becomes necessary to amputate at the elbow- joint. Here it is advisable to save the olecranon process, as this may be easily removed afterwards, if necessary. The operation is easily performed. Placing yourself on the inner side of the arm, and marking the sides of the joint with the thumb and finger, elevate the flesh in front, or as much of it as possible; transfix it with a double-edged knife; and, by cutting outwards, form a flap of about three inches in length, having grazed the bone the whole way. Then, an assistant holding back the flap, insert the heel of the knife into the radio-humeral articulation, and by a circular incision at its base, divide the integuments behind ; when, having reached the ulna, if you would save the olecranon, withdraw the knife- divide all the humero-cubital ligaments; and, dislocating the joint widely, pass a saw in and cut off the process, which will be held in its position by the tendon of the triceps attached to it. 266 AMPUTATION OF THE ARM. Should you desire to remove the olecranon, after luxating the joint, divide the lateral ligaments of this process from behind, and then it only remains to cut across the tendon of the triceps muscle. Amputation of the Arm* May be performed either by the circular incision, or the double or single flap, and upon any part of the member. In all cases, however, the limb should be amputated as low down as the con- dition of the parts will admit, so as to secure all the advantages afforded by a long stump. When you operate by the double flap, it is advisable to cut the anterior flap first, as the biceps muscle in front retracts more than the triceps behind; and when operating by the circular incision, it was proposed by S. Cooper to divide the biceps simultaneously with the skin, by the first incision, so as to suffer it to retract before the knife is carried through the deep-seated muscles. It has been advised by some, that when it becomes necessary to amputate above the attachment of the deltoid muscle, it would be better to operate through the shoulder joint, because of the great liability of the pectoralis major and other muscles to contract and leave the bone naked, or the immobility of the stump. The oper- ation through the bone, however, is less hazardous, and should be generally preferred. Several methods of performing it may be adopted. The following plan I have found to succeed very well. Bring the patient to the ege of the bed, and extend his arm to a right angle with the body. Let an assistant compress the artery against the first rib, or against the articulation of the shoulder, as I have been obliged to do on account of a peculiarity in the con- formation of the chest, by which the elevation of the clavicle was greatly increased. Stand on the outside of the member, intro- duce a long double-edged catlin about the middle of the deltoid muscle, a little below the acromion process, and thrust it directly through, in front of the bone, so as to bring out its point in the axilla, behind the fold formed by the pectoralis major. The in- strument must then be made to cut itself out, by being carried obliquely downwards, and an anterior flap will thus be formed, comprising half the deltoid and the outer portion of the pectoralis major. The knife must now be insinuated at the same point, and * The description of this operation is taken, in the most part, from Prof. G.'s article on the Arm in the American Cyclopaedia of Medicine and Surgery, vol. ii. [Ed. AMPUTATION AT THE SHOULDER JOINT. 267 thrust through in the same manner behind the bone, so that, in cutting itself out, a posterior flap of similar form and dimensions may be made. The flaps being turned back, a circular sweep of the knife must be made around the bone, and the operation finished by sawing the bone, securing the artery, and adjusting the flaps so as to have their line of union placed in a perpendicular direction. Amputation at the Shoulder Joint. We now come to amputation at the shoulder joint. There are a "hundred and one" different methods of performing this opera- tion, any one of which will answer, provided the anatomy of the part be thoroughly understood. My usual plan is, to place the arm in an oblique position, inclining slightly outward and down- ward, to feel for the acromion process, present the knife there, and carry it with an easy curve round to the axilla; then, placing the arm more in, so as to expose the head of the humeris, to enter the joint, and carrying the knife through it, to cut obliquely out, thus forming an anterior and a posterior flap, an assistant holding the axillary artery between the fingers until it can be secured. Another method is that of Lisfranc. There exists, between the coracoid and acromion processes, a triangular space, having the clavicle behind, and nothing but fibrous tissues above. If you are operating on the left arm, carry it outward until it stands at nearly a right angle; place yourself behind the patient; take the arm in your left hand, the two first fingers being placed on the triangle alluded to above, and the thumb resting on the posterior surface of the humerus ; then plunge in a double-edged knife, about eight inches long, on the posterior border of the axilla in front of the tendons of the latissimus dorsi and teres major, and parallel to the outer side of the humerus, the blade resting in'such a position that its flat side may form an angle of 35° with the axis of the shoulder, and having its upper edges a little in front. The knife grazes the external and upper surface of the humerus, and arrives beneath the acromion. Then depress the point and raise the han- dle forming an angle of 30° to 35° with the axis of the joint; separate it from the arm for two or three inches, and then press directly with the point, which, passing through the joint, appears in front of the clavicle on the inner side of the acromion, in the triangle previously spoken of. Then, the handle remaining almost stationary, carry the end of the blade from within outwards, and a little upward, passing around the head of the bone, and, as 268 AMPUTATION OF THE TARSO-METATARSAL JOINTS. soon as disengaged from between it and the acromion, the knife can descend freely on the outside of the arm, and cut a posterior flap about three inches long, which an assistant should instantly raise. Next, keeping the hand depressed, and cutting with the knife from heel to point, pass it from behind forward on the inner side of the head of the humerus; depress the handle till it becomes perpendicular to the horizon ; pass the knife on the inner side of the bone ; and, an assistant compressing the artery, finish the anterior flap. When you amputate the right arm, you may either pass the knife in at the indicated triangle, bringing the point out in front of the posterior part of the axilla; or, standing behind the patient, you may make the first flap as before, and stepping to his side, finish the anterior. You may adopt either of these expedients you please. I generally adopt the first, and find no difficulty in performing the operation. Amputations of the Tarso-Metatarsal Joints. As the same rules apply to the amputation of the toes as to that of the fingers, we will not repeat them here, but go on to the ampu- tations of the tarso-metatarsal joints. Where you would remove all the meta-tarsal bones at once, it becomes especially necessary that you should perfectly understand the anatomy of the parts. In consequence of the second articula- tion being so far behind the others, it is impossible to open it by the same incision that opens the others. The method of perform- ing the operation is this : Placing the heel near the edge of the table, apply the palm of your left hand under the sole of the foot, your thumb resting on the tuberosity of the fifth metatarsal, and your index finger half an inch in front of the internal side of the joint. Next, make a semilunar incision across the dorsum of the foot, from without inwards, extending down to the bone, and pas- sing half an inch in front of the articulation, while an assistant retracts the skin, and if the tissues will not yield, they must be dissected up. Then attack the articulation, without removing the fingers of the left hand, which serve as guides; place the point of the knife on the outer side of the joint; open it as far as the third metatarsal bone, and carrying the knife half a lin& forwards, cut almost transversely, and thus reach the second metatarsal. Divid- ing the ligaments with the point of the knife, then, the index finger serving as a guide, enter the joint on the inner side. The CHOPART'S OPERATION. 269 mortice is now to be destroyed. Pass the point of the knife between the first cirneiform and the second metatarsal bone, with the edge turned towards the leg, and forming an angle of 45° with the toes, and, the instrument having entered the joint, bring the handle to the perpendicular and cause it to pass through the internal side of the mortice, not forgetting its slight obliquity inwards. Next, with- draw the instrument, and carry its point transversely on the dorsal ligament at the posterior part of the mortice, and then from behind forward on the outer ligament; bear gently on the end of the foot, to separate the articulating surfaces; with the point of the knife divide the external and then the middle interosseous ligaments, from above downwards, and terminate the operation by dividing all of the plantar ligaments, and forming a flap from the sole of the foot. LECTURE XXXIV. AMPUTATION OF LOWER EXTREMITIES CONTINUED--THROUGH THE TAR- SAL BONES--CHOPART'S OPERATION--METHOD OF CHELIUS, LISFRANC, AND OTHERS--AMPUTATION AT ANKLE JOINT--OF THE LEG--RESEC- TION OF BONES AT THE KNEE JOINT--AMPUTATION OF THE THIGH-- AT THE HIP JOINT. In our lecture of yesterday, gentlemen, we pointed out the method of amputating between the tarsus and meta-tarsus. When the disease extends so high as to render this operation impracti- cable it may be advantageous to resort to the Amputation through the articulations of the Tarsal Bones. We here operate through the articulation of the astragalus with the scaphoides, and that of the calcis with the cuboid. But where the disease merely implicates the cuboid and the corresponding meta-tarsal bones, only these bones should be removed. Chopart's method of operating through the tarsus is one of several which have been proposed. The object of this plan is to forma double flap, one from the dorsal and the other from the plantar surface of the foot. The patient is seated, and an incision is ex- 270 AMPUTATION AT THE ANKLE JOINT. tended across the instep two inches in front of the malleolus, from one edge of the foot to the other. From the angles of this incision another is carried upwards to a small extent upon the tibial and fibular margins of the foot. The quadrangular flap of integuments thus formed is dissected back to the line of the articulation, the knife plunged into the latter, through which it is carried so as to divide the ligamentous connections, while the foot is strongly flexed, and after it has completely severed the attachments of the bones, the edge is turned forwards and carried along the lower surface of the bones, in order to cut a flap of the requisite dimen- sions from the sole of the foot. This operation may be very promptly executed by one who is conversant with the arrangement of the articulations by the method pursued by Richeraud, Chelius, Klein, Lisfranc, Velpeau, and others, and this plan is preferable to any of the others. Every thing being properly disposed, if the operation is to be performed on the left fool, the surgeon fixes the index finger of his left hand upon the articulation of the calcis with the cuboid bone, which will be found half an inch behind the prominence formed by the posterior extremity of the meta-tarsal bone of the little toe, and his thumb upon the tubercle of the scaphoid bone, the palm of his hand grasping the sole of the foot. Then, inserting the edge of a narrow bladed catlin upon the point marked by the thumb, he makes an incision across the instep to the point represented by the index finger. This incision should present a convexity towards the toes, and should be carried through the superficial parts, which retract as they are divided. The instrument should next be inserted in the articulation of the head of the astragalus with the scaphoid, and while the ligaments are divided, the foot should be luxated downwards so as to open the joints and allow the knife to glide through them. After the attachments of the bones have been cut asunder, the operation is completed by forming a flap from the sole of the foot. As the articulating surface of the stump presents con- siderable thickness, it is important to give the flap considerable dimensions: hence it has been properly recommended by Klein and others to make it of the length of the meta-tarsal bones. Amputation at the Ankle Joint. You will occasionally meet cases in which it will be necessary to sacrifice the whole tarsus. Under these circumstances—espe- cially if the patient is in good Circumstances—it will be necessary AMPUTATION OF THE LEG. 271 that you should save as much as possible of the limb, and you may then operate through the ankle joint. The plan is : first, to remove the entire tarsus, and form a flap from the sole of the foot; and, secondly, to saw off the malleoli, and bring up the flap over the surface of the articulation. Stand in front of your patient; (who should be placed as for amputating the leg,) seize the foot in the left hand; place the knife on a line with the internal or ex- ternal malleolus; carry an incision along the side of the foot to a sufficient extent to form the flap, then directly across the sole and along the side of the foot, to the malleolus of the opposite side; and dissect back the flap. Next, cut across the joint in front; divide the ligamentous structures; carry the knife back; and dissect off the structures under the os calcis. Then saw off the malleoli, and bring the flap up over the stump, thus forming a soft cushion suffi- cient to bear a certain amount of pressure. Amputation of the Leg. It very frequently happens that we are under the necessity of amputating the leg, and it has long been supposed that the prefer- able point for the performance of this operation, is about three inches below the knee. This, therefore, has been called the point of election. The reasons for this preference are the amount of muscular substance at that point for forming the flap, and the ab- sence of tendons. Now, where the individual is in such circumstances as may ena- ble him to obtain a wooden leg, it will be well to amputate at the point of election; but where his circumstances are different it will be best to amputate as low as possible, that he may enjoy the com- fort of an artificial leg and foot, which will in a great measure cor- rect the deformity. I may state, in general terms, that the operation may be per- formed by the double circular incision, or by the single or the double flap method. The English and American surgeons generally prefer the double circular operation in this as in most amputations : but for my part, I think that it is too protracted, and that it possesses no advantages over the flap operations. Either method, however, will do very well. When you adopt the single flap amputation, the flap is formed from behind ; and although it is certainly true, that when you oper- ate by this method in the upper portion of the leg there is no diffi- culty in obtaining a flap sufficient to cover the stump, it is equally 272 EXCISION OF BONES AT THE KNEE JOINT. true, as I have always observed, that there is a proclivity in a flap thus formed to fall down from the bone; and it is also true, that, on account of the fact that the long end of the muscles are thus left unattached, the flap is apt to slough. So that, although I have several times performed the operation with a single flap, I have long abandoned the method, and now generally adopt the double flap plan of amputating the leg. When you operate by the single flap, placing yourself on the inner side of the patient, you feel for the margin of the tibia; transfix the leg;behind and grazing the tibia and fibula,cut downwardsand back- wards to form a flap of sufficient size. Then, grasping the knife firmly, you place the left foot forwards—not the right, for the knee would then be in the way—carry the heel of the instrument over to the margin of the flap, and divide all the integuments and muscles in front of the leg by a circular incision on a level with the base of the flap, which an assistant in the meantime retracts- With the point of the knife you next divide the interosseous membrane, and then you saw the bones. The angle, of the tibia, being drawn up by the muscles, is apt to project, and remain uncovered by the flap. I generally, therefore, saw off the sharp upper edge, by simply inclining the instrument, and bringing it to bear at first in an oblique direction for several strokes upon the bone; and then, removing the saw from the inclined groove thus made, I divide the bones on a line with the end of this first section ; thus, as it were, notching out an angular shaped piece from the tibia, and giving to its end a bevelled edge. I will now describe to you a more simple method, and the one which I generally adopt. In the first place, you feel for the fibula, and draw out the integuments and muscles: next you cut obliquely in on one side to the bone; and then you reverse the knife, and cut obliquely upwards on the opposite side; thus forming an external and an internal flap of equal length; which being reversed, and drawn up; the deep seated muscles, together with the interosseous ligament, are to be divided in the usual manner, by a circular inci- sion around the limb, carrying the point of the catlin between the tibia and fibula. Excision of Bones at the Knee Joint. It may sometimes be necessary, instead of amputating the limb, only to cut out a portion or portions of the bones, as, for example, the head of the tibia or femur, or the extremities of both bones. The necessity for performing this operation is generally produced AMPUTATION OF THE THIGH. 273 by some diseased condition of the joints. The method of perform- ing it is as follows—Place the leg in a slightly flexed position, insert the knife above the patella, and make an incision which will pass around the anterior half of the limb : then commence at the same point, and carry a second incision below the patella to the side opposite to the termination of the first incision, cutting boldly down to the bone : and lastly, place the leg in such a position that the bones may stand perpendicular; divide the crucial ligaments, and saw off the heads of the bone or bones, or as much as it may be necessary to remove, taking care not to wound the popliteal artery. Afterwards place the limb in a straight position with the square ends of the bones together; apply splints, as for fracture; and endeavor to procure bony union. Of course the joint will be permanently stiffened by this union. In reference to the sawing of the bones of the leg, there is one rule—though of little importance—to which I will direct your atten- tion. You will find that at the upper end of the tibia the articula- tion of the fibula is oblique with the tibia, and that the bones are held in position only by the articular ligaments; and in consequence of this arrangement, if you saw these bones together, the fibular will slip downwards an inch or so below the tibia. On this account, I am in the habit of dividing the fibula first; and then I insert the saw on the tibia on a level with the divided end of the fibula. But, to go on, let us pass to the Amputation of the Thigh. You may operate here, as in the leg, by the circular incision, or by the single or double flap method ; and the flaps may be formed from the internal and external, or the anterior and posterior portions of the limb. I prefer the lateral—the external and the internal—to the anterior and posterior operation. The latter method allows the secretions to collect, while the former plan gives them free exit. The double flap method is to be preferred; and in performing the operation by this plan, the two flaps may be formed either by cut- tino- from the bone outwards, or from without inwards. There can hardly be said to be any particular point of election in amputation of the thigh : we should operate at the point which the necessities of the case indicates, without sacrificing more of the limb than is necessary, except where the artery passes through the tendinous sheath, formed by adductor muscles. The operation should always be regarded as one involving haz- R 274 AMPUTATION AT THE HIP JOINT. ardous consequences. The amount of soft parts which have to be divided is so great, that the constitution sometimes receives a shock from which it never recovers, and should this not happen, the patient is not unfrequently destroyed in the end by irritative fever, profuse suppuration, and even gangrene. When you determine to operate by the double flap method, and to cut the flaps from the bone outwards, you place the patient upon a table properly arranged; cause an assistant to command the artery, either by means of the tourniquet appJied high up the thigh, or by compression where the artery is passing over the hori- zontal branch of the pubis; and, placing yourself in front of the patient, you insert the knife as though you were about to pass it through the thigh bone; but turning the point of the instrument around it, you transfix the limb, and then form the flap by cut- ting out. After doing this, you again insert the knife at the same point, and cut out at the same angle on the opposite side, taking care, here as with the first flap also, to secure an ample fold of the soft structures to cover up the bone securely. Should you desire to perform the operation by cutting the flaps from without inwards, the operation does not differ materially from that method when carried out elsewhere, as already described. The flaps should be made from the internal and external, rather than from the anterior and posterior portions of the thigh. Sometimes, where there is a considerable loss of soft parts on one portion of the limb it may be desirable to operate by the sin- gle flap method. This flap may be cut from any portion of the limb; but should the condition of the structures leave it optional with the surgeon, the anterior part of the thigh should be selected. The soft parts should be pinched up between the thumb and fingers of the left hand, and a narrow catlin thrust through in a transverse direction in front of the bone so as to cut an anterior flap of the proper size. The parts on the posterior portion of the limb may then be divided by a half circular cut down to the bone. It is unnecessary to describe the method of operating by the circular incision, as it has been spoken of elsewhere, and as it is performed in a similar manner when applied to the amputation of this limb. Amputation at the Hip Joint. We are sometimes driven to the unfortunate necessity of dis- articulating the thigh at the hip joint. While I cannot agree with Charles Bell, that this operation ought never to be performed, I WOUNDS. 275 would restrict it to those cases in which amputation cannot be performed through the continuity of the bone, between the head and the trochanter minor, or lower down, provided, also, that the acetabulum and the adjacent parts of the innominatum be sound. There are some dozen methods of performing the operation; and each one may succeed as well as another. The one which I prefer is that by which an external and an internal flap are formed, as follows. Draw the thigh over a table, and flexing it slightly, feel for the anterior superior spinous process of the ilium : then measure one inch and a half downwards from the spine of the ilium, and a half inch on the inside of the termination of this line insert the point of the knife. If you push the knife directly back, it will fall upon the rounded head of the femur. Do this; and when you feel the instrument impinge on the bone, incline the blade so as to graze it; draw the buttock outwards; bring the point of the knife through; and cut out. Next, insert the knife in the same manner, and cut the inner flap ; and then, seizino- the limb in your own hand, abduct it, and cut as though directly upon the head of the bone. Thus you will enter the joint; when you must divide the ligaments, and-finish the operation. LECTURE XXXV. WOUNDS--DIVISION OF SUBJECT--SIMPLE INCISED WOUNDS--HEALING PROCESSES. I propose, gentlemen, to commence to-day with the subject of wounds. We define a wound to be a solution of continuity in the soft parts, inflicted by external violence. When we consider the subject under all its aspects, we see that wounds may be exceedingly diversified, in accordance with the kind of instrument by which they are inflicted, the nature of the part in which they occur, &c. But notwithstanding the endless diversity in their characters, and consequences, we may divide them all into a few groups. First, a simple cut, a "simple incised wound," is one inflicted by a merely cutting instrument. Sec- ondly, a "punctured wound " is one made by a sharp narrow in- strument. Thirdly, a "contused and lacerated" wound'is one 276 SIMPLE INCISED WOUNDS. which is much bruised and lorn ; and, as a modification of this kind, we have "gunshot wounds." Again; when a poison has been insinuated, it is called a " poisoned," or "envenomed" wound. The bites of venomous animals, dissection wounds, &c, come under this head. You can readily perceive how convenient it will be, in the consideration of our subject, thus to divide it We will take up the separate groups in the order in which they have been mentioned; and to begin, we will call your attention to " simple incised wounds." Wdien a simple cut is inflicted in the soft parts, certain phenomena and changes occur which demand our investigation. Among the phenomena which present them- selves are, first, pain—which differs in intensity, according to the sensibility of the parts affected, and which also differs in its dura- tion—and secondly, a separation of the edges, or a gaping, more or less extensive, according to the direction of the wound, its ex- tent, position, &c. The causes of this gaping are various. Thus, when the instrument merely penetrates the skin, the cause is to be found in the elasticity, and organic contractility of that struc- ture, and when the wound is deeper, muscular action is also brought into play to separate the edges. Again; some parts of the skin are less adherent to the subjacent structures than others; and hence wounds in such a part will gape more than where the skin moves with Jess freedom over the parts. For example, we may cite the fact, that wounds on the scalp gape much less than those on other parts of the body. In reference to the position of the wound as a cause, it is evident that if on a limb, it will gape more if it be in a transverse direction than if in the line of the limb. The position of the part, as to flexion and extension, also exerts an influence in opening the wound. But to return. Another of the sensible phenomena presented, (I am still speaking of simple incised wounds,) is a discharge of blood. In slight, superficial wounds, this is a mere oozing from the small vessels, and gener- ally not much is lost; though occasionally, the discharge is con- siderable : while if the wound extends to any of the larger vessels, jets of blood will spout out synchronously, with the systole of the left ventricle of the heart. Again, we may have the discharge of some other material existing in the body; as the synovial fluid, for example, if the wound penetrates into the cavity of a joint: or a bursa mucosa may be involved in the injury, and its con- tents may be expelled ; or the bile, urine, or contents of the in- testines, may be discharged. These complications can, of course, PROCESS OF HEALING IN WOUNDS. 277 arise only when the wound is inflicted in particular parts; and these phenomena do not properly belong to wounds in general. If the wound penetrate the lung, air may be discharged from the vesicles; and, by infiltrating into the cellular tissue, it may give rise to that condition denominated "emphysema." Such, then, are the phenomena which present themselves when there occurs a " solution of continuity in the soft parts, from external violence." Others sooner or later succeed, which result from the processes that nature adopts to repair the injury, or heal the wound. These are resolvable into two processes, union by the "first intention," and union by the "second intention," as they are respectively called. The latter process is sometimes denominated 'fiealing by granulation." Let us see in what these processes consist, and in what respect they differ. In the first, or union by the first inten- tion, a plastic material is thrown out between the opposing sur- faces, and, by certain vital changes, is converted into a living portion of the organization. In the second,—that of healing by granulation—we find, together with the plasma, another material described already as pus. Suppuration, then, is essential to this mode of healing, but not to the first. In the mode of union by the first intention, adhesion sometimes takes place in twenty-four hours. Some think, that in these cases healing takes place by a direct union of the divided vessels, without the aid of any plastic exudation ; but I am inclined to believe that the same laws are concerned, that obtain in cases of a more protracted character. Thus we see in a simple incised wound, that, after the hemorrhage has been arrested, a mould of coagulum may be found between the divided portions of tissue. Now, it is obvious that this must be removed before union can take place; for—notwithstanding the high authority of Hunter to the contrary—none now believe that this extravasated blood is capable of becoming organized. All agree, that it must be removed by being partly expelled, and partly absorbed. Coincident with its removal through these double means, certain other changes take place. These have, on a pre- vious occasion, been carefully explained. The fibrine and albu- men of the blood are increased in quantity; and an exudation takes place, consisting, at first of blood serum, and gradually con- taining more and more fibrine (or blood plasma, of which fibrine is the base) capable of becoming organized, and answering the purposes of nature in the process of healing and repairing lost 278 PROCESS OF HEALING IN WOUNDS. structures. At first fluid, it becomes congealed, and its farther condensation gradually goes on. Meanwhile, the microscope evin- ces the presence of granules ; which go on increasing in number, and are capable of undergoing such changes, as result in the forma- tion of simple cell membranes enclosing nuclei, these being again composed of nucleoli. As these cells increase in number, they group themselves together in various ways, according to the nature of the structure about to be formed, which will be the same as that of the part in contact with which they lie. If it be cellular tissue, for example, they will be irregularly distributed; while in other cases, they may arrange themselves in a linear direction, &c.,&c. Those in contact with the living structure undergo certain changes which result in their becoming organized. This occurs to layer after layer, until ultimately the cavity of the wound is filled, and the opposite vessels inosculate. This is the nature of the process, even in healing by the "first intention," as it is called. But the healing is not yet complete. The surface is moist; and there is still an exudation taking place. This becomes dry, and forms a scab, or incrustration, beneath which a new skin is being pro- duced by the same process of cell-formation. A particular series of nucleated cells are deposited in regular layers, and form that ar- rangement called "epithelium." As regards the mode of healing by the second intention, by gran- ulation, by suppuration, I have already intimated that the process is the same, with one exception. We have the same exudation, cell production, &c; but a portion of the plasma has become so deteriorated as to be incapable of undergoing, in a normal manner, those changes which lead to organization, and a kind of abortion takes place. True, a cell or globule is formed ; but this differs from an organizable cell, as has been elsewhere explained. This process is infinitely slower than union by the " first intention." The pus globules interfere with the process, but by shielding the plasma, they are sometimes useful in the manner of a natural dressing to the parts. The process of healing is in both instances the same, although more tardy in the one case than in the other. A series of exceedingly minute granulations gradually fills the cavity; then cicatrization takes place, and beneath the incrusta- tion the epithelium cells are arranged, and a new skin is formed. These are not merely interesting pathological considerations, but have a practical influence upon our treatment of wounds. The TREATMENT OF SIMPLE INCISED WOUNDS. 279 discovery of the doctrine of adhesion has, as has been remarked by John Bell, accomplished more for surgical science than even that of the discovery of circulation itself. Many are the surgical oper- ations we would fear to perform, if we had not confidence in this principle in nature's operations. LECTURE XXXVI. WOUNDS CONTINUED--TREATMENT OF SIMPLE INCISED WOUNDS--SU- TURES--SUTURA SICCA--SUTURA CRUENTA--TREATMENT OF CONTUSED AND LACERATED WOUNDS. At our last meeting I attempted to portray the leading charac- teristics of simple incised wounds, and to explain the mysterious processes adopted by nature in repairing the injury. It will be my object, to-day, to point out the measures to be pursued in aid of these processes. In other words, to consider the treatment of these wounds. We have already said that the healing of a wound is the result of one or the other of two processes, and that these are respectively denominated, union by the first, and union by the second intentions. We have also explained in what particulars these processes differ from each other. Our object in the treatment should be, as a general rule, to favor the healing by the " first intention." The means of so doing will be explained in their proper order. Mean- while we will call your attention to some other points in the treat- ment. In a common incised wound, or, in fact, in any wound, extraneous bodies may be conveyed into the body, and they are liable to be retained there. Our first duty, then, is to ascertain if the wound contains any foreign material, and if such is the case, to remove it if possible. Another important duty will then be to arrest the hemorrhage. This will sometimes cease spontaneously; but if such be not the case, it becomes the duty of the surgeon to call into requisition all the means and appliances within the com- pass of his knowledge, or suggested by his ingenuity. I cannot here enter into a detail of all these means and appliances. Com- 280 SUTURES. mon cold or styptic applications may often succeed, but it will be sometimes necessary to tie either the divided ends of the bleeding artery, or its main trunk. Our next duty will be to bring the edges of the wound into con- tact; and to fulfil this indication, involves several considerations. First, to obtain this end, the position of the part must be regarded. Let us, for example, suppose a transverse wound of the throat, and one on the anterior portion of one of the lower extremities. In the first case the head should be brought forwards, and in the second instance, the limb should be placed in extension. By act- ing thus, in both cases, the edges of the wounds will be brought into nearly perfect apposition. Position, however, is but one of the measures to be adopted, in ensuring the contact of the edges of a wound ; there are others of much greater importance, and to these we must now direct your attention. In the second place, then, we will consider the compress and uniting bandage. The compress may be of various forms. It should be constructed of soft material, and it should be so placed as to bear on the edges of the wound, in order that when the bandage is brought to bear on it, its pressure will be exerted in such a direction as to approxi- mate the divided surfaces. There is yet another means of union which we employ. It is called a suture, which term means literally a stitch. We have the dry suture or " sutura sicca," and the bloody suture or "sutura cruenta." The former consists merely of adhesive strips, or of some glutinous substance; the latter pre- sents a great variety of modifications. In most instances this last is made with a common needle and a ligature. The blood}- suture which is most frequently resorted to, is the common interrupted stitch. A common curved surgeon's needle armed with waxed thread, is passed through both sides of the wound, at some distance from the edge, and tied over the line of division ; and this is repeated as often as the extent of the wound renders it necessary. The ap- proximation should be assisted by lateral pressure with the hand, while the thread is being tied. A more expeditious plan is to take a needle armed with a long thread, and pass it through on alternate sides, leaving long loops on each side, which are afterwards cut, and the opposite ends are tied as in the first case. In other in- stances, especially in cases of wounds about the abdomen, peri- neum, &c, we use what is called a quilled suture. A curved needle with a strong double ligature is passed, as in the other cases, and tied over a quill or bourgie, which is placed in the line CONSTITUTIONAL TREATMENT. 281 of the punctures. The stitches in this case, not acting so forcibly on the edges of the wound, are not so apt to cut through. This suture also keeps the deeper parts more exactly in juxtaposition, and it should be preferred in wounds about the abdomen. Again; we should mention the twisted suture. It is used in the operation for hair-lip and in wounds about the eye, &c. Straight needles, either of silver or steel, (a common sewing needle will answer) are passed, in sufficient numbers, across the wound. Over each of these a ligature is passed in a twisted or figure-of-eight direction, and drawn sufficiently tight to ensure the approximation of the parts. There are other modifications of the suture, but as they are of minor importance, I need not take up your time with their explanation. In common wounds, the interrupted suture is generally the best you can choose. If the nature of the wound render it possible, you should use but the dry suture, since no additional injury is inflicted by it. If you are obliged to resort to the "sutura cruenta," you may, according to the position of the wound, its character, &c, use either of the three mentioned, alone, or together with the "sutura sicca." In some cases the loss of substance may be considerable, and yet it is desirable that the wound should heal by the first intention. If, in such a case, the sutures fail in obtaining the requisite approximation of parts, we have to resort to other plans in addition ; for without due contact between the divided surfaces, union by the quicker process cannot occur. Modifying the relative position of the adjacent parts, will often avail much in this respect; and thus, too, we may use the surrounding parts to supply the place of the lost tissues. For example, we may some- times cause the requisite approximation, by dissecting the skin from the subjacent tissues, and availing ourselves of its natural elasticity extend it so as to fill up the space. We may also resort to lateral incisions, which will allow a sufficient extension of the skin. Gaping will take place, but this will soon be filled up by the neighboring parts, or by new products. It will be proper, in the next place, for me to consider briefly the other collateral circumstances in the cure. Q,uiet and rest should be enjoined on the patient, and we should see that all the vital functions are regularly performed. In all processes of healing, a certain degree of inflammatory action is necessary. This may, on the one hand, transcend the requisite degree of intensity; or it may, on the other hand, become 282 CONTUSED AND LACERATED WOUNDS. too slight. If the inflammation is of too intense a character, the antiphlogistic treatment should be enforced, in due accordance with the state of excitement; the diet should be regulated; and pain, if present and severe, should be alleviated or relieved. Besides this constitutional treatment, local measures have here- tofore engaged much attention; but as our science advances, we find that the more simple applications are the best. We are chary of too much dressing, and manipulation. Besides, the approxima- tion of the edges, the best local treatment consists of simple water dressing, either cold or tepid, and applied either by means of lint, or soft, spongy, bibulous paper. In some cases, you may find some of the antiphlogistic applica- tions of benefit—sugar of lead, for example. In endeavoring to heal a wound by the first intention, you should avoid the popular application of warm poultices. They are calculated to excite sup- puration. We should always try to heal by this "first intention," and if we fail in our attempt, we can then modify our treatment to favor suppuration and granulation. It will then be time enough to apply warm poultices. LECTURE XXXVII. CONTUSED AND LACERATED WOUNDS--THEIR TREATMENT--PUNCTURED WOUNDS--THEIR TREATMENT. I have mentioned, that what we call contused and lacerated wounds are generally produced by blunt instruments, though this is not invariably the case. Hence we may have a wound that is lacerated, without the laceration being accompanied by contusion; and we may have considerable contusion, without laceration, or, at least without laceration of the integuments. A mere contusion may result from a fall, or a blow, and the. skin remain untorn. In such a condition, however, it will very frequently be the case that there is laceration. Beneath the skin, in the delicate structures there situated, laceration may exist. Minute vessels may be torn asun- der, and their contents extravasated into the interstices of the areolar tissue of the part. Hence arises what is called " ecchy- mosis;" which is nothing more than a dark colored effusion from CONTUSED AND LACERATED WOUNDS. 283 these ruptured vessels. Ecchymosis, then, may be one of the phenomena in contused and lacerated wounds. Other character- istics follow, among which an impairment of the vital properties of the part may be noticed; and this may be exhibited in various ways. If it is merely a temporary suspension of the natural func- tions of the part, the vital powers will soon recover themselves, and resume their action; but if the injury is more severe, mortifi- cation, to a greater or less extent, may result. All these circum- stances will modify both the prognosis and the treatment, and, therefore, should all be taken into consideration. The complica- tions existing in these cases are infinitely varied. Some of the wounds are longitudinal, relatively speaking; some transverse, &c; in some there may be laceration of important vessels, and in others, vessels may be torn asunder. The hemorrhage is not so great as in simple incised wounds; and even when the principal artery of the part is severed, there is sometimes no alarming hem- orrhage, and no ligature may be needed, the blood soon ceasing to flow of itself. But this is not always the case. Sometimes, if the vessel is by some means prevented from contracting, great loss of blood may take place. All I wish you to understand me to affirm is, that such wounds are less apt to be followed by serious hemorrhage, than simple incised wounds. Pathologists have at- tempted to explain this, but the discussion of these explanations will be more appropriate in another part of the course. The pain resulting from a contused and lacerated wound is of- ten less severe than when a smooth cut is inflicted ; and secondary bleeding is more frequent than in an incised wound. We have alreaay seen that the vital powers of the part are im- paired, and that often a portion of the tissues becomes dead, or mortifies. Now, as soon as this dead portion becomes detached, the vessels are no longer closed, and the bleeding comes on. Many examples of this secondary hemorrhage are seen in common gun- shot wounds, in which the ball has raked the coats of a vessel. Another peculiarity in these wounds is the fact that they very rarely unite by the first intention. The rule is, that they heal by suppuration and granulation, though there are exceptional cases. As a general rule, too, it may be stated, that prostration more fre- quently follows, as a result of lacerated and contused wounds, than in cases of simple incised wounds. That paleness; that slow and heavy respiration; and those nervous symptoms, represented by the term collapse, are more apt to present themselves in these injuries. 284 TREATMENT OF CONTUSED AND LACERATED WOUNDS. Such, then, in a general manner, are the characteristics of a lacerated and contused wound. Let us now consider the duties of the surgeon in such a case. In a case of simple contusion, the injury is generally superficial, though not always so, and the parts are restored to their normal con- dition by resolution. The extravasated blood is absorbed, and the part recovers its vital powers; the pain subsides, and the vessels resume their offices. The best plan to be pursued is simply to rest the part, and apply to it some stimulating or evaporating lo- tion. In some cases, the blood which has been extravasated may act injuriously on the surrounding parts, by exciting abscesses, by pressure, &c, and although you should not be anxious to evacuate such a collection, yet it is sometimes best that it should be dis- charged. Such cases are instances of what are called bloody ab- scesses. They occur especially on the head; and, as occurring there, they will be referred to hereafter. In lacerated and contused wounds, the same treatment, with some modifications, should be pursued, as in wounds of an incised character. Any foreign material, or extravasated blood, should be removed; the advantages that may be derived from position should be secured; and the requisite sutures, compresses, se is removed, to close the opening at once. BURSAL TUMOR NEAR HYOID BONE. 419 It is not my purpose to speak at length of oedema glottidis. It is an exceedingly fatal disease, and, to one unaccustomed to seeing it, it is hard to be recognized. But when you have seen several cases, you can never mistake it. There will be a prominence on each side, at the back of the fauces; and when felt with the finger, this tumor will be found soft and rounded. I have seen cases, in which, in addition to the other inconveniences, the tongue was thrust forward, and projected between the teeth. Now, where you find this disease existing, I would recommend, that, in addition to the general treatment, you carry a proper instru- ment back over the tongue, and scarify the tumors freely, so as to allow the fluid to escape; and to continue the scarifying to the mu- cous membrane, and the sub-mucous cellular tissue, that the fluid may escape from them. After a few days, you will find the pa- tient perfectly relieved of every dangerous symptom. You are not, however, to desist from your treatment. Should the symp- toms continue, with cough, harsh breathing, &c, carry back, from time to time, an ordinary probang, wet with a solution of the nitrate of silver, and bring it to bear upon the part affected. With regard to abscesses, I need only say, that they should be opened according to the ordinary rules of our science. I would remark, however, that owing to the neighborhood of the glottis, the pUS—0n the abscess being opened—acted upon by the inspiratory effort, is apt to be drawn into the larynx, and may produce suffo- cation. I would therefore recommend, that you make the punc- ture during the first stages of expiration. Before I leave this subject, there is one affection, not generally met with in the books, to which I deem it expedient to call your attention. If you will examine the throat, you will find, near the os hyoides, and connected with it, a closed sac, or bursa, lined by a serous membrane, and secreting a fluid like that secreted by the membranes which protect the heads of the bones in the articula- tions. Now, where this sac becomes inflamed to a certain degree, it becomes distended, and projects, sometimes laterally, and some- times on the median line, almost as low as the two lobes of the thyroid gland. It is a soft fluctuating tumor, and is sometimes mistaken for goitre. When very large, this tumor interferes with deglutition and respiration, and may produce a cough. What are the methods of relief in such cases '( I apprehend that the most expedient and the best is, to seize the tumor; extend the sac; plunge in a small trocar; draw off the 420 GOITRE. fluid ; inject a solution of iodine, and leave this there, precisely as in the radical cure of hydrocele. You will generally find the sac, a few days afterwards, distended and painful; but soon absorption will go on ; the fluid will be all taken up; and the sac will be closed by granulation and adhesion. Where the operation fails, it may be repeated again and again. Another method of bringing about the same result is by seton ; and, when both of these fail, we are obliged, as a last resort, to excise the whole sac. We lay the tumor bare down to the sac, taking care not to injure any important struc- ture ; and then we seize the sac in a vulsellum, and remove it. Should the whole not be removed, the remainder must be cau- terized, and the wound be treated upon general principles. Another disease, frequently occurring here, is an affection of the thyroid gland, known as goitre. Now, this gland is very vascular, being made up of a number of blood-vessels, the meshes of which are filled up with glandular matter. It is remarkably inclined to undergo changes; particularly by an enlargement of its vessels, and sometimes by a change in the internal substance. From what- ever cause it may result, we have, at any rate, a gradually enlarg- ing tumor, known variously as goitre, bronchocele, &c. I should remark, that so far as the internal arrangement of the tumor is concerned, it is infinitely varied. Sometimes it is made up of nu- merous small cysts, containing a straw-colored liquid; and at others it is composed of a continued chain of small cells. As to its con- sequences, you will perceive, that, being situated beneath a layer of the cervical fuscia, and being bound down by it, it must act me- chanically upon the trachea, and may cause death by suffocation. Again ; owing to its proximity to the gullet, it may obstruct it, and prevent the ingress of food; and from its relations with the great vessels of the neck, and particularly the vein, it may prevent the return of blood, cause serious derangement of the brain, and eventually produce very serious consequences. Now, considering all these circumstances, and even disregard- ing the deformity, it becomes exceedingly important that our art should afford some means of relief. Various expedients have been recommended. The first which I shall allude to is, to secure the gradual wasting away of the tumor, by a ligature of the thyroid arteries, by successive operations. When the patient can stand this, I have no doubt that you will succeed in the cure. But it is an exceedingly hazardous procedure; and I must confess it is one from which I would myself recoil. TREATMENT OF GOITRE. 421 Another means is, to extirpate the gland. But from its intimate relations with numerous important vessels, and other structures, I am free to confess, that I should scarcely feel sufficient confidence, either in my heart, or my hand, to resort to such a plan. I have some little experience in surgical operations: there are few even of the most important, which I have not repeatedly performed. But of all of them, this, in which I once assisted, was the most ap- palling, tedious, difficult, and disagreeable. At every inspiration, the patient appeared to be on the point of suffocation; and not- withstanding every effort, air entered a divided vein, and the patient laid apparently dead for several moments, but rallied, and seemed to be doing well for some time, when she died from fever. Now, although the operation apparently succeeded in this case, it was so appalling, that though not very timid, I shall never again attempt to remove an enlarged thyroid gland. You may do so if you will. Fortunately, there are other plans of treatment; and the best of these, I think, is, when the tumor is encysted, to open it with a trocar, and inject it with iodine. Where this fails, and there are no vessels preventing, you may incise the cysts, and heal the wound by granulation. Unfortunately, however, it sometimes hap- pens, that an individual suffers from goitre, and there are no cysts; but the gland gradually expands ; and the disease, if not relieved, may cause vesicular emphysema of the lungs. Should the case be urgent, there are two expedients to be resorted to. One is the gradual removal, from time to time, of different portions of the tumor, by strangulation with a ligature, which is made to pass through it by means of a needle, in different directions and as profoundly as may be safe. You may use a metallic, or a silk ligature. When you use the metallic—which is the best—you must continue to * tighten it, from day to day, until the vessels of the part are de- stroyed, and it sloughs off; and you should then heal up the wound. From the nature of the gland, you will find it very apt to become atrophied when a part is thus destroyed ; but where no disposition to this atrophy appears, you may repeat the operation. The chief difficulty is that arising from the neighborhood of the structures of the trachea. Inflammation may extend to these struc- tures, and destroy the patient. Still I would resort to it, and if the glottis became closed, would avail myself of the benefit of tra- cheotomy, until the inflammation has subsided. The other expedient is, to remove successive portions of the tu- 422 TREATMENT OF GOITRE. mor by the knife, and at different times, taking care to save the skin. You may deem it exceedingly hazardous to cut into a sub- stance so vascular; but what capital operation is not hazardous? Bear in mind, then, that all these operations are dangerous : and I cannot leave the subject without remarking, that in practice, you will frequently meet with these cases. But do not think from aught I have said, or from a love of operating, that you should operate upon them all. The lesson that I wish to impress upon you is simply this, that in extreme cases, rather than Jet your patient die from suffocation, you had better operate. With regard to the local treatment, I have very little to say. Iodine and burnt sponge, have been recommended ; but I must confess, that I think they do no good. Indeed, I am free to acknowledge, that, in vascular goitre especially, where I have seen these iodine preparations used, the tumor has gradually increased ; and there is reason to affirm, that throughout the economy, wherever stimulants are applied, the flow of blood is increased. For these reasons, then, I seldom resort to any of those applications; but on the contrary, when the tumor is vascular, I direct the patient to apply, from time to time, a relay of leeches, and in the intervals, to use mild emollient applications. More relief is thus obtained than 1 ever found from iodine, burnt sponge, &c. Do not misunderstand me, however. There are cases in which, from the indolent nature of the tumor, these preparations may do good : but, as a general rule, you will find the other course preferable. DISEASES AND ACCIDENTS ABOUT THE THORAX. 423 LECTURE LX. DISEASES AND ACCIDENTS ABOUT THE THORAX--WOUNDS, AND THEIR COMPLICATIONS--HEMORRHAGE--COLLAPSE OF THE LUNG--WOUNDS OF THE LUNG--EMPHYSEMA--PLEURITIS--EMPYEMA--HERNIA PUL- MONALE--EXTRAVASATION OF BLOOD INTO THE CAVITY OF THE PLEURA--TREATMENT OF THESE ACCIDENTS--WOUNDS OF THE HEART. We have certain diseases and accidents occurring about the tho- rax, to which it is necessary for me to call your attention. So far as ivounds in the regular contour of the thorax are con- cerned, there are some complications which it is very important that you should understand. You may meet with simple wounds of the parietes. These may, or may not, be serious. They are often serious from hemorrhage, which must proceed from the inter- nal mammary, or some of the intercostal arteries. Where it pro- ceeds from the internal mammary, all that you will have to do is to ligate the artery, in the manner illustrated some time ago; that is, by cutting down upon the intercostal space, and seeking the artery as it passes downwards nearly parallel with the sternum. Where the hemorrhage proceeds from the intercostal artery, in con- sequence of its passing in a groove, and being tied down by the intercostal fascia, you may find it difficult to draw out the end of the vessel. Sometimes when the external wound is small, the outward hemorrhage may be slight, and you may be disposed to think it of little consequence. But the hemorrhage may go on internally, and the danger may not be discovered until too late. When the external wound is small, and the vessel is bleeding in- ternally, it is your duty, to dilate the wound, to seek the vessel with a pair of Physic's forceps, to pass a needle with a ligature, and to tie up the artery. Where you fail in doing this, and time presses, insert the finger, and compress the artery. It may be ne- cessary to keep up this pressure for some time; and a case may even occur, in, which you may find it necessary to have a relay of assistants for this purpose. As regards other external complications, I deem it unnecessary to refer to them; for, with the exception of those cases already spoken of, wounds of the parietes of the thorax are treated as wounds elsewhere. An instrument may penetrate into the cavity, without wounding 424 EMPHYSEMA. any of the organs; yet the result will be a complete collapse of the lung on that side, from air rushing in, and forcing the organ up to the superior and hinder portion of the side to which it belongs. All that is to be done here is, to stop any hemorrhage, in the man- ner already described, to remove foreign bodies, if there are any, and if there is neither hemorrhage nor foreign material, to close the wound at once, by adhesive strips or suture, and heal it as soon as possible, thus excluding the atmosphere. As soon as the air which has entered the cavity is absorbed, the lung will resume its nat- ural position; and if there is no other complication, the patient will recover and suffer no subsequent inconvenience. Wounds of the thorax, however, are not always thus got rid of. They may involve some important organ, or some blood-vessel, as there is no organ in the cavity, which may not be implicated in the wound. There is, therefore, a great difference in the prognosis. There are some injuries, as wounds of the heart and great vessels, or of the thoracic duct, which must, necessarily, prove fatal. It is through this duct that all nutrition takes place; and it is necessary, therefore, that we enter into some detail in regard to these acci- dents. In the first place, then, we will consider wounds of the lung. When you remember the extreme vascularity of this organ, and that it is composed of minute ramifications of the air tubes and blood- vessels, you will at once perceive that even slight wounds, pene- trating either lung, must involve some of these vessels and tubes. This will at once enable us to understand some of the attending circumstances of such wounds; for, as in the instance just spoken of, there will be collapse of the lung, hemorrhage from the mouth, &c. This hemorrhage is sometimes slight, and sometimes very profuse, and always accompanied with more or less difficulty of res- piration, and cough. As I have slated, it is sometimes slight. In other cases, the bleeding is so profuse, that if it is not quickly arrested, the result is promptly fatal. Another circumstance, frequently attending wounds of the lung, sometimes following promptly, and sometimes after the lapse of some hours, is an infil- tration of air into the cellular tissue, drawn, partly from the exter- nal wound, and partly from the wound in the bronchial tubes. It may take place into the cellular tissue of the lungs, or into the tissues between the pleura and the ribs; and, as this cellular tissue is in continuity throughout the system, the whole body may be- come puffed, as though a bellows had been inserted, and the body TREATMENT OF WOUNDS ABOUT THE THORAX. 425 blown up. Here there is no pitting as in a collection of fluid. In consequence of this infiltration of air about the neck and body, and especially about the glottis, this emphysema may quickly de- stroy the patient. Again : taking place sooner or later, we may have pleuritis, or inflammation of the pleura, as a consequence of a wound of the thorax. This is a dangerous complication; and, unless promptly subdued, it will soon prove fatal to the patient. Again: it sometimes happens, in consequence of a wound of the lung, that a difficulty takes place of a different nature, and appear- ing at a time more remote. The external wound heals, but a pseudo membrane is thrown out from the pleura, and a serous or purulent fluid fills up the cavity. The ribs bulge; the diaphragm is pressed down ; and respiration is carried on almost entirely by the lung of the opposite side. This condition may continue for some time ; but ultimately the patient becomes the subject of irri- tative fever; and, unless relieved of this, he dies. This purulent collection in the thorax is called empyema; and it is not unfre- quently the result of wounds in this region. In wounds penetrating the thorax, we sometimes, though rarely, have a protrusion of a portion of the lung, or a case of hernia pul- monalis ; and this may occur, whether the lung be implicated or not, especially when the external wound is large. The reason that this is not apt to occur is, the liability of the lung to collapse, on account of the rushing in of the air. It occasionally takes place, however, from the wound happening at the moment of a strong inspiration. There is another consequence of these wounds, and one of great importance, being a necessary result whenever any vessel of the lung is wounded. I mean an extravasation of blood into the cavity of the pleura. Blood is thrown out from the wounded vessel or vessels; and, unable to flow outwardly, it by degrees compresses the lung, and fills the whole cavity; thus considerably embarrass- ing the respiration. When it reaches this extent, it is important that a sufficient amount of air should enter the lung to support life, or the patient will die of asphyxia. Such being the principal consequences of a wound in the thorax, we shall now proceed to the treatment of these accidents. When we inquire what are the duties of the surgeon in these cases, we find that there is a wide difference of opinion. In general terms, I have remarked, that the first duty is, immediately to close the 426 TREATMENT OF WOUNDS ABOUT THE THORAX. external wound; and it is in reference to this very point, that a dif- ference of opinion exists. Some contend for a course exactly the reverse, advising that the wound be left open and dependent, so as to allow any blood that may collect to flow out. This is a practice very highly recommended, and I confess, that there are circum- stances under which it may be adopted; but, when you consider those steps by which nature, when unaided, stops hemorrhage, you must admit, that by this course, you place the patient in that very position in which nature is deprived of all the collateral aid, by which she is enabled to form a clot in the vessels. Such, I say, would be the result of placing the wound in a dependent position, and allowing the blood to flow away. Let us next see, what would be the result of closing the wound. Blood would gradually fill the pleural cavity and the wound in the lung, and the coagu- lum which forms, not being able to escape, extends up to the wounded vessels, thus affording a temporary check to the flow, and rendering all safe, until plasma can be thrown out. I say, then, that all wounds implicating the thorax should be closed as soon as possible. But you may reply, that thus we cause an accumulation in the pleura, to such an extent, perhaps, as shall encroach upon the mediastinum. This is true ; but, generally, we have only to leave the accumulation alone, and it is gradually absorbed. Should it, however, be necessary to interfere, then, after the external wound has healed, all we have to do is, to seek the most dependent point, and, by performing the operation of paracentesis, to draw off the fluid. This, I apprehend, is the best method of treating these wounds. Having closed the wound, and attended to the other circum- stances of which I have already spoken, are we calmly to stand by and do nothing more to aid our patient? Certainly not. Where the hemorrhage is profuse—if you find blood flowing freely from the wound, and also voided by expectoration—I say, that under these circumstances, if the patient is young and strong, you should not hesitate a moment; but place him in the erect posture; tie up the arm ; and bleed him ad deliquium. At first it may appear that this procedure is absurd, as there is too great a loss of blood al- ready going on, to admit of a further loss. But this objection is more apparent than real; for a certain flow must take place, before the hemorrhage at the wound can cease ; and it is far better that the blood should come from the arm, than from the wound, where it may do so much harm by extravasation. I say, then, when you PARACENTESIS THORACIS. 427 are called soon, and the patient is not too much reduced, you should bleed, in the erect posture, and ad deliquium; and then you should place him in a horizontal position, his head being slightly elevated, and carefully inspect and dress the wound. Repeat the bleeding as often as may be necessary; place the patient under the influence of tartar emetic; and give opium freely, to prevent cough. Having stopped the hemorrhage, there are other circumstances to be looked after. We have seen that sooner or later pleuritis or peripneumonia may be developed. Now, as soon as either of these appear, or any of their symptoms, you should bear in mind, that they may follow traumatic inflammation, and that this may be quickly fatal; so that all that can be done, must be done promptly. Combat the inflammation at once, by leeches, general blood-letting, and all those methods that are used in combatting pleuritis or pneumonia under other circumstances. Where the constitution is good, and the disease has been allowed to go on from day to day without being checked, I would advise you to resort to the prepa- rations of mercury, aided by squills, digitalis, &c, also using revul- sives to the chest. But where the patient is already exhausted by hectic, and there is no time to be lost, the operation of paracen- tesis must at once be resorted to. If the wound is on the right side, seek for the intercostal space above the sixth rib ; with a scalpel divide the integuments parallel to the upper border of the lower rib ; expose the intercostal muscle ; insert a grooved director, and cut upon it, first in one direction, and then in the other; divide the aponeurosis; expose the pleura; and then draw off the liquid. Some have recommended to keep open the external wound. I, however, object to this; and in order to close it at once, I would advise you to draw up the integuments before making the external incision, so that they may form a kind of valve; and if the fluid collects again, repeat the operation, rather than keep open the wound. When the operation is to be performed on the left side, it is necessary, from the position of the heart, to vary the spot for the opening, and to operate very far back, on the border of the longissimus dorsi. As regards other wounds of the thorax, those involving the heart, great vessels, thoracic duct, &c, it is unnecessary to say much. Those of the heart, though generally fatal, are not always so, even where the left ventricle is wounded. There are instances, where the wound has been so narrow, that the clot has closed it before 428 WOUNDS ABOUT THE ABDOMEN. the blood could flow out into the thorax ; and the patient has re- covered. But where the wound is large, though sometimes there appears to be a recover}7 for a short time, a sudden flow of blood will cause death. So also with wounds of the large vessels; for the most part, they are necessarily fatal. Hence I need not say much of them here. The annals of science show some curious examples of wounds in the heart, followed by recovery, especially among the lower animals. So, also, are there some curious exam- ples among human subjects. One case I remember, where a plug was driven into the heart, and, notwithstanding this, the lad lived five months. The case is given upon good authority; but I mention it, not to encourage you with hope in the treatment of such wounds, but merely as a curious example. LECTURE LXI. WOUNDS ABOUT THE ABDOMEN--WOUNDS, SIMPLE AND COMPLICATED— PROTRUSION OF ORGANS--WOUNDS OF ORGANS AND THEIR TREATMENT. We design this morning, gentlemen, to make a few observations on wounds about the abdomen. In our last, we had occasion to re- mark, that on account of the importance of the organs in the tho- racic cavity, a wound about that neighborhood was of a serious, and often fatal character. We may apply the same remark to wounds about the abdominal cavity. In this cavity we have or- gans of the utmost importance—the kidney, the bladder, the stom- ach, liver, intestines; in the female, the uterus and its appendages, &c, besides vessels of great size, and most of them of great im- portance. In our remarks concerning these wounds, we find it convenient to pursue the same course as in speaking of wounds of the thoracic region. First, we have those wounds which, while they penetrate the cavity, injure none of the important organs of which I have spoken. These wounds will differ in importance, according to their extent. A wound may, for example, only penetrate the cavity, and be of so little extent that no organ will protrude, and there will merely be a solution of continuity of the abdominal walls. WOUNDS ABOUT THE ABDOMEN. 429 The ultimate consequences of these wounds are very uncertain. They may heal without any difficulty; or they may result fatally, from being complicated with a wound in some large vessel, causing a great flow of blood into the cavity; which condition the surgeon may not detect, until the patient is about to expire. They may also become serious from the supervention of inflammation of the peritoneum. This membrane is exceedingly prone to inflame; and, when once inflammation is established here, it extends rapidly. Hence, after the lapse of a short time, a simple penetrating wound, apparently trifling, may expose the patient to the risk of his life. A wound of any considerable extent is apt to be attended with a protrusion of one or more of the organs contained in the cavity. The character of the organ protruded, and the extent of its protru- sion, depend on the position and extent of the wound. The very circumstances attending the reception of the injury, often expose the patient to accidents of various kinds. The protruded organ, for example, is exposed to the atmosphere, and when the patient falls to the ground, it may become covered with dirt, pebbles, &c.} which often become the cause of very serious results. As you may well suppose, the ultimate consequences of those wounds ac- companied by protrusion are more apt to be of a fatal tendency than if they were not thus complicated. Especially are such wounds liable to be followed by violent peritoneal inflammation, extending to those organs most connected with the point of injury. We should, therefore, be very cautious and guarded, and not treat lightly the first symptoms of peritoneal inflammation. Let us then see what are the duties of the surgeon in wounds of the abdomen, putting out of the question those, complicated with injury to some of the organs. First, he must stop the hemorrhage; and then he must carefully approximate the edges of the wound. The means of accomplishing this. latter indication, are various. In the first place, you should avail yourself of position. Fix the patient on his back, with his head and shoulders elevated, and with the thighs slightly flexed on the pelvis. Such a position will relax the abdominal muscles, thus preventing the pressure which they would otherwise exert, and which might cause a protrusion of the organs, as well as a gaping of the wound. Your second means of approximation will consist in the application of inter- rupted or quilled sutures. In most cases, these will be sufficient, with the aid of adhesive plaster, and the application of compresses 430 WOUNDS ABOUT THE ABDOMEN. and a roller, or a bandage carried round the abdomen, and so ar- ranged as to press on the point of injury. These are all the general rules of treatment in such simple cases. In all cases where union by the first intention may be hoped for, pursue the same course, as by so doing you can lose nothing. Where 3rou have, associated with the wound, a protrusion of some organ, your duty is a far more serious one. Here, after stopping the hemorrhage, you should cleanse the protruded organ with tepid water, or with milk and water, and, having placed your patient in such a position as to relax the abdominal muscles, by cautious and gentle means, return the organ into the cavity, and then close the wound as in the previous case. But your duty does not stop here. You must carefully watch over the case; not with regard to the wounded part alone, but in fear of violent inflammation coming on. Any sign of this will call for prompt and free blood-Jetting; for leeches on the painful parts; and for the evacuation of the bowels. Besides all this, you should place the patient on large doses of calomel and tartar- ized antimony; you should use fomentations to the abdomen; and more than all, you should give large doses of opium—I say, large doses of opium; for, however useful this agent may be, in all the phlegmasia?, yet there is no form of inflammation in which it is so useful as in acute peritonitis, and especially in traumatic perito- nitis. Should it be necessary, you must repeat the blood-letting from time to time; but as the vital energies grow weak, your reli- ance must chiefly be placed on calomel, tartar emetic and opium. You should push the use of the latter to the fullest extent, with- out producing the unpleasant effects upon the brain, which some- times supervene. When the vital forces are impaired, you must substitute leeches for venesection; and it may sometimes also be necessary to control irritation, by the use of blisters and other counter-irritants. These are the means which you are to adopt; and allow me to say, that provided you do not delay too long, or do not resort to them with a timid hand, you will often have the satisfaction of seeing that success crowns your efforts. With regard to the use of opium it might be interesting to in- quire, how any agent, partly stimulating in its effects, could be use- ful here. I should suppose that, by its sedative operation, it lessens the flow of blood to the part. This, however is not all, for opium WOUNDS INVOLVING THE ORGANS. 431 greatly modifies the action of the capillary vessels, which are very numerous here; and there is also another important reason to be considered in reference to its use in cases of acute peritonitis. While the intestines are in their natural position, there is a kind of perpetual motion in these parts, stimulated into action as they are, by food, drink, &c. But as perfect rest is highly important in the treatment of any inflammation, it is a matter of the utmost conse- quence that the bowels should be kept as still as possible in the treatment of violent peritonitis, and it therefore becomes necessary, if I may so say, to stop the organ. But be this reasoning satis- factory or not, experience upholds us in continuing this method of treatment. Let us next go on to speak of those injuries which are compli- cated with wounds of some of the abdominal organs. These in- juries differ as to the different organs, nay, even as to the different parts of the same organ. The alimentary canal is a hollow organ, destined to contain articles for nourishment, and also to receive the products of the secretory action of various organs; so that a wound entering the canal, will be followed by a flow of these, its contents, into the peritoneal cavity. As the peritoneal membrane is exceedingly delicate, these bodies cannot fail to excite violent inflammatory ac- tion, running on, unless it can be arrested, to the speedy death of the patient. But this is not all; for suppose the liver be implica- ted in the injury. This is an extremely vascular organ ; and a wound in any part of it must open such vessels, as shall cause hemorrhage to an alarming, or even fatal extent. Unfortunately, too, this hemorrhage is concealed, and consequently is only known to exist by its effects. We have also, traversing the liver, numer- ous excretory tubes, or ducts. A number of these ducts must also be wounded ; and thus the bile, a yery irritating matter, flows into the peritoneal cavity, and cannot fail to cause violent, and often fatal inflammation. It will be even worse, if the wound penetrates into the excretory duct of the gall bladder, or into the gall bladder itself. So serious are these wounds into the duct, or the bladder, that they may be pronounced, at once, as fatal, not from any immediate consequence, but from the violent peritonitis, to which they give rise. A^ain: when a wound penetrates the spleen, from the vas- cular nature of this organ, it is apt to end suddenly in fatal hemor- rhage or to result in a similar manner as those spoken of above. So also when wounds penetrate into the bladder, kidney or ureter; 432 WOUNDS OF THE INTESTINES. such wounds are almost necessarily fatal; as the urine is of so acrid a nature, that it will speedily cause the death of any part with which it may come in contact. As regards wounds of the ovaries and uterus, in the female, the first thing to be remedied is hemorrhage; and the next to be guarded against, is metritis or ovaritis, either alone, or combined with peritonitis. With regard to wounds of any of the large ves- sels, I need say nothing in addition to what was said yesterday on injuries of the thoracic vessels. They are generally fatal before their precise nature is discovered. Such are the general indica- tions to be fulfilled, in the treatment of wounds of the abdomen. But this is a subject of so much importance, that I must consider it under several different heads. Suppose, first, a wound in the stomach. It will be your duty, after having cleansed the wound, and removed all foreign bodies, to bring the surface of the wound in the stomach together by means of animal sutures; and then to close the external wound. The external wound may not be of sufficient extent to expose the wound in the stomach; and yet you may be sure that it has been punctured. Now, when you have not strong reason to suppose that such is the case, I apprehend that nothing will justify your extending the wound to examine the stomach. Your chief reliance must be placed upon keeping the patient quiet; combatting the first appearance of inflammation ; and allowing nothing whatever to enter into the stomach. The patient meanwhile is to be sup- ported by enemata. So, also, when the intestine is punctured; if the external wound, does not expose the internal, you must, as in the preceding case, rely on the same treatment; and nothing will justify your opening the abdomen to seek the wound. Where, however, the intestine has protruded, and you find a wound in this protruded portion, a different procedure is necessary ; or, where you discover no wound in the protruded part, but are sure from the escape of feces or other indications, that there is one higher up, then it may be ex- pedient to draw out the adjacent convolutions of intestine, and examine them most carefully, passing them through the hand until you find the point or points, (for there are sometimes more than one,) which have been injured. When you find these wounds, your duty is, to close them as soon as possible. Suppose the wound has entered, but not passed through the intestine. All that you will then have to do is to cleanse and empty the bowel, to WOUNDS OF THE INTESTINES. 43 3 close it by one, two, or more sutures, and cut these off close to the knot. The animal ligatures are the best in these cases. Having finished this dressing, and cleansed the parts thoroughly, the ques- tion arises, whether you should return the intestine into the cavity, or secure it by ligatures, to the external wound. Where the wound is transverse or oblique, and if it is of limited extent, I ap- prehend that there is no occasion to keep the injured intestine in contact with the external wound. Plasma is thrown out rapidly under such circumstances, and not only prevents extravasation, but even unites the intestine to the surfaces with which it is in contact. The ligature soon sloughs out, into the intestine, and gives no farther difficulty. Suppose, however, that the intestine is cut entirely through. Here we cannot unite it sufficiently to prevent extravasation ; and the best method is, to draw out the ends of the intestine at the ex- ternal opening, and apply the suitable ligatures, keeping the intes- tine at the external wound; which wound should be kept open, until the fecal matter passes by the natural way. In this connec- tion I would mention, that various methods, and modifications of this operation have been proposed from time to time. Few of them, however, will be found to succeed on man. The principal one of these, is that of Gobert; which chiefly consists in passing the upper end of the intestine into the lower, and retaining it there by sutures. To succeed in this plan, however, another modification is necessary. You are aware, that mucous surfaces will not adhere to serous ones. It becomes necessary, therefore, to turn the margin of the lower end in upon itself. Having done this, we bring the upper serous surface into the lower, and secure it in contact by points of suture, taking care not to close the external wound, until these parts are perfectly healed. Then it may be closed, and the ligatures will pass off as in other cases. This method will succeed very well with the lower animals, and sometimes, even with man ; but I doubt if, on the whole, the method already spoken of will not be found the best. There are several other expedients, which I think it un- necessary to mention here. I will merely observe, in concluding, that, having attended to these preliminaries, we must expect in- flammation, and that we must combat this by the most powerful antiphlogistic treatment. Blood-letting, general and local, should be practiced with a liberal hand, and repeated, if necessary, accord- ing to the urgency of the case; fomentations should be applied to the abdomen; and opium, to allay pain and quiet the peristaltic B* 434 PARACENTESIS ABDOMINIS. action of the intestine, will often render essential service. It is desirable that the contents of the bowels should be evacuated, but purgatives and enemata are of doubtful propriety. The latter, so generally recommended, even at the outset of the treatment, I have known to destroy life where the large intestine has been wounded, by the fluid of which they are composed, passing through the wound into the peritoneal cavity. When )7ou have reason to suppose, however, that the wound is high up, injections should be used early, to empty the bowels. The patient should be confined, during the whole treatment, to small quantities of the mildest mucilagin- ous and farinaceous drinks. In some cases, by your skill and judg- ment, you may save life ; but generally, such inflammatory action is set up, as shall inevitably result in death. You must not, however, suppose that every wound which trans- fixes the abdomen and peritoneum, must also involve, of necessity, some of the contained organs. There are cases, in which gun shot have raked through this part, and swords transfixed it, without in- juring, in the slightest degree, any of the organs within. You must, therefore, be guided by circumstances. If blood passes by stool, then the intestine is wounded. If there is great collapse, then some vessel is wounded. If these symptoms are absent, then the chief difficulty to be contended with will be the wound in the parietes. ESSAY No. 7. OPERATIONS ABOUT THE ABDOMINAL WALLS--PARACENTESIS ADOMI- NIS--PUNCTURE OF THE URINARY BLADDER--OPENING SMALL INTESTINES--GASTROTOMY. Among the enlargements and swellings for which surgical aid is desired, perhaps there is none more common than that caused by a collection of serum within the walls of the abdomen, either as one large cyst enclosed by the peritoneum, or as several cysts collected together within the peritoneal cavity. Ascites will fre- quently increase under the most skilful medical treatment, and the accumulation will go on to such an extent as to threaten im- mediate death by suffocation, if relief be not promptly afforded. Under these circumstances paracentesis abdominis, or tapping of the abdomen, becomes necessary. PARACENTESIS ABDOMINIS. 435 There is great difference of opinion with regard to the curative tendency of this operation. Some surgeons believe that dropsy of the belly may be perfectly removed by this means alone; while others contend that it will always, sooner or later, be followed by death. I am inclined to believe that as a curative measure, para- centesis is quite valueless; as in every instance the water will re- accumulate, and the swelling, and consequent suffering, progress even more rapidly than before. Be this, however, as it may; there can be no doubt that tapping for ascites, causes an instan- taneous relief from great suffering, and that this relief is of a day or two in duration : during which period, the patient is comforta- ble ; and all the functions of nature are regularly carried on, thus affording to remedies a better opportunity of acting, and in some degree restoring the sufferer to strength. Indeed, so great is the relief afforded, that if the individual has ever been tapped before, it will be a difficult matter for his surgeon to resist his importuni- ties; for tapped again he certainly will be. The operation is one of the easiest, quickest, and least painful in surgery, and is very seldom followed by any inconvenience. In performing this operation, the French surgeons generally, re- commend that the instrument be passed at some spot in the left flank ; and when no particular reason exist for selecting otherwise, the puncture is made through the center of a line drawn from the anterior superior spinal process of the ilium on the left side. The English and American surgeons, on the other hand, prefer intro- ducing the trocart through the linea alba, somewhere between one and three inches below the umbilicus. If operated upon in the first method, the patient may remain on his back; but if after the English fashion, he must be seated on a chair, or near the edge of his bed, and the body must be kept erect. Several forms or modifications of the trocart have been from time to time recommended. Bell speaks highly of a small flat in- strument, which is also lancet pointed; and this instrument, under various modifications, has been very generally adopted. I find, however, that an ordinary triangular pointed trocart of medium size answers the purpose as well as any other. When about to perform the operation, a piece of strong homespun should be pro- cured, of sufficient breadth to extend from the sternum above to the spine of the ilium below, and long enough to pass around the body. This should be split from either end to within about six inches of the center. The point of puncture having been selected, 436 PARACENTESIS ABDOMINIS. the bandage of homespun is passed around the body, its ends being crossed behind and held by assistants, and a hole having been cut through its center. This hole is so placed as, through it, to leave the point of puncture bare. The surgeon should then place himself in front of the patient, holding the trocart in such a manner, that the handle will press against the palm of his right hand, the thumb and index finger of which should pass along the trocart and press firmly upon it, so as to regulate the depth to which it is pushed. The assistants then drawing upon the ends of the bandage so as to make constant pressure upon the abdomen, the trocart is driven into the cavity by a sharp quick blow. The operation is performed in a second, and is almost painless. As soon as the instrument has penetrated the abdominal walls, the stylet should be withdrawn, the canula being firmly held in its position, by the first and middle fingers of the left hand. Whilst the water is being drawn off, the bandage must be kept constantly tight enough to keep up a firm pressure on the abdomen, otherwise a fainty feeling may overcome the patient. Should fainting ac- tually occur, the flow of water must instantly be put a stop to, some gentle stimulant given, and the patient kept quiet until all unpleasant feelings have passed away when the drawing off of the liquid may be resumed. When this is necessary, it has been recommended by Fleury, to leave an elastic gum catheter in the opening after withdrawing the canula. This catheter should be introduced through the canula after the stylet has been drawn out; and as soon as this is done the canula itself is withdrawn, leaving the gum catheter in the wound; which may be worn for several hours without inconvenience, as it adapts itself to the position of parts, and the water flows constantly through it, the flow being easily checked or stopped, by pressing a cork into the orifice of the catheter, and resumed when the feelings of the pa- tient will permit. When as much of the water as can be drawn off is removed, and the instrument is withdrawn, the bandage should be carefully and smoothly adjusted over the abdomen, the ends drawn moderately tight, and either tied behind, or drawn forward and pinned in front. The wound only requires simple water dressing, and will give no trouble. Should hemorrhage occur—which is very rare—the entire soft parts around the tumor may be caught up between the fingers, and firmly pressed, until the disposition to bleed has ceased. This operation is not gen- erally resorted to, until great distention and consequent suffering PUNCTURE OF URINARY BLADDER. 437 renders it necessary. Bell, however, advises, and with apparent justice, that the liquid be drawn off early ; and as no evil is apt to result from the operation, and much suffering is thereby saved the patient, it will perhaps be well to follow his advice, at least in such cases as are found to increase rapidly, as it appears generally admitted that the collection returns much sooner after the opera- tion, if the previous effusion has been great, than when the accu- mulation was of small amount. The urinary bladder sometimes becomes so much distended by its contents as to endanger life, by a rupture of that tyst, and the consequent discharge of urine into the abdominal cavity. This distention of the bladder may be the result of a paralysis of that organ, by the pressure of a tumor on the urethra or neck of the bladder, or any cause calculated to check the discharge of urine, without also checking its secretion. Under such circumstances, puncture of the bladder and the drawing off of the urine becomes necessary. Two methods of performing this operation are now recognized among surgeons, puncture through the rectum, and puncture over the pubis. Formerly it was also sometimes recommended to enter the bladder through the perineum, or to draw off the urine by forcing an instrument into the bladder through the urethra : these methods, however, are no longer recognized. Of the two methods now adopted, puncture over the pubis ap- pears to be most generally preferred. When about to enter the bladder from this point, the patient should lie on his back in the right side of his bed, and near its edge, with his head and should- ers slightly elevated, and his legs drawn up. The surgeon then, standing on the right side, should make the integuments terse above the pubis, by stretching them apart with the finger and thumb of his left hand, while he plunges the trocart at right angles to the axis of the body, into the bladder, through the linea alba, about an inch and a half above the pubis. The instrument used should be about four inches long, and of such a curvature as to represent the part of a circle, whose diameter is six inches. When used the concavity of the trocart should look towards the pubis. The stylet should be immediately withdrawn, and the canula kept in its place by tapes attached thereto, and fixed to a bandage, previously passed around the body. After the bladder has been emptied, the canula should be closed by apiece of cork, and left in 438 PUNCTURE OF URINARY BLADDER. its position until the urine finds a vent again per vias naturales. While worn, the canula must be uncorked from hour to hour, and the urine be permitted to come away. After the seventh or eighth day all danger of infiltration of urine will have passed, as the course of the canula will then have become lined by an adventi- tious membrane isolating it completely. Should puncture by the rectum be preferred, the patient must lie on his back with the leers drawn up, as though about to un- dergo the operation for stone. The left index finger, being then well oiled, is introduced into the rectum, and passed on until the tumor formed by the enlarged fundus of the bladder is plainly felt. A curved trocart, about four or five inches long, is then passed along the finger as a guide, the convexity of the instrument resting on the finger, and its piercer drawn just within the canula. The trocart is passed in, until it reaches the anterior wall of the bowel at the spot touched by the bladder, and the handle being then driven forward by a firm quick stroke, the point is bared and enters the bladder, followed by the canula. The insirument being kept in situ, the finger is withdrawn from the rectum; the piercer is then also removed, and the canula, held between the index and middle fingers of the left hand, is left in the bladder. As soon as the urine has all flowed away, the canula should be corked and left in its position, remaining in the bladder until the urine finds a vent through its natural passage again. As soon as this occurs it may be withdrawn, and the wound will soon heal. The most con- venient method of retaining the canula in the bladder is to secure a bit of tape to it, and then passing one end in front and the other behind, attach them to a bandage passed around the body for that purpose. If this method does not succeed, a com- press and bandage must be applied over the rectum. The canula being closed by a cork, the urine can be let off from time to time; but if this be objected to, the instrument may be left open and the urine permitted to drip constantly away. In the latter case the canula should communicate directly with some vessel. After this operation, the greatest difficulty results from the re- moval of the bandages, &c, necessary on the patients going to stool. At this time the canula should be lifted up as much as pos- sible, and pressed firmly against the upper wall of the rectum while the feces are passing. The chief object to be kept in mind when reverting to these operations, is that we avoid wounding the peritoneum with the ARTIFICIAL ANUS. 439 trocart. It will be remembered that this membrane being re- flected over the base of the bladder, falls slightly in front and behind it, forming a hanging pouch between the bladder and pubis before, and between the rectum and bladder behind. Hence, when the fundus of the bladder is lifted by the filling and disten- tion of that viscus by urine, the peritoneum is pushed up, in such a manner as to leave a large space, of both the anterior and poste- rior walls of the organ, uncovered by serous membrane. It is through this naked part of the walls of the bladder that the trocart is passed in each of these operations. Some authors of high authority contend that these operations are never necessary, and maintain that forced catheterism is always preferable. Erichsen, after describing the operations, observes : " A far safer procedure than this, and one that is recommended by Sir B. Brodie, Mr. Liston, and most surgeons of authority in these matters, is forcible catheterism. As the retention is generally owing to an enlargement of the middle lobe of the prostrate, relief may be afforded by pushing the point of a silver catheter through this obstacle into the bladder. A false passage is thus formed, in which the instrument should be left for about forty-eight hours, when it will generally enter it with sufficient readiness on being introduced again." On the contrary, many distinguished surgeons, among whom is Sir Astley Cooper, recommend puncture above the pubis, as a simple and efficacious remedy. Cooper prefers a straight trocart and canula, both of which should be rather short. These he intro- duced into the bladder just above the pubis, in a downward and forward direction, having first incised the integuments. The water having been drawn off, he recommends the substitution of a gum elastic tube for the silver one, as less apt to cause ulceration and more easy to the patient. It sometimes happens that scirrhus attacks the large bowel, and its calibre becomes thus gradually lessened, until eventually it is quite closed. Under these circumstances, or where the contents of the bowels are retained from the closure of the rectum from other causes, it may become necessary to open the intestines through the abdominal walls, and so give exit to the feces. The bowel mav be opened anywhere above the seat of obstruction, and having been thoroughly emptied of its contents, should be securely fast- ened to the external wound and caused, if possible, to adhere thereto. M. Sittre, the first surgeon who recommended this opera- 440 ARTIFICIAL ANUS. tion, advised that the opening be made in the left iliac region at the sigmoid flexure of the colon. Since that time the operation has been frequently performed on different parts of the body, and in the first case recorded, in which the operation was performed on an adult, the coecum was opened from the right side. Surgeons have now generally settled upon two methods of operating in such cases; the method of Littre, and that of Calisens, as modified by Amussat. According to the first method, or that of Littre, "the subject lying on his back, make in the left iliac region an incision, com- mencing on a level with the anterior superior spine of the ilium, and prolonged almost parallel to Poupart's ligament, to the extent of two or three inches. The integuments, muscles, and fascia transversalis, are successively divided with precaution ; after which the peritoneum is opened and the sigmoid flexure sought. Sometimes it has happened, that immediately after the opening of the peritoneum, a portion of small intestine has protruded, and its dilatation, with its color, reddened by inflammation, cause doubt. You recognize the nature of the intestine by the absence of expan- sions and longitudinal bands, and by the resistance of the mesentery which comes from the right side, whilst the resistance of the iliac meso-colon is felt from the left. Moreover, the colon has a natural ten- dency to present itself at the opening. A loop of thread is passed into the meso-colon to fix the intestine to the wound, and the intes- tine is divided longitudinally. It is evacuated; and at the end of two or three days when the adherences have united the intestine to the peritoneum and external wound, the thread may be removed ; but care must be taken lest the new anus contract too much."— (Malgaigne.) The operation of Calysens, as modified by Amussat, is thus described by Erichsen. " A transverse incision is to be made two fingers breadth above, and parallel to the crista ilii of the left side, or rather in the middle of that space, which is bounded by the false ribs above and by the crista ilii below ; the incision should commence at the external margin of the erector spinse and extend outwards for about four inches. The spinous process of the lumbar vertebrae, the crista of the ilium, and the last false rib, are the principal guides. The superior margin of the crista ilii is, however, the safest of these, and the transverse incision may be said to correspond to the middle third of this part of the ilium. After having divided the skin, and all the more superficial tissues, the deep layers are next to be incised as they present themselves ; OBSTRUCTION OF THE BOWELS. 441 if necessary the external border of the quadratus lumborum may also be cut across. The dissection is then very carefully to be carried through the layers of cellular tissue, which lie immediately upon the intestine, and the colon sought for; this will, in general, readily present itself, and may at once be recognized by its color and distended appearance. The operation may then be completed by passing a tenaculum or needle armed with a strong waxed thread, into the most projecting part of the gut and by this means drawing it to the surface of the wound, in order to prevent its shrinking or sinking back when opened. It is now to be punc- tured with a large trocart or bistoury, and its contents having been evacuated, the sides of the opening in the intestine are to be fixed to those of the incision in the skin by four or five points of suture, so as to prevent the contents of the bowel being effused into the cellular tissue of the wound. It is of importance to draw the co- lon well forward before opening it, in order to prevent its contents from being effused into the loose cellular tissue, where they may set up considerable irritation and retard the union of the parts. If the patient is very fat, the operation will be much facilitated by dividing the deeper seated tissues in a crucial manner, so as to give the operator more space." I will only add, that what is regarded as the great advantage of this over the original method of Calli- sens, is, that the incision being made in a line parallel with the course of the larger nerves and vessels, they remain uninjured. The peritoneum, too, remains uninjured, and it is for this reason that the operation is so seldom followed by peritonitis. It has been observed, that even where death results, no symptoms of inflam- mation have occurred, the death having depended on some other cause. The exemption from peritonitis may, in a measure, how- ever, result from position, as the patient lies on his back, and the wound being dependent, the contents of the bowels escape freely, without any cause to make them settle, or become effused in the surrounding tissues. This is the method of operating, which is preferred at the present day; and when resorted to, the patient, when being operated on, should lie on his belly, slightly turn- ing on the right side, with the body raised by placing one or two pillows under the belly. The bowels sometimes become obstructed by a foreign body retained in them, by strangulation, or stricture of the intestines, by volvulus, or twisting of the gut, or some other cause. Under these circumstances, as life is endangered, it has been proposed to cue 442 GASTROTOMY. down upon the seat of the obstruction, and remove its cause. This operation has been frequently performed, and often followed by relief, if the foreign body has caused so much irritation as to oc- casion abscess, this should be freely opened, and the body removed. Where the seat of obstruction can be certainly determined, we should make the incision directly over it, proceeding as directed below. Where the seat of obstruction cannot be discovered, a longitudi- nal incision should be made in the linea alba, about three inches long, and carried down to the peritoneum; this membrane should then be very carefully opened, and the opening enlarged by pass- ing the left index finger through the wound, and slitting the mem- brane up with a probe-pointed bistoury directed thereon. As soon as the membrane is opened, the small bowels are apt to protrude, and should be carefully drawn one side, and held in a soft towel by an assistant. The surgeon should then carefully seek the ob- struction. If this should consist of an invagination of the intestine, the invaginated portion should be gently drawn out, and the whole returned into the abdomen. If the bowel is occluded by a hernial constriction, the constricting bands should be as carefully divided as possible, by a probe-pointed bistoury well guarded, or the loop of intestine gently drawn out from the opening in which it has been caught. If it be a case of volvulus, the gut should be un- twisted, and all returned into the abdomen; and the external wound must be closed by the continued suture, and allowed to heal. Should the difficulty arise from a foreign body, this should be removed through a longitudinal incision along the convexity of the gut, and the case then treated as one of wounded intestine. Where a foreign body lodges in the stomach, and so causes dan- ger to life, it has been proposed to remove it by cutting down upon and into the stomach. The operation has indeed been performed, but so seldom that it is as yet impossible to decide as to its expe- diency. Gastrotomy has been performed in the following manner. The patient being put on a high table with his legs hanging over at one end, is put fully under the influence of chloroform. The surgeon then takes his position between the patient's legs, and carefully examines the region of the stomach. If the body has by its irritation caused abscess, or if it be undoubtedly felt projecting at any point in the stomach, the incision should be made directly upon it, as it is very likely that it has already occasioned sufficient inflammation to cause adhesions to be formed ; and here also the CJESARIAN SECTION. 443 incision should be made in a longitudinal direction. If the posi- tion of the body cannot be discovered, a longitudinal incision should be made in the linea alba,three inches in length, and down to the peritoneum; this membrane must then be very carefully opened, and the opening enlarged by passing the left index finger through the wound, and slitting the membrane up with a probe-pointed bistoury directed thereon. If the transverse arch of the colon should present itself, it must be gently pushed down, and the an- terior surface of the stomach will be reached; this should be cau- tiously opened, and great care taken not to prolong the incision to either curve, as by so doing the coronary arteries might be wounded. The body being removed, the wound must be treated as a wound of the stomach from any other cause. Erichsen has suggested, that some instrument might be invented, by which for- eign bodies in the stomach might be seized and removed through the throat and mouth, and reminds us of the fact that jugglers sometimes introduce instruments of large size into the stomach by throwing them very far back. The suggestion is a good one, but experience alone can determine upon its practicability. Caesarian Section. It sometimes happens that the female pelvis is so much con- tracted, by disease affecting the bony structure, from accidental causes, or as the result of congenital malformation, that it becomes impossible for a full grown foetus to be forced through the natural passages, even though it be dissected completely in utero. When every means is known to be unavailing, and neither manipulation, skill, the use of instruments, nor even embryotomy, can possibly remove the foetus, the caesarian section, or the opening of the uterus by incision through the abdominal walls, offers the only resource. Under these circumstances, the patient, having emptied the blad- der thoroughly, is placed on her back as though for gastrotomy. The center of the linea alba is then marked with a line of ink from a little above the umbilicus to the pubis. The patient is then placed under the full influence of chloroform, and an assistant on each side pressing the uterus gently but firmly against the ab- dominal walls, causes the intestines to fall from between it and them, and continues this pressure until the operation is completed, and the wound closed. The incision should be commenced just above the navel, in the centre of the linea alba, and carried down- wards in the same line to about two inches from the pubis, care 444 OESARIAN SECTION. being taken by the assistants to keep the uterus in close contact with the abdominal walls, as there is a constant tendency of the small bowels to escape through the wound. The cavity of the abdomen having been opened, the uterus at once presents itself, inclining generally a little to one side. If this obliquity be great, the organ should be gently straightened, and held by an assistant in its proper position. An incision should then be made, by sev- eral successive strokes of the knife, through the walls of the uterus, directly in its mesial line longitudinally, from above downwards, and extending to some depth. A director, ending in a pointed bulb, is then carefully passed through the remaining tissues, and the opening in the womb extended thereon. Thus far there is apt to be but little hemorrhage, and the womb can generally be opened immediately. Should hemorrhage, however, follow the incision through the abdominal walls, this should be checked before going farther. The length of the opening made in the womb must de- pend on circumstances. It should be large enough to fulfil the object for which it was intended, without any risk of lacerating the part, and should be no larger than will be essential for that pur- pose. The uterus being opened, the membranes ought at once to be ruptured by the hand, and the waters be permitted to escape. Some part of the infant will then immediately present itself; and its body being grasped by the surgeon, it should be drawn through the wound, and removed sufficiently to permit the cord to be di- vided ; which should be done by the usual method. At this stage of the operation, the bleeding is apt to be profuse; and creat care should also be taken by the assistants to keep up the pressure over the abdomen, and keep the bowels out of the wound. It has been much debated, whether the cord should now be returned into the uterus, the wound closed, and the secundines left to be delivered through the natural passages, or the placenta at once detached, and all removed together through the incision. It appears best, however, at once to introduce the hand, gently but quickly detach the placenta, and at once to empty the womb through the artificial opening. Should the line of incision through the uterine walls fall directly over the seat of attachment of the placenta, it has been advised, either to cut through the placenta and proceed as in other cases, or to disengage and deliver it before, or simultaneously with, the foetus. The latter procedure appears much the best; as by it much bleeding will be prevented, and the tedious process of dividing and OKSARIAN SECTION. 445 afterwards delivering the placenta, avoided. After the operation the womb rapidly contracts, and in fifteen or thirty minutes will have regained its natural size; when the tendency of the bowels to escape through the wound will have greatly lessened. Skey recommends "a circular bandage of about nine or ten inches in breadth, divided across the middle, and the cut edges connected by about a dozen strong silk threads of eight or ten inches in length," to be passed around the patient's body before commenc- ing the operation. As soon as the hemorrhage has ceased, and the womb is well contracted, "it is to be drawn down over the abdomen, and held tightly by two assistants. It will be found to form an excellent temporary substitute for closure of the abdomi- nal wound, while it permits free manipulation between the threads, in the passing of the sutures." The wound in the abdomen should not be closed until all hemorrhage has ended, and the uterus is firmly contracted. If kept open a few moments unnecessarily, no evil will result therefrom; but if closed too soon, the patient is ex- posed to the most fatal form of hemorrhage, that which is con- cealed. As soon as all bleeding has ceased, the wound in the uterus should be observed, that no part of the bowel may have been caught therein and left there; and the os uteri must be also examined, to discover that it is open. The wound in the abdomen should then be closed by sutures, sufficient in number to secure the perfect contact of its entire edges, with the exception of about a half inch of its lower end, which should be left open for the es- cape of any discharge that might occur. The after treatment should consist of measures calculated to allay irritation, and support the vital energies. Anodynes, to check restlessness and relieve pain, and opium for the same purpose, and to arrest inflammation, with generous diet, will be the proper treatment. Depletory measures should be strictly avoided. It is out of the question to enter into an extended history of this operation here. I can only add, that it is quite an ancient one, and was far more frequent some time since than now, embryotomy being now preferred in many cases in which csesariotomy would formerly have been performed. The success of this operation has varied greatly, with different surgeons, and in different countries. In America it has succeeded in a very reasonable proportion of cases, while in Europe, and in Great Britain particularly, it has been nearly always fatal. The reason for this difference appears to be, that among us, the opera- tion when performed, is generally resorted to early, and before the 446 OVARIOTOMY. depressing influence of long-continued suffering, exertion and anx- iety, have so exhausted the patient as to render reaction, after the shock of a severe operation, impossible. In Europe, on the con- trary, csesariolomy is postponed to the last moment, and seldom performed until the patient appears beyond all chance of recovery. It has often failed, therefore, because undoubtedly performed too late. If the operation is to be performed at all, it should not be put off a moment after labor has set in, as nothing can possibly be gained by delay, and success is almost ensured by operating promptly, while the patient is mentally and physically fresh and vigorous. Let it be remembered, however, that the operation is only justifiable in such cases as cannot possibly be relieved by other means. Let the proportions of the foetal bulk and the pelvic capacity be well un- derstood and carefully compared ; and when the disparity becomes so great as to render the passage of the one through the other im- possible, then it becomes our duty to resort to coesariotomy, and equally our duty to operate early, and promptly. Ovariotomy. Although ovarian dropsy is by no means a painful or fatal af- fection, yet it is so troublesome that it was long since proposed to put an end to the disease by the removal with the knife of the entire cystic tumor. Much discussion has existed with regard to the propriety of this operation. Some surgeons contended that it should never be re- sorted to, because it seldom or never, was followed by perfect re- lief, and was not applicable to all cases, while there was no known means of distinguishing beforehand, whether a case was suited to the operation or not, it frequently happening that after the first incisions were all made, and the most painful part of the opera- tion was over, the surgeon discovered that the cyst could not be removed ; and so was obliged to discontinue the operation. This objection, however, can only apply to doubtful cases; and while it is true that ovarian cysts seldom cause acute pain, yet, it has been well observed, that so great a degree of distention as is fre- quently found can scarcely exist without causing a vast amount of discomfort, amounting in some cases to actual pain. And while this affection can but rarely, if ever be said truly to cause death, yet it is impossible to believe that such a condition as is exhibited by one who has suffered for any length of time from this disease, can be compatible with longevity; nay, it must in every case shorten life. OVARIOTOMY. 447 It has been observed, that where the operation has been under- taken, the abdomen opened, and the tumor exposed, but found unfit to be operated upon from being adherent, the external wound heals without difficulty, and no unpleasant symptom results. The operation is aaapted to those cases in which no adhesions have been formed ; and the most favorable tumors for removal are those composed of a single cyst containing clear serum. In such cases the operation has seldom failed to give relief, provided they have been subjected to no previous irritation, by which adhesive inflammation may have been excited, as bandaging, tapping, &c. Before the operation, the bowels should be emptied by a cathar- tic, followed immediately before the incisions are commenced, by an enema, and the emptying of the bladder with the catheter. The patient should then be placed on her back upon a table, with her head and shoulders slightly elevated, and her legs hanging over the end of the table. Chloroform having been given, the operator takes his position between the subject's legs, commences just below the navel, and carries an incision through the abdomi- nal walls downwards towards the pubis, following the center of the linea alba, and from three to five inches long, acccording to the size of the tumor. The cyst thus exposed should be "seized with a strong pair of hooked forceps, with pointed and projecting teeth; by means of which the sac should be firmly held. As the fluid flows off, both the cyst and the prominent abdomen become reduced in size, and the former gradually elongating, is drawn without effort through the wound." (Skey.) If the cyst be multi- Iocular, each cyst must be seized and its contents evacuated, as it comes into view; when they can without difficulty, be gently drawn out at the wound until their root appears therein. Should this be prevented by adhesions, or if the tumor be solid, the hand must be introduced, the adhesions carefully and gently divided, and the tumor drawn towards the opening. If the adhesions can not be divided with safety, the contents of the cyst should be drawn off, and the cyst divided as near the adhesions as possible. After being emptied, the cyst will with ease be drawn out at the wound, if not prevented by adhesions. Erichsen advises, that the tumor should be drawn well forward, and "the pedicle transfixed by a nevus needle armed with strong whip-cord, which being tied on either side, the pedicle should be divided above it." Care must be taken that the needle does not transfix an artery or vein. To avoid this, the pedicle of the tumor should be untwisted, as it were and carefully examined before it is pierced by the needle. 448 OVARIOTOMY. Before tying the ligature it has been advised to dissect the perito- neum from that part of the tumor about to be constricted. In doing this, great care is requisite to avoid wounding any of the vessels, and particularly the viens, which are very numerous and covered by very thin walls. In this way the chances are much lessened of any slough of the pedicle falling into the cavity of the peritoneum, and thus the risk of peritonitis is diminished. Erich- sen, from whose work this account is chiefly drawn, adds, "I at- tribute much of the success that attended the removal of an ovarian tumor, partly solid and partly cystic, weighing about fifteen pounds, which I recently extracted from a lady sixty-five years of age, to the adoption of this precaution " The pedicle should be divided about half an inch above the ligature. If severed nearer than this it will retract, and slipping from under the ligature give rise to secondary hemorrhage. The abdominal wound should be closed by the interrupted suture, over which broad and long strips of adhesive plaster should be fixed, and a laced bandage should be constantly worn around the body. The patient should be kept perfectly quiet in bed ; nothing but ice and barley water, or some such liquid, should be allowed for a day or two; and she should be kept constantly under the influence of opium, and in a chamber the temperature of which must constantly be kept at rather a high point. About once in six or eight hours, the urine should be drawn off with a catheter; and the bowels must be kept quiet, if possible, for at least twelve hours ; after which an enema may be given ; but active medicine must be strictly avoided. If peritonitis should occur, it must be treated precisely as the same affection following the operation for strangulated hernia. It is a matter of some moment, to prevent any part of the pedicle from sloughing, and falling into the cavity o'f the abdomen, after it has been ligated. With this object in view, Erichsen has advised, that an ordinary hair-lip pin be passed through the lips of the abdominal wound, near its lower edge ; and that the pedicle after its division be drawn forward, and at- tached to the pin by wrapping around it the strong ligature by which the pedicle was transfixed, in the usual form of a figure-of- eight. The patient should lie on her back, with the head and shoulders slightly elevated, the legs flexed by pillows under the knees, and the abdominal muscles kept perfectly relaxed. All depletory measures must be strictly avoided ; and, indeed, the case must be treated precisely as one in which caesariotomy has been performed. T. S. W. ABDOMINAL HERNIA. 449 LECTURE LXII. ABDOMINAL HERNIA. Definition of Hernia—Inguinal Hernia—Crural or Femoral Hernia— Umbilical, Thyroid, Ischiatic, Perineal, Vaginal, Diaphragmatic Hernia—Hernia of the Linea Alba— Ventral Hernia—Intestinal Hernia—Epiplocele—Entero-Epiplocele—Bubonocele—Oscheocele, or Scrotal Hernia—Reducible Hernia—Irreducible Hernia—Strangu- lated Hernia—Internal Strangulated Hernia—Causes of Hernia. We have, this morning, gentlemen, to enter upon the discussion of a very important subject, viz : abdominal hernia. When any organ, naturally occupying a cavity, protrudes from that cavity, we call such protrusion a hernia. Thus we have hernia of the brain, and of the lung; and so far as the-abdomen is concerned, we have abdominal hernia. This affection considered in all its bearings, may be divided into several varieties. In the first place, we divide it according to the point at which protrusion takes place; and, when we refer to these numerous points, we find that at some, the abdomen presents natu- ral outlets, of which we shall speak more particularly as we pro- ceed. Besides these, we have similar protrusions, taking place sometimes where there is no natural opening, as through the linea alba, and in other situations. We may also have an organ belonging to one cavity protruding into another; an abdominal organ into the thorax, for example ; or the omentum or intestines into the vagina, &c. But let us go on to consider these numerous varieties. One of them, and the most frequent, is where the protrusion takes place at the inguinalring. This constitutes inguinal hernia. Another variety is, where the hernia passes under Poupart's ligament, through the crural ring. Here we have crural or femoral hernia. Again, and es- pecially in newly born infants, you will find cases in which, from a want of the proper development of those structures forming the um- bilicus, there is a protrusion on the median line, through thatopening. This is called umbilical hernia. Again : from an imperfect develop- ment of those structures which naturally close the obturator or thy- roid foramem, we have sometimes a protrusion there; and to this va- riety we apply the name of thyroid hernia. In another class, from similar causes, the organ having passed backwards and downwards, c* 450 VARIETIES OF HERNIA. protrudes at the ischiatic opening, and we have ischiatic hernia. Again : from a want of development, a portion of intestine may protrude directly into the perineum, in the neighborhood of the anus, and form a perineal hernia; and in the female we may also have a protrusion along the vagina, constituting a vaginal hernia. In the openings which exist through the diaphragm, we sometimes find a protrusion upward, giving rise to what we denominate dia- phragmatic hernia; and again, we may have a protrusion along the median line of the linea alba, at the point of the interlace- ment of the fibres; and this will be a hernia of the linea alba. Be- sides these, there are other cases in which the hernia arises from some fault in the walls of the abdomen, either from a want of de- velopment, or from some injury. The protrusion may be on one side, or on the other, high up, or low down. To this form, the term (though improper) of ventral hernia is applied. You will thus perceive, that by considering the various points at which hernia may take place, we have a number of varieties. There are, moreover, varieties dependant on other considerations. In the first place, we may divide them in reference to the organ protruding. Some cases are found to contain intestine only, and are called intestinal hernia, or enterocele. Others contain omentum only, and therefore are called omental hernia, or epiplocele. We very frequently find hernia to consist of both omentum and intestine. We apply to this variety, therefore, the compound term entero-epip- locele. We find, generally, that the floating intestine is the portion in- volved in enterocele, though occasionally we even have the coecum and colon protruding. Sometimes, and especially in cases of long standing, we may find every organ contained in the abdominal cavity involved. Portions of the liver, of the spleen, &c, may be found in the sac. Again: turningour attention to the circumstances connected with the hernia, we find several varieties, founded on the extent to which the organ has protruded; and particularly is this the case, in inguinal hernia. Here, when we find the tumor above the ligament in the groin, we call it bubonocele. But when the hernia has existed longer, being constantly inclined to descend, it passes gradually down into the scrotum, having the testicle behind it • and at this stage we call it oscheocele or scrotal hernia, and so on through many varieties. In a large number of cases we find, that, though while the in- VARIETIES OF HERNIA. 451 dividual is in the erect position the tumors exists, yet as soon as he is placed in the horizontal position, the organs return sponta- neously, or may be easily returned by manipulation, to their natural cavity. Such a case is called a reducible hernia. It very frequently happens, however, that where a hernia exists for a long time, the portion of peritoneum that accompanies it takes on inflammation; plasma is thrown out, and the tumor becomes so firmly united to surrounding organs, that it can neither return spontaneously, nor be reduced by any manipulation; and yet the intestine may be so situated, that this will not interfere with its natural functions. To this form of hernia we apply the term, irre- ducible. Be careful not to confound this with another form of hernia, which, though irreducible, is so from a totally different cause; and it now behooves us to consider in what this difference consists. We frequently find, that where a hernia has been for a long time reducible, it suddenly becomes irreducible, from a stricture at the abdominal opening, so tight and unyielding that gas even cannot pass, and mortification soon takes place. It is highly im- portant that you should not apply the term irreducible here; for this is what we denominate strangulated hernia. Such a condi- tion is always serious; for the stricture not only prevents the passage of gas and feces, but also of blood; and a violent inflam- mation, soon running on to mortification, is the result. Some surgeons have proposed to divide this form of hernia into two va- rieties. The most trivial they denominate incarcerated, and the most serious strangulated hernia. These varieties differ in degree only. By incarcerated hernia, is meant that state in which the organs cannot return, but in which circulation still goes on. There is a distended state of the intestine, which prevents its return, and causes some constriction. Here, by cautious manipulation, we may succeed in pressing the distending matter into the cavity, and in returning the organ. There may have been some inflam- mation caused by the strangulation; though this should not pre- vent you from returning the organ, as it will soon subside, when everything is again placed in a natural position. When, however, there has been a perfect stricture; when we cannot empty the sac of its contents, and violent inflammation seizes the organs; then to all intents and purposes, we have strangulated hernia. If this condition is not speedily relieved, such serious mischief will 452 CAUSES OF HERNIA. have taken place, even in a few hours, that death must sooner or later result. By way of appendix I may add, that sometimes we have stran- gulated hernia internally. This may occur in some one of the following ways. A small aperture may form in the mesentery; after some time, a small piece of intestine may insinuate itself into this opening; and this may gradually increase, until a consid- erable fold, or knuckle, passes through; and the patient is de- stroyed by mortification from strangulation. Again : from the interlacing of the numerous adventitious bands of attachment which sometimes form here, the intestines may become inserted in some one or other of them; and sooner or later the patient dies of strangulated hernia. Death has frequently occurred from this cause. Such was the case of the lamented Legare, who unfortu- nately died too soon for the good of his country. Such are the numerous varieties of hernia. All of them are of importance, in a practical point of view. As to the causes of hernia, it is convenient to divide them, as usual, into predisposing and exciting. The predisposing are in- born as it were, and appear to be frequently inherited. So far is this the case, that we sometimes find it as a kind of heritage in families. When we come to consider the nature of this predispo- sition, we find, that it sometimes consists in the want of a proper development of some of the structures, surrounding and closing the different outlets; while, in other instances, the predisposing con- dition is the result of some accident or disease, which so weakens the parieties of the abdomen as to give rise to these protrusions. Sometimes, a wound penetrates the cavity of the abdomen ; and, notwithstanding it has healed kindly and quickly, it will very fre- quently happen, that hernia, at some future time, will take place at the cicatrix. It is also the result, in some instances, of operations for the removal of tumors, and I might go on to mention numerous other predisposing causes. With regard to the exciting causes, I need not say much, since they are quite obvious. All violent action of the abdom- inal muscles, as lifting weights, &c, particularly where a pre- disposition exists, may bring about a hernia. I have seen hernia in children, produced partly by the influence of position, and partly by the use of a toy, called a velocipede. A boy placed astride of this hobby-horse is compelled to use both feet, while the abdominal mus- CAUSES OF HERNIA 453 cles are relaxed; and thus may be entailed upon the child the horrible infliction of an inguinal hernia. Riding in vehicles, where the abdominal muscles are in a state of relaxation, is frequently an exciting cause. Not so, however, in horseback exercise ; for in this position every muscle in the body is brought into action. I would mention, in conclusion, as among the exciting causes, every thing which may cause a pressure upon the abdomen; as clothes tightly buttoned, and, in a very fair proportion of cases, the use of stays. This practice is also, not unfrequently, a cause of another deplorable condition, viz : prolapsus uteri. These stays, or corsets, force the organs down towards the outlet, and cause them, either to escape through the ring, or to press upon the brim of the pelvis. Under these circumstances, or I should say by means of this barbarity, the female often, in the very bloom of life, has entailed upon her the misfortune of a prolapsus uteri. It is not, however, with this effect of the practice that we have now to deal. Lacing, if properly conducted, would not lead to such evil results. If, instead of extending only to the umbilicus, it passed down to the pubis, and was properly fitted to the spine and to the abdomen, it might even be productive of good. It is upon these short jackets—these useless, unmeaning things called stays, that I would pronounce my anathemas. The practice of wearing them is one which should be denounced by every physician, and from them should receive no quarter, until it is extirpated from the land. Many of those head-aches, miscalled nervous, find here their cause. They keep up a constant pressure upon the vessels and organs of the parts which they cover, and lay the foundation of mischief, for which art can afford no remedy. 454 DIAGNOSIS OF HERNIA. LECTURE LXIII. HERNIA CONTINUED—ITS DIFFERENTIAL DIAGNOSIS--INGUINAL HERNIA— SCROTAL HERNIA--CRURAL HERNIA--THYROID HERNTA--PHRENIC HERNIA--TREATMENT OF HERNIA--BY TRUSS--VARIETIES OF TRUSS. It may be proper, gentlemen, before proceeding to the treatment of hernia, to make a few remarks on its differential diagnosis ; to say something of its symptoms, and, especially of those by which we distinguish it from other diseases. An inguinal hernia, which has not yet descended far, having just escaped through the ring, will appear thus. You will find at the ring a smooth, round, elastic tumor, while the patient is in the erect position; but it will return into the abdomen on his assuming the recumbent one. You will find, moreover, that on slight pres- sure, the tumor will also disappear, and the contour of the external ring be very perceptible. You will have to distinguish this from tumors in the groin, abscesses, and a varicose condition of the veins, particularly of the superior epigastric. I have frequently seen this vein so enlarged as to cause a large tumor; and such a tumor may be mistaken for inguinal hernia. But, by its easy reduction, by the return of hernia as soon as the recumbent posture is assumed, and by the absence of all hardness, you may distinguish it from other tumors in these parts. Abscesses do not disappear on pres- sure, are unaffected by position, and fluctuate; and are thus easily distinguished. But where hernia descends into the scrotum, be- comes very large, and is of Jong standing, then circumstances may arise to cause a difficulty in the diagnosis. An enlarged scrotum may be caused by hydrocele, by a varicose condition of the cord, by hydetids, and so far as feeling is concerned, may be mistaken for hernia. Let us see how to distinguish them. In the first place, so far as the rise and progress of hernia and hydrocele are concerned, they are diametrically opposite. In hernia, if we trace the disease back- ward, we find that first, it commences in the groin, and then de- scends gradually, until it is seated in the scrotum. In hydrocele, on the other hand, we find that it begins in the scrotum, and gradually ascends, as the tunica vaginalis becomes enlarged, to the ring. But this is not all. If you take the tumors in the hand, you will find that they differ in feeling. In hydrocele, until it becomes very large, the tumor is of a pyramidal shape, large below, and gradually HERNIA DISTINGUISHED FROM VARICOCELE. 455 tapering up towards the ring; and if you seize it in the palm of the hand, and draw it downwards and forwards, so as to stretch the spermatic cord, there will be no enlargement at the ring. In her- nia, exactly the reverse takes place; for although the tumor is large below, and tapers upward, instead of ending above in the cord, you find it still large at the ring. It is true, that in some cases of old hydrocele also, this condition exists, from some of the fluid mounting into the inguinal canal; but there are other circumstances, which enable us to distinguish more accurately. In reducible inguinal hernia, upon placing the patient on his back, the omen- tum or intestine will spontaneously pass up; or, if it does not do so, on seizing with the hand, and kneeding it, it will easily be returned. Now, in hydrocele, no pressure can possibly force the liquid into the abdomen ; and thus you may easily distinguish it. Again; except in old cases, where the structures are thickened, hydrocele is transparent, and may thus also be distinguished from hernia. There are some cases, however, which are exceedingly obscure ; as, for example, where hernia becomes engrafted on hy- drocele. You will meet with such cases, and you will find them exceedingly embarrassing; but, by bearing in mind the pecu- liar gurgling sound made by hernia when reducible, and the fluc- tuating of hydrocele, you will be able, almost always, to distin- guish them. Again : we are liable to find in this part a varicose condition of the spermatic cord, which "varicocele" sometimes becomes so large as to form a tumor in the scrotum. This condition I have known, again and again, to have been treated (by able surgeons, who should have known better,) with a truss, thus making matters a great deal worse. Now, when you seize such a tumor in your hands, and roll it between the fingers, you will readily distinguish the varicose condition, by a peculiar, knotty feeling. But this is not all; for placing the patient on his back, the tumor gradually subsides; so that, in this respect, it might be mistaken for hernia. But, in the varicose condition, if you place the thumb across the cord, where it glides over the pubis, notwithstanding you thus close the abdominal ring, the tumor will return on the patient's again standing up. The reason is, that in this case the tumor is formed by venous blood ascending; and, therefore, the thumb of- fers no impediment to its re-formation. In hernia, after it is re- duced, the tumor cannot form again, unless the pressure is re- 456 DIAGNOSIS OF PHRENIC HERNIA. moved. By bearing this in mind, we can easily distinguish her- nia from varicocele. As regards cancerous degenerations, &c, there can be no diffi- cultv. They are hard, and frequently knotted; and, more than all, if you draw down the tumor, you will find that the ring is occupied only by its natural contents. I say, then, that by bearing all these things in mind, you can easily distinguish inguinal hernia from those affections with which it is liable to be confounded. By a similar process you may distinguish crural hernia. This is likely to be mistaken for tumors in the groin, for psoas or lumbar abscesses, and more than all, for varicose conditions of the femoral or saphena vein. In crural hernia, the tumor is generally small and easily re- duced. It may be distinguished from abscess, by the latter being irreducible, and by the peculiar characteristics of abscess. Yet I have seen a case of this kind mistaken for hernia, and that, too, by a distinguished hospital surgeon. The patient was actually made to put on a truss, which I found him wearing, when ray turn of duty came round. I diagnosticated a psoas abscess; and the truth was, that the patient labored under caries of the lumbar vertebrae. Now, if you will bear in mind, that crural hernia protrudes be- tween the femoral vessels and the pubis, and below Poupart's ligament, you will not confound it with any tumor external to the vein. A varicose condition of the vein will return, notwith- standing pressure be made over the pubis; and, in addition to this, the tumor is not always found in the same position, but may, even where the saphena vein is concerned, extend as low as the knee; while also, in some thin-skinned persons, it may be detected by the peculiar color. If you attend to all these circumstances, you cannot possibly mistake crural hernia for any thing else. As regards hernia of the diaphragm, or phrenic hernia, hernia of the thyroid foramen, &c, you are to be guided by the same general principles. A hernia, through the thyroid foramen, from the thickness of the muscles by which it is covered, may escape notice at first; but if it be large, it will soon push these aside and make its appearance. With regard to phrenic hernia, as it escapes into the thorax, of course the diagnosis is extremely difficult. But where a large amount of bowel has passed into the thorax, we can suppose a case where the physician may diagnosticate it; but this is TREATMENT OF HERNIA. 457 very difficult; and even when he thus succeeds, art, unfortunately, can afford but little chance of relief. Let us next consider what is the surgeon's duty in cases of hernia. In entering upon the treatment of hernia, we have an exceed- ingly wide field before us; and, to understand it, we must bear in mind all that was said yesterday. I shall begin with ordinary reducible hernia. Here the treatment is simple. But because simple, it must not be regarded as unim- portant; for any individual laboring under reducible hernia, is lia- ble, at any time, to such circumstances as shall place his life in jeopardy; and though the tumor be small at first, and gives but little inconvenience, yet it is constantly inclined to increase, and may become so enormous as greatly to impede the motions of the sufferer. It becomes necessary, then, that you should observe every precaution, and at once take such steps as shall guard your patient against any increase of his malady. It is true, that where hernia is perfectly established, a radical cure is extremely difficult and doubtful; but it is also true, that by taking the disease in the beginning, and while the patient is young, we may effect a radical cure ; or, if we cannot cure the hernia, we can so protect, and guard against its evil effects, that it shall cause but little inconvenience. The indications are, to return the hernia into the abdomen, and to keep it there. WTith regard to its return, all that is necessary, in reducible hernia, is to place the patient on his back; when, by slight manipulation, the organs will be easily returned into their cavity; and the patient before rising should put on a truss to retain them there. These trusses are exceedingly numerous in kind. Most of them have a spring, as a fundamental part, with a pad to press on the ring. The spring should pass round the side opposite to the hernia; and the pad should be placed immediately over the ring. These pads are made of several different substances, such as glass, leather, horn, wood, &c. The glass pads are preferable, as they are less liable to excoriate the surface. A truss which is very much used in this country, is that of Hull. It consists of a spring, and two pads, one of which is placed over the sacrum, and the other over the ring. To prevent slipping up, a perineal band is added. The truss must be carefully adjusted, so as not to allow the pad to come below the upper margin of the pubis; for it would then press on the cord, whereas it ought barely to press on the ring, and not touch the pubis at all. The object of 458 TREATMENT OF HERNIA. some of these trusses is, (the pad being of wood,) to produce such inflammation, as shall cause the obliteration of the ring, and prevent the future escape of the hernia. In a young subject, this may suc- ceed ; but in ordinary cases, where the hernia has been of some duration, the glass pad truss, from Reinhardt, of this city, is a very good one, and has the advantage of being made so that it may be adjusted to either side. The variety of trusses exceeds enumera- tion. It is my object, however, only to give general rules. Where the hernia exists on both sides, a truss which has two pads must be used. Some are so arranged that the springs pass above the penis. In some cases, particularly with negroes, it is difficult to keep the truss on. Under such circumstances, I use a common leather strap, about an inch and a half wide, having a buckle at one end, and holes at the other. Over this end, slides another strap perforated with a hole; and another short strap is added, having a buckle, under which is the pad. This second strap is applied to the perineum. With such an adjustment, I have for many years treated hernia successfully, particularly in the labor- ing class, for here either they will not wear the truss, or it moves. Now this cannot move; for being inelastic, it does not yield. There are a variety of other expedients proposed for the radical cure of hernia; but it cannot be necessary to go into a minute dis- cussion of them all. In umbilical hernia, we use a truss, consisting as before of a spring and pad. A common girdle with a pad of leather, or cork, or a bit of wood folded in cloth, makes a very good apparatus. Although you may not effect a radical cure of hernia, by these means, yet you may very much modify its evil effects; and if the patient will constantly wear the truss, he will be relieved from much inconvenience, and from all danger of strangulation. In our next lecture we will continue the subject. RADICAL CURE OF HERNIA. 459 LECTURE LXIV. HERNIA CONTINUED--RADICAL CURE OF HERNIA--INCARCERATED AND STRANGULATED HERNIA--TREATMENT. At our last meeting, gentlemen, we had under consideration the diagnosis and treatment of common reducible hernia. We stated that our chief reliance was placed on the mechanical means of retention; and that, when the patient was young, such means were available, not only in retaining the hernia, but also in pre- venting that enlargement of the opening, which would otherwise occur, and which would always render the liability to a return much greater. We also stated, that by the early use of a truss, in some in- stances a cure might be effected; and that to facilitate this result, it had been proposed, especially in later years, to make the pads of some hard material, in order to excite such a degree of adhesive inflammation in the part, as would lead to the obliteration of the opening. Various instruments have been invented for the fulfil- ment of this purpose; but, so far at least as a radical cure is concerned, all means of treatment must be regarded as very un- certain. I would now remark, that steps far more bold have been taken; expedients far more formidable have been resorted to. In older times, even the operation of castration was in some cases tried. If you understand the nature of the affection, you must at once perceive that such a course would be of no avail. In modern times, other and more plausible methods have been recommended. Some have proposed to open the abdominal walls at the hernial aperture, return the gut, and effectually close the wound. Another expedient of recent origin is, a kind of auto-plastic operation—the dissecting up of a flap, and the securing of it in the ring, so as to block it up. Now, this possibly may succeed; but I am free to confess, that I entertain great doubt of its prac- ticability. I know of one case in which the operation resulted fatally. Considering all the circumstances, therefore, I would not recom- mend either of these measures; but would advise you to rely on the persevering use of the truss. To these expedients I might add many others having the same object in view :—as puncture of the sac and injection of tincture of cantharides, tincture of iodine, &c; 460 STRANGULATED HERNIA. the intrusion of a portion of the integument into the ring, by a blunt, hollow, wooden instrument, shaped like the finger, but perforated with small openings on the side, for the passage of a curved needle, mounted on a stylet, designed to convey a ligature, by which the glove-like process of the skin is secured in situ, until adhesion has taken place ; the sutures and corks of Belmas, &c. We must go on now to consider our subject in a different point of view. I have remarked that the hernia is liable to become so fixed in the sac, as to render its return a matter of more or less difficulty. This condition is sometimes designated as an incarceration, and sometimes as a strangulation of the hernia. In some instances it is difficult to draw a distinction between an incarcerated and a strangulated hernia, as the difference is one of degree only. In the former condition there is, according to the amount of constric- tion, more or less inflammation of the part, more or less restless- ness, with vomiting, anxiety, &c.; but the accident has not pro- ceeded so far as to produce mortification. Such are the phenomena which characterize an incarcerated hernia. But when there is a still greater constriction at the hernial outlet, and the circulation of the part is seriously interfered with, or arrested, there is always great danger of gangrene, and we have a case of strangulated hernia. The tumor becomes tense, painful to the touch, and sometimes discolored. The bowel becomes soft, fragile, and dis- tended with gas; and even a rupture of the gut may occur, espe- cially if it be roughly handled. Black, isolated spots of gangrene may be developed on the surface of the intestine, and its con- tents may, in that way, be emptied into the abdominal cavity, and thus hasten the disastrous result. When the stricture first comes on, as it may after unusual exertion of any kind, the patient experiences a sensation of pain in the part, and he finds the tumor more tense than usual, and more sensitive. He tugs at it; handles it rudely in his attempts to return it; and, in that way, increases the danger. Sometimes the symptoms follow each other more rapidly than at others. The stomach becomes irritable; small watery evacuations are discharged ; the pain becomes more diffused; great restlessness supervenes; gaseous accumulation takes place in the tumor; and the abdominal walls become more rigid. The bowels, in some cases, are soon violently obstructed ; but often, if enemas have been administered, and sometimes even without them, feces may pass. These, however, come from below the seat of the hernia; and once the contents of that portion of STRANGULATED HERNIA. 461 the intestine have been discharged, no more fecal matter makes its appearance, the evacuations consisting then of nothing but mu- cus. As the case continues, the symptoms increase in severity. Violent inflammation has now seized upon the sac and the neigh- boring peritoneum. The patient becomes confused ; the pulse is more and more accelerated ; the skin becomes cold and clammy; and the efforts at vomiting are more frequent, and more violent. An inverted action of the intestines may now be induced, and fecal ejections from the stomach mark the violence of the symp- toms. By this time, the sufferer begins to be still further annoyed by the supervention of hiccups; profuse, cold, and clammy sweats cover the surface of the skin; the pulse flutters, and is soon re- duced to a mere thread in volume; unless speedy assistance be rendered, the vital forces yield to the morbid complications; and all may be over in a comparatively short space of time. Six, twelve, or twenty-four hours may suffice to do the whole. Such, then, is a strangulated hernia. And, when we consider this picture, and recollect that it is a disease which runs immedi- ately to its termination, giving you no time to seek assistance, I need not say how important it is, for you to be thoroughly pre- pared for the emergency. It is impossible for you to attach too much importance to a knowledge of the anatomy of hernia. This is a tumor that cannot be rashly cut into, and the anatomy of the part should be thoroughly understood, before the performance of the operation for its relief, when it is strangulated, can be thought of. And no practitioner can be excused on the plea of ignorance. He who suffers his patient to die before him, on ac- count of his inability to operate; and then affirms that the death has resulted from colic, or from inflammation of the bowels, is a dis- grace to his profession. This operation of all others, should be thoroughly understood. And in this connection I would make one more remark. The performance of the operation for the relief of strangulated hernia, has been held up to the student of medicine as a kind of bugbear, as exceedingly difficult, though highly im- portant. It is highly important, but not exceedingly difficult. It is true that modern surgery has greatly complicated the subject; but if you bear in mind the anatomical relations of the parts, there is no difficulty whatever in operating; in cutting down cautiously, layer after layer, so as to be sure of what you are about, till the seat of stricture is reached ; in inserting the finger and making 462 TAXIS FOR STRANGULATED HERNIA. the proper incision in the constricted part; and in returning the liberated gut into the abdominal cavity. Yet this operation is the bugbear which is held up by the world to frighten the young sur- geons; and, in some instances, I am sorry to say, to deter them from the performance of their duty, and to induce them to conceal the true cause of the death of their patient, by affirming that he died "of colic^ or " of inflammation of the bowels." But let us return from this digression, which the importance of the subject appeared to demand of me. I would not have you infer, that all cases, even of strangulated hernia, require the knife. There are other expedients which may prevent the necessity of a resort to the performance of the opera- tion. Let us then endeavor to understand the causes inducing, and the circumstances attending, a case of strangulated hernia, in order the better to understand the methods of relief. There is, as the essential condition, a stricture of the orifice through which the intestine has passed. But this stricture cannot always be said to be of a spasmodic character. The cause of the constriction is often dependant as much on the misplaced organ, as on the walls of the outlet. Gas and feces ma}' accumulate, and preternaturally distend the sac of the hernia, forcing against, and thus constrict- ing the edges of the opening; and this may go on, till the whole, or a portion of the circulation is arrested at the margin of the ring. Then follow the symptoms I have been describing. Now let us attend to the various methods to be adopted for the relief of the patient, bearing in mind the condition of the parts. In the first place, it will be right to try the taxis; that is to say, the judicious manipulation of the part, with the view of attempting to empty the intestine of its contents, and return it into the ab- dominal cavity. The patient should be placed on his back, and in that position which will most tend to relax the abdominal and femoral muscles, Poupart's ligament, and the parts about the neck of the tumor. The head and shoulders should be slightly elevated • and the thigh should be flexed on the pelvis, and inclined to the opposite side, in order to relax the fascia lata, and Poupart's liga- ment, to which it is attached. The leg should also be flexed on the thigh. Having attended to these preliminary steps, seize the whole tumor in the palm of the left hand, and draw it down. You will often find that this will considerably reduce the size of the tumor, by giving more space for the gas to pass and OTHER TREATMENT. 463 enable you to return the gut. By a kind of kneeding of the intes- tine, it may now be returned into the cavity, in a good number of cases. Another method which has been recommended is, to apply a gradually increasing and continued pressure over the surface of the tumor. This may be successful in some cases, but is not generally so. Either the hand of the surgeon, or a compress and bandage may be used. By means of a pocket-handkerchief, for example, we may tie up an inguinal hernia, and keep up, for a half-hour or so, an equable pressure on it. But even should these plans fail, there are yet other expedients which may be resorted to, in aid of the taxis. We may place the patient in a warm bath, bleed him from a large orifice, in order to induce a general relaxation of the system approaching to syncope, and again try the taxis. If this fails, we may still resort to other measures, if the case is not a very urgent one. Chloroform has been recommended ; not only for its relaxing effect, but also to stop all voluntary muscular ac- tion. I presume it may be advantageously employed. It is, per- haps, the best of the relaxing agents; and should the difficulty demand the knife, it becomes a great aid to the operator, as well as an incalculable relief to the patient. As we have seen, the bowels are always costive; and, as the peristaltic action of the intestines may aid materially in the reduction of the hernia, if the symptoms are not urgent, we may resort to the use of enemata and cathartics to move them. I would advise, if it be determined to give a cathartic, that you should use castor oil and turpentine, in preference to calomel and jalap, which have been recommended by some. Of all the internal remedies, none are to be com- pared to the oil of turpentine. It is of course more apt to succeed, if there is only a state of incarceration of the intestine. I have ao-ain and again seen it attended with success, when all other means had failed. By its use, the resort to the operation may frequently be avoided. It should be given in the largest dose allowable. I have used half an ounce at a time; and have often found the patient to be relieved in the course of from one to two hours. Warm fomentations to the tumor, will be found useful adjuvants to your other remedies; as will also the use of evapora- ting lotions, or ice. In the winter, where it is attainable, a little snow and ether often proves a ready and useful refrigerant appli- cation. But while I am advising these measures, I would at the same 464 OPERATION FOR HERNIA. time caution you against a too long postponement of the operation. Time is here of the greatest importance. The operation becomes a dangerous one, only from its having been delayed so long, that the congestion of the tumor has gone on to an unhealthy inflam- mation, or to gangrene. I cannot consider it a formidable one to perform. It merely consists in cautiously opening the hernial sac, in dividing a few aponeurotic bands, and in returning the intestine. To do this, of course, you must know the anatomical relations of the parts, and keep them in mind while operating. ESSAY No. 8. OPERATIONS FOR STRANGULATED HERNIA. Operation in general—Preliminary considerations—Operative Pro- ceedings—After Treatment—Special Operations for Inguinal Hernia—For Crural, or Femoral Hernia—For Umbilical Her- nia, fyc. As the operative, proceedings for the various forms of hernia present many considerations common to all or most of the varieties, we shall first describe the principles of the operation in general, and then consider their special application. The operation in general requires attention, in the first place, to the preliminary considerations ; then, to the operative proceedings ; and, lastly, to the after treatment. The preliminary considerations are of great importance: but having determined to operate, no unnecessary delay should occur. The exigences which induce this determination have been men- tioned in the preceding lecture. The instruments and apparatus to be provided, will consist of—a flat grooved director, a scalpel, a sharp-pointed bistoury, a hernia knife, a pair of dissecting forceps, a tenaculum, some needles, ligatures, and sponges, some adhesive strips, a piece of linen spread with simple cerate, a compress, and a bandage. The bladder should be emptied, the parts shaved, and the patient placed on a table or bed, near the end, for the conve- nience of the operator, and in such a position as to relax the parts. The most convenient position for the surgeon is between the le^s of the patient; whose feet should be supported on a chair, while his knees are held by the assistants. OPERATION IN GENERAL. 465 The operative proceedings are commenced by an incision of suffi- cient length, through the skin, and in the axis of the tumor. This is effected in the safest way, by pinching up a fold of skin trans- versely to the line of incision—being careful not to pinch up any thing but the skin—and by transfixing the base of this ridge of integument with a scalpel or bistoury, the cutting edge of which is to be turned up, so as to divide the whole fold. The incision being thus commenced, may be extended at either end, with the assist- ance of a director, to such a length as will afford ample room for further proceedings. The operation is then to be continued, by carefully dissecting down to the peritoneal sac. The relative anat- omy of the parts must be remembered, while the various layers of fascia are being divided on a director; and any vessel, whose bleed- ing will obstruct the view, is to be tied or twisted at once. Con- cerning the next step in the operation, there is considerable differ- ence of opinion. Some contend that the sac should always be opened, and others that it should be opened only when the stricture cannot be relieved without doing so. We will first describe the usual operation, or that in which the sac is opened, and then allude to the other method of proceeding. Sometimes it will be found, by the sudden jet of fluid, that the sac has been opened unwittingly. In such cases, there is some risk of the accident being unperceived; when the dissection may be con- tinued, in careless or inexperienced hands, even to the opening of the bowel, in mistake for the sac. Such a disastrous result cannot be too carefully guarded against. Each layer, as it presents itself should be examined, and then divided with great caution. When the peritoneal sac is reached, it may be known by its glossy, smooth, bulging, and rounded appearance, its membraneous character, and the " arborescent arrangement of vessels upon its surface." Some- times it is in close connection with its contents; but generally it contains a little fluid—especially towards the lower portion—which separates it from the intestines and omentum. In most cases of loug standing, it will be found more or less thickened, or otherwise changed from its original character. If the tumor is not a large one, the sac should be first opened into at its lower portion, where there is most apt to be some fluid collection which will protect the contents from injury. In all cases, the opening should be made with the utmost caution. A small portion of the membrane is to be carefully raised up with a tenaculum, or a pair of forceps; and an opening is first to be made in this part, 466 OPERATION IN GENERAL. by cutting the raised portion transversely, with a scalpel or bistoury. Into the orifice thus made, a director is to be introduced; upon which the sac is then to be slit up. Sometimes the sac is so trans- parent, that the operator may be able to see some portion of the omentum, or some collection of adipose tissue, through its walls; in which case, he may choose such a spot to open over. The next step is the division of the stricture. This is effected in the safest manner, by carefully introducing the index finger, as a director, over the intestines, and up to the stricture, with its palmar surface up and its back against the folds of intestine, to to keep them out of the way; which object may be also secured, by spreading the other fingers and the back of the hand over the protruded mass, and slightly bearing it backwards and downwards. The finger is preferable to the steel director; not only because it can perceive the presence of any fold of intestine, which may slip up and fold over the path of the knife, but also because the cut- ting portion of the instrument can be more accurately applied to the strictured point. The nail being insinuated under the stric- ture, the hernia knife, or a probe-pointed bistoury wrapped to within a few lines of the point, is now passed flat-ways along the finger, introduced under the stricture, and then turned up, so that the cutting edge may catch the strictured point; which is then divided for about a quartei or a third of an inch, byjsimply depress- ing the handle. The direction in which this incision should be made, its extent, &c, will be considered when we come to speak of the particular operations for the different varieties of hernia. The stricture being thus relieved, the next thing to be done is to examine the parts protruded, and to effect their return, provided they are in a fit condition for the resumption of their functions. If any bands of lymph, or loops of omentum or mesentery, or plastic adhesions, are found to bind the gut, they must be disentangled or divided ; and the intestine must be returned freed from all obstruc- tions of the kind. The parts, however, must not be handled roughly or unnecessarily. In effecting the reduction, the intestine should be first introduced. The hands should be clean, the nails carefully pared and rounded, so as not to wound the delicate struc- tures, and the fingers should be wetted or oiled. The parts should be slightly drawn down, so as to allow the portions of intestine and mesentery nearest the orifice to pass in without folding ; and if the bowels are much distended with gas or fluid, gentle efforts may be made to lessen their tension by assisting its passage along OPERATION IN GENERAL. 467 the intestine and through the orifice, back into the general canal; while it should also be seen that as the intestine is replaced, its contents are not allowed to bag back, and thus to interfere with the return of the last portion. In such a result, when the large intestine is the part involved, it is advised by some " to puncture the intestine by means of a fine needle, and let out the contents rather than to make rough and protracted efforts to replace it."* After the intestine and its mesentery have been returned, the omentum, if sufficiently healthy and not in great quantity, must be replaced by the same process of careful manipulation. If simply congested, it may be returned ; but if it is thickened, lumpy, and irregular, degenerated in structure through the long continued absence from its natural position, or inflamed and gangrenous its replacement, if practicable, could only be conducive of serious, or even fatal disease. " In all the cases of hypertrophied, inflamed or gangrenous omentum, the best practice consists in cutting off the mass, as recommended by Sir A. Cooper and Lawrence. If it be left in the sac, inflammation or sloughing of it may occur, and the patient can derive no corresponding advantage to the danger he will consequently run. The excision of the mass may readily be performed by seizing and cutting it off at the external ring."f If any arteries bleed, they must be ligated; and the ends of the ligatures should be tied together, brought out of the wound, and kept there, in order to avoid the risk of .their falling into the ab- dominal cavity, and exciting peritoneal inflammation. In these cases great care should be taken, lest, in excising the omentum, there may be some portion of intestine enveloped in its folds. These folds should be carefully opened and examined, before the knife is applied. The sac, as a general rule, should be allowed to remain; care having been previously taken, not to permit it to slip up with the intestine, which it is apt to do, unless held down while the intestine is being replaced. If it returns with the bowel, it may prove a cause of strangulation internally; either from the fact that it was the original cause of the constriction—which in that case remains unrelieved—or from some new entanglement in which it may afterwards engage the bowel. The wound, lastly, is to be closed by the application of a sufficient number of sutures and adhesive strips, and a pad of lint is to be laid over its whole * Skey. Operative Surgery, Am. Ed., p. 443. f Erichsen Am. Ed., p. 72S. 468 OPERATION IN GENERAL. length, and secured by the application of a compress and ban- dage. Such is the ordinary operation in which the sac is opened. That in which the sac is not opened, may be performed in the same way, in the earlier stages; and the only difference consists in not proceeding to the opening of the sac, but dividing the stricture outside of the same, by running the knife upon the finger placed outside of the sac, to the orifice, and dilating it by cutting out- wards or upwards, as the case may be. Other methods of proceed- ing have been recommended; such as simply dissecting down to the orifice, and relieving the stricture by cutting cautiously through the rim of the outlet, or the somewhat more safe plan of a subcu- taneous section, as proposed by M. Guerin, and successfully per- formed by Dr. Pancoast, though restricted by him to those cases of strangulated inguinal hernia, in which there is no reason to suppose that the intestine has become gangrenous, and in which the constriction exists at the external abdominal ring. If the operation is commenced with the intention of endeavoring to re- lieve the stricture by first dividing the rim of the orifice, and only proceeding to the opening of the sac if necessary, the first plan is to be preferred; and, since we can never say positively that the neck of the sac is not the seat of stricture, this is to be considered as generally the most prudent course. As a general rule, the operation in which the sac is opened, seems still preferred, not- withstanding the warm advocates whom the other method—origin- ally pursued by Petit, upwards of a hundred years ago—has met with recently in the persons of Ashton Key and Luke in Eng- land, and Preiss in Germany, and the qualified approval it has received from Sir A. Cooper, Erichsen, and other reliable author- ities. The statistics of the operation, and his conclusions concerning it, are thus summed up by the last author: "Mr. Luke, who has had great experience on this subject, states that he has operated in eighty-four cases of hernia. In twenty-five of these the sac was opened; in fifty-nine the sac remained unopened. Of the twenty- five in which it was opened, eight died; while of the fifty-nine in which Petit's operation was performed, only seven died. That the ordinary operation, indeed, of opening the sac is an exceed- ingly fatal one, is well known to all hospital surgeons, and is fully proved by surgical statistics. Of seventy-seven operations for OPERATION IN GENERAL. 469 hernia, reported by Sir A. Cooper, thirty-six proved fatal; and of five hundred and forty-five cases recorded in the journals, and collected by Dr. Turner, two hundred and sixty are reported to have died. The result, therefore, of Mr. Luke's operation is most favorable, when contrasted with such as these. "The operation, without opening the sac, may be practiced in all forms of hernia, but is more readily done in some varieties of the disease, than in others. It is especially applicable in cases of femoral hernia, in which the stricture is commonly outside the sac> ********** 0f thJrty-one cases of femoral hernia operated on by Mr. Luke, the sac only required to be opened in seven. [n inguinal hernia it is not so easy to perform Petit's operation; indeed, in the majority of cases, the surgeon will fail to remove the stricture in this way. This is owing to the con- striction being usually seated in the neck of the sac, and is espe- cially observable in congenital hernia. Of twenty inguinal her- nias operated on by Mr. Luke, the sac required to be opened in thirteen instances. "For the various reasons that have been mentioned, I am de- cidedly of opinion that this operation should always be attempted in preference to the ordinary one of opening the sac, in those cases in which the hernia has not long been strangulated, presents no sign of the occurrence of gangrene in it, and more especially when it is femoral." The argument offered in support of the opera- tion is, that it is less dangerous to run the risk of returning the parts in an unfit condition, or still strangulated, than to open the perito- neal sac, and expose its interior, and the delicate walls of the intes- tine, to the atmosphere, and to direct manipulation. It is difficult to tell how far this manipulation and exposure may be the cause of the subsequent peritonitis, which proves fatal in so many cases, or how far they may only increase an inflammatory tendency, which may have been established by the strangulated condition of the parts, but certain it is, that in some cases they do produce this result, or at least they arouse this tendency to a fatal degree of activity. Nor will it do to bring up other instances in which the peritoneum and bowels are handled with impunity; for it must be borne in mind, that the structures, in cases of strangulated hernia, are not in a normal condition; and therefore, the same degree of irritation, w7hich in other instances would produce no effect, in these cases, in which the parts are highly congested, and sometimes even mashed and bruised, may serve to light up a high degree of in- 470 TREATMENT AFTER OPERATION. flammatory action. The risk of returning the bowel, still strangu- lated, is not so great as might at first thought, be supposed; for it has been found, that when the stricture is dependant on the sac or the omentum, rather than on the tissues outside, the replace- ment cannot, in most cases, be effected, till the sac has been opened, and the constriction removed. The danger of returning the bowel in a gangrenous condition can apply, as a general rule, to those cases only in which the strangulation has been of some duration; when it undoubtedly will be most prudent to open the sac. In all cases, it will be best to ascertain that none of the evidences of gangrene exist, before the hernia is replaced; such as the change in the constitutional symptoms, the cessation of pain, the tendency to collapse, the chilliness, &c, as also the appearance, feeling and odor of the exposed tumor. In such cases, of course, the sac must be opened, and the parts examined. In large and old herniae, Sir A. Cooper recommended that the sac should not be opened, and that no great exertion should be made at reduction, on account of the large extent of intestine to be handled, the difficulty attending its introduction into a cavity long unused to its presence, the great likelihood of the existence of extensive adhesions, and the length of time and amount of ma- nipulation it would require to dissect these away and return the bowel. The after treatment will depend, in a great degree, upon the symptoms which present themselves. The patient must be placed in an easy, relaxed position in bed, and kept as quiet as possible; and the bowels should be allowed to rest. Their early action is a favorable sign, but their forced action is not on that account to be at all desired. Nothing can be gained by the administration of cathartics, while a great deal of irritation may be produced by their action. If there have been no fecal discharges in the course of the first day, a simple enema may be administered; and this will be sufficient. As soon as the patient is fixed comfortably in bed, he should have a full dose of opium or morphine, unless there are some indications which clearly forbid such a course. The diet should be mucilaginous and mild. For the first three or four days, nothing but gruel, barley or rice water, and afterwards beef- tea, should be allowed. Such are the general directions to be observed. But there are certain accidents and complications, the management of which re- quire special attention; and the most frequent of these is perito- OPERATION IN GENERAL. 471 nitis. This is sometimes of such an adynamic or passive charac- ter, as to be overlooked, or mistaken for some other condition. The acute form presents the usual symptoms of ordinary peritonitis, and must be managed here, as elsewhere, by a strictly antiphlo- gistic course of treatment. It occurs in strong, healthy subjects, and is characterized by great anxiety of countenance, violent, lancinating pain, which is greatly increased on pressure, a hard, quick and frequent pulse, a dry tongue, and a hot skin. The breathing is short, being entirely performed by the thoracic muscles, and the patient keeps his knees drawn up, to prevent the pressure of the muscles upon the abdominal walls. Blood-letting must be resorted to, both general and local; and calomel, in com- bination with opium, must be administered at regular intervals, till the inflammatory symptoms have subsided. The mercurial must not be used in such doses as to act on the bowels. Its con- stitutional effect is here desired. Purgatives are inadmissible, although constipation is the usual condition present. "The tympanitis may best be removed by turpentine enemata, and any lurking tenderness by the application of blisters."* The adynamic form of this species of peritonitis, is character- ized by low, typhoid symptoms, and generally occurs in those of a weakened constitution. Usually there are some evidences of local inflammation, some pain or tenderness; but sometimes these symptoms are entirely wanting in cases in which, after death, the evidences of inflammatory action are very apparent. The pulse is quick, small and frequent, and the general depression is quite marked from the first. The countenance expresses great anx- iety, the abdomen becomes swollen, and the vital powers rap- idly give way. The treatment of such cases is to be entirely regulated by the character of the symptoms. The "tendency to death" must be obviated, by sustaining the strength with nourish- ing and stimulating drinks, by the use of opium, the application of blisters to the abdomen, &c, &c. Mortification will sometimes present itself. It will either be found to exist when the operation is performed, or it takes place after the hernia has been reduced. In the former case, the part should not be returned, unless but a small portion of the gut is in- volved ; and then the diseased portion should be left near the orifice, in order that, when it sloughs off, the contents of the intes- * Erichsen. 472 OPERATION IN GENERAL. tinal canal may not be emptied into the general abdominal cavity. This course had better be pursued in all doubtful cases; that is, whenever the parts are so deeply congested, or have been so severely constricted, as to render the possibility of their recovery a matter of uncertainty. When the intestine has lost its glossy appearance and its firm, elastic feel; when it has assumed a greenish, dirty hue, and has become soft and easily torn; and especially when it gives out a putrid odor, it may be known to be irrecoverably gan- grenous, and no attempt should be made at its reduction. Some surgeons doubt that it is advisable even to relieve the stricture, in such cases; but most authorities agree that it should be divided; and that the tumor should be freeiy opened, if it has not opened of kself, in order that the formation of an artificial anus may be facilitated. When the mortification occurs after the operation, the fact will sometimes be discovered by the detection of fecal matter on the dressings, and the subsequent formation of an artificial anus. In other cases, the patient dies from prostration, and the condition is inferred from the general symptoms preceding this result, or more certainly from the post-mortem appearances. The results of this condition depend in a great measure upon the extent of the gangrene, and the situation of the dead portion. If only a small portion of the intestine is destroyed, and this por- tion has been returned, but remains in a position which permits the contraction of such adhesions as will serve to prevent the ex- travasation of the feces into the peritoneal cavity, the patient may recover; and in some cases, without even an intestinal fistula. The part may slough into the intestinal canal, and pass off through the natural passage, while the integrity of this canal is preserved, by the adhesion which has taken place against the internal ab- dominal parieties. The next most desirable result is, the adhesion to the orifice, and the formation of an artificial anus. This result will depend upon the extent of the injury, and the constitutional powers, as well as on the favorable position of the part, before the rupture of the bowel took place. Great care must be taken, therefore, when returning a portion of intestine whose recoverability is doubtful, not to push it away from the orifice ; and in relieving the stricture in a case where the protruded bowel is already in a gangrenous condition, the operator should be careful not to disturb the adhe- sions around the orifice more than he can possibly avoid. OPERATION IN GENERAL. 473 A wound of the intestine, will sometimes complicate the case. The accident is most apt to occur either in the process of the dis- section at its latter stages, or when the stricture is being divided ; though in careless hands, it may occur even at the first incision. Sometimes the intestine at the neck is grasped so tightly by the constricting orifice, that the finger nail cannot get sufficiently far within it to guide the knife. In such cases, it becomes necessary to use a narrow director, which cannot be managed as safely as the finger; so that the intestine in some instances will curl over into the groove, and be cut by the knife. The existence of the wound is soon detected by the character of the discharge, which wells up from the bottom of the wound. The part must be imme- diately examined, the bowel being prevented from slipping up till the wound is closed. If this is small, it may be caught up by its edges with the forceps and surrounded with a fine ligature, which should be drawn pretty tightly, a practice advised by Sir Astley Cooper, and adopted now by the best authorities. If the wound is too large to be readily managed in this way, it must be closed by any of the ordinary methods for treating wounds of the intestine. An intestinal fistula, or artificial anus, may sometimes, as already mentioned, be the result of hernia. It is always a source of greater or less constitutional irritation; but when it involves a portion of the small intestine so high up the canal that a considerable waste of alimentary material is the result, a fatal termination is to be apprehended, unless a closure, is effected. In such cases, strong nourishing diet should be allowed, and a surgical cure should be attempted. If the opening is a small one, without any very ma- terial obstruction of the canal, the condition is designated as fis- tula. If most or all of the contents of the bowel pass out, and there is a more or less complete occlusion of the natural passage, we have an artificial anus to deal with. In the former case we may effect a cure, by stopping up the passage by which the con- tents of the gut are allowed to escape. This may be done by sim- ply applying a pad of linen to the orifice, and securing it there by means of a bandage, which should be made to exert some pressure on the part. In dealing with an artificial anus, however, the clos- ure of the wound is not the only, or even the first, indication to be fulfilled. The natural passage must first be freely opened, by the removal of the " eperon," or the projecting angular fold of intes- tine which blocks up this passage. This eperon or spur consists 474 INGUINAL HERNIA. of the back wall of the intestine folded on itself, and so projecting forwards into the canal; and it is to be removed, either with the enterotome of Dupuytren, or by the simpler method adopted by Dr. Physick. Dupuytren's instrument is a kind of squeezing or pinch- ing apparatus, like a pair of scissors whose blades are bluntly serrated. The eperon is grasped between the blades, and a grad- uated pressure is applied, by means of a screw which runs through the handles. The instrument is applied pretty tightly at first, and the pressure is gradually increased on each succeeding day, till the part has sloughed off. The process should be a grad- ual one, in order that the fold of intestine may not be removed before such adhesions have taken place as will suffice to cement the divided wall of the intestine behind, and prevent an escape of material into the peritoneal cavity. Dr. Physick's plan is simply to pass a ligature through the projecting fold, and to leave it tied loosely for a few days in order to excite a sufficient amount of plastic effusion to unite the parts, when the spur is to be removed with a bistoury. There are other accidents which may occur, during the opera- tion, or afterwards, and which the surgeon must be prepared to meet with; such as the wound of a blood-vessel, a sudden tendency to collapse from the shock of the operation, and the inflammation and sloughing of the sac after the operation. The last rarely oc- curs. It generally proves fatal, and may possibly be mistaken for a reproduction of the hernia, from the increased swelling and pain in the part. Such accidents, or any others which may occur, must be managed in accordance with the general principles of surgical science, as referable to each case. We pass now to a description of the surgical anatomy of, and the particular operations for, the different varieties of hernia; and we will commence with Inguinal Hernia. The inguinal canal is the name applied to the course by which the testicle has descended from the abdomen to the scrotum. It is occupied, and kept in a measure opened, by the spermatic vessels in the male, and by the round ligament in the female. It termi- nates, at each end, in the internal and the external abdominal rings; so called, not from their relations to the median line of the surface of the body, but in reference to the abdominal cavity. The internal abdominal ring is about an inch and a half farther from INGUINAL HERNIA. 475 the median line than the external abdominal ring, this being the usual length of the inguinal canal, while the external abdominal ring opens quite near to the os pubis. This ring is formed by a slit in the aponeurosis of the external oblique muscle, just where it is reflected from Poupart's ligament to the symphysis pubis; thus making a triangular opening, whose base is against the bone, and whose sides, or columns, are formed by the divided tendon. The internal ring is formed in the fascia transversalis, a layer of fibrous tissue, which commences at the back part of the Poupart's liga- ment, and runs upwards, just outside of the peritoneum, and in such close proximity to it, that it was called by Langenbeck, the external layer of the peritoneum. The inguinal canal is bounded in front and below by Poupart's ligament, and a few of the divided fibres of the internal oblique muscle; behind and above, by the fascia transversalis, the conjoined tendons of the internal oblique and transversalis muscles, and the fibres of the internal oblique muscle. Through the space thus bounded, the spermatic cord passes in the male, and the round lig- ament in the female. The spermatic cord is invested, first, by the tunica vaginalis communis, a kind of serous membrane, originally protruded from the abdomen by the descending testicle; then, by a process of the transverse fascia, which in old hernia cases is apt to become dense and laminated, and is then called by some the fascia propria of the hernial tumor; next, by the cremaster muscle, which is nothing more than a few bundles of lengthened muscular fibres from the internal oblique; then, as it passes through the outer ring, it receives an additional covering from the fibrous and cellu- lar tissues there, the intercolumnarfascia; and lastly, after leaving the ring, it is covered with the superficial fascia of the part, which becomes the tunica dartos of some authors, and the skin. By bear- ing these relations in mind, it becomes easy to account for the presence of the various layers, of greater or less density, which are generally found to invest an inguinal hernia; though these different structures cannot always be identified in that unnatural condition of the parts, which is generally brought about by the affection. Just a little to the inner side of the internal ring, passes the epigastric artery. It arises from the external iliac, quite near Pou- part's ligament, and runs inwards and upAvards between the fascia transversalis and the peritoneum, crossing behind the spermatic cord or the round ligament, as the case may be, just at the inner 476 OBLIQUE INGUINAL HERNIA. side of the internal abdominal ring. It forms a prominent ridge on the internal surface of the peritoneum, as it courses diagonally across this region to the rectus muscle. When we speak of the inguinal canal, and the external and in- ternal rings, it must not be supposed, that in a natural condition of the parts, such open passages do actually exist. In good health, they are blocked up Avith the tissues of the part, and exist only as so many weaker points, where a passage may be more easily ef- fected than at other parts of the abdominal parieties. The cul-de- sac, or pouch of peritoneum which the testicle carries down to the scrotum with it, soon becomes cut off at its neck, except in those cases in which the parts are affected Avith a congenital hernia, and where a hernia accompanies the descent of a testicle, which had been retained in the abdomen. Where this pouch has been divided from the peritoneum, there is often found a pucker, or kind of navel- like depression on the surface of the membrane, just over a A\-eak spot in the transverse fascia; and this becomes in hernia, the in- ternal ring. The external ring, in health, is closed up by the in- tercolumnar fascia, and also, from behind, by the conjoined tendons of the internal oblique and transversalis; and it is only opened when the bowel has escaped through the internal ring, or through the inguinal pit or "fossa inguinalis of Hesselback," a weak spot in the abdominal parieties, just opposite the external ring and to the inner side of the epigastric artery. Having thus examined the surgical anatomy of the parts, we are prepared to consider the different forms of rupture, to which the inguinal region is liable. Inguinal hernia is to be divided, in reference to the points of escape, into two forms; oblique or external, and direct or internal inguinal hernia. Oblique or external inguinal hernia follows the same course as the testicle in its descent, and therefore receives pretty much the same investments. It may be incomplete, or just in the canal; it may be complete, or scrotal; it may be congenital, in which case it is within the tunica vaginalis; or it may be "encysted," or " in- fantile." The relations of oblique inguinal hernia, as already stated, are pretty much the same as those of the spermatic cord or round ligament, these structures themselves, and the testicle, in •cases of scrotal hernia, usually lying immediately behind the tu- mor. "In some cases the elements of the spermatic cord become separated, the vas deferens lying on one side, and the spermatic PART OF INTESTINE INVOLVED. 477 vessels on the other. In other rare cases again, an instance of which there is a preparation in the University College Museum, the hernia lies behind the cord, and has the testis in front. In other cases again, it may happen, as was observed during an op- eration, in which I assisted my friend, the late Mr. Morton, that the elements of the cord are all separately spread out on the fore- part of the hernial tumor."* Direct or internal inguinal hernia occupies but a portion of the inguinal canal, not escaping by the internal ring, but forcing its way through a weak portion of the abdominal wall, opposite the external ring. This weak spot is marked, internally, by a slight triangular depression to the inner side of the epigastric artery, and is called the inguinal pit. The peritoneum at this point is sup- ported only by the transverse fascia, and a feAv fibres of the inter- nal oblique muscle, with a portion of the conjoined tendon of this and the transverse muscle. The hernia pushes forwards or rup- tures the back wall of the canal, enters directly the external in- guinal ring, and afterwards pursues the same course as the oblique or external form. According to Erichsen, there are two varieties of direct inguinal hernia; one passing out above the remains of the umbilical artery, and the other below, the latter being the most frequent. In inguinal hernia, the relations of the epigastric artery must always be remembered. In the oblique form, this vessel lies to the inner side and behind the neck of the tumor; while in direct hernia, it lies on the outer side of the neck. In old and large her- niae it is often deflected from its oblique course across to the rectus muscle, and made to clip downwards, in a half circle, by the weight of the large tumor. In such cases too, the distinctive features of the two main varieties of inguinal hernia are often totally obliter- ated, so far as the external appearance is concerned. From the constant traction exerted by the tumor, the two rings are approxi- mated, and the canal, in many casas, becomes entirely obliterated. The iJium is the part of the intestinal canal, which is most fre- quently involved in inguinal hernia; and next to it the coscal ex- tremity of the large intestine, with its vermicular process. When any portion of the colon is contained in the hernial tumor, the whole of the gut is not covered with peritoneum. In operating for the strangulation, there is, therefore, greater risk of the surgeon's *Erichsen, p. 732. 478 OPERATION FOR INGUINAL HERNIA. wounding the intestines, than in other cases ; and the same remark will obtain, also, in reference to the bladder, when it is involved. Sometimes the uncovered side gets tAvisted round to the front of the tumor, and so causes the hernia to appear to the operator as if it had no sac, or induces him thoughtlessly to cut into the organ itself, in mistake for the peritoneum. Congenital inguinal hernia, as already mentioned, lies in the tunica vaginalis communis. Its relations, therefore, are somewhat different from those of ordinary oblique inguinal hernia. De- scending directly in the yet unclosed canal, and dilating this pas- sage, it lies in actual contact Avith the cord and testicle, and has no peritoneal sac proper to itself. Though this form of inguinal hernia is called congenital, in many cases it does not present itself till some time after birth. In such cases, it is to be pre- sumed that the inguinal canal has become but partially closed, after the descent of the testicle; or, in other Avords, that the peri- toneal prolongation has not become sufficiently condensed around the cord. Encysted or infantile inginnal hernia is merely a variety of the congenital hernia. The canal being obstructed at a certain point, the hernia descends to that point, and then causes the wall of the passage to bulge doAvnward into a kind of pouch, which is ulti- mately changed into a partial cyst, as the tumor passes down. In such cases, therefore, to use the Avoids of Sir Astley Cooper, "on opening the tunica vaginalis, instead of the intestine being found lying in contact with the testicle, a second bag or sac is seen en- closed in the tunica vaginalis, and enveloping the intestine. This bag is attached to the orifice of the tunica vaginalis, and descends from thence into its cavity; it generally contracts a few adhesions to the tunica vaginalis, while its interior bears the character of a common hernial sac. The operation for strangulated inguinal hernia, does not differ in many respects from that already described for hernia in general. The incision should be of different lengths, in accordance with the size of the tumor. In old cases where the hernia is a large one, it will sometimes be neccessary to extend it to the length of three or even four inches. The parts are to be shaved ; the patient brought to the edge of the bed, and his legs opened for the operator to get between them ; the bladder is to be emptied, and then the incision is to be made in the median line of the tumor, extending from just above the external abdominal ring, as far down as the size of the OPERATION FOR INGUINAL HERNIA. 479 hernia may suggest. In making this incision, it must be borne in mind that the hernia may have no sac, and therefore great care must be taken lest the intestine be opened. Sometimes such an amount of blood follows this incision, that it becomes necessary to stop and secure the arteries from which it flows. No attempt should be made to continue the operation, till the wound is suffi- ciently free from biood to admit of the parts being seen. The dissection is then to be carefully continued, and not unfrequently the superficial fascia, which is next reached, is found stronger and thicker than in a normal condition, this being more apt to be the case with those Avho have been in the habit of wearing a truss. After dividing this fascia on the director, the band of intercolum- nar fascia is arrived at, and in some cases it will be found that the constriction is caused here, in part if not entirely. This layer is sometimes thickened, and occasionally it lies in close connection Avith the superficial fascia. After dividing it in the same manner as the others, if the hernia is of the oblique variety, the cremaster muscle, so called, will be seen spreading over the tumor, and the cord Avill generally be invisible, as it lies behind the hernia, Avhile if it is a case of direct hernia, the cord, and generally its cremaster muscle, Avill be seen in most cases, on the outer side of the neck of the hernia. Next Ave come to the transverse fascia, which is to be carefully slipped up on a director through the whole length of the wound. The neck of the tumor is then to be examined; and if the stricture appears to be situated outside of the sac, either in Avhole or in part, there is no occasion to expose the intestines until the outside section has been tried, and has failed to relieve the stran- gulation. The incision for this purpose must be made, as a gen- eral rule, directly upwards; but if the precise nature of the hernia can be distinctly made out, it may be inclined from the direction of the epigastric artery, which, it must be remembered, lies on the inner side of oblique hernia, and on the outer side of direct hernia. In most cases of long standing it will be difficult to make out the distinction. Should the division of these structures fail to relieve the boAveJ, the sac must then be carefully opened, and the operation concluded in accordance with the directions already laid down. Great caution must be observed at the latter stages of the opera- tion. In some cases no sac is found, and the operator comes directly upon some portion of the large intestine, or the bladder, which thus runs the risk of being mistaken for the peritoneal pouch. 480 ENCYSTED INGUINAL HERNIA. The incomplete inguinal hernia does not, of course, require such an extensive incision for its relief. In other respects, the proceed- ings are the same as when the hernia is complete. It is almost always of the oblique variety, and therefore the knife may gener- ally be turned outward in dividing the stricture, though, as there are some instances of incomplete direct hernia, this plan should be adopted only in those cases, of whose nature there can be no doubt. Congenital inguinal hernia, or more correctly hernia in the tunica vaginalis, Avhen it becomes strangulated, is seldom relieved except by the operation; and as the stricture is almost always found to be in the neck of the sac, this must pretty generally, if not always, be opened. The stricture may aiAvays be divided in an outAvard direction, as the hemia is of course of the oblique variety. If the operator is at all doubtful of the correctness of his diagnosis, how- ever, he should cut directly upAvards, so that, in either case, he may avoid the artery. Encysted inguinal hernia, it must be remembered, lies Avithin the tunica vaginalis, and also in an additional covering of its own. So that, in operating on this variety of hernia, it becomes necessary to enter the vaginal tunic, and then to open the cyst, or hernial sac proper, which is composed of a double fold of serous membrane. Thus it may be seen, that in operating for inguinal hernia of any kind, a variety of contingencies may present themselves, the precise nature of which cannot be knoAvn beforehand. In some cases, the cord may be found in front of the tumor : or its constituents may be separated, and lie over different portions of the hernia. This condition, however, is very seldom met Avith. In congenital hernia the testicle is sometimes found adherent to the intestine, the omentum or the mesentery; and if such adhe- sion is not too close or extensive, it becomes necessary carefully to dissect the parts asunder. Sometimes the ccecum, colon, or bladder is found to be the pro- truding organ ; and frequently, in these cases, such adhesions have formed, as to prevent the replacement of the viscus; Avhen all we can do is to relieve the structure, and close the Avound. The parts in some such instances, become gradually replaced of themselves ; and this tendency may perhaps be somewhat aided, by judiciously applied pressure. After the relief of the strangulation has been effected, and, if practical, the parts have been replaced—the intestine first, then FEMORAL HERNIA. 481 the mesentery, and lastly the omentum, if it is in a fit condition, and there is net too much of it—the wound should be cleansed, and its lips brought together by means of the interrupted suture; a compress and bandage should be applied; an opiate should be administered ; and the after treatment should be conducted in accordance with the directions already given. The kind of corn- press and bandage recommended by Skey, would seem to be the most appropriate in these cases. He says, "A pad of lint should be placed over the ring, and over the pad a large handful of cotton wool, or in its absence a folded towel or masses of lint, so applied as to compress the ring from below, Avithout involving the walls of the abdomen. Over these, a bandage should be dexterously ap- plied, like the figure of 8, passing round the abdomen and the thigh of the affected side, fixed by a needle and thread, or by pins at every turn, as it passes over the compress, and from that point carried back. By this means the compress will form the centre of pressure."* Femoral Hernia. The intestine, in femoral hernia, escapes through the femoral ring, or the orifice through which the femoral vessels pass from the abdominal cavity. The space beneath Poupart's ligament and between it and the ileo-pectineal ridge, is securely blocked up with muscles, cellular tissue, layers of fascia, &c, except at its inner and lower point, where these vessels pass ; and here the femoral ring is located. Poupart's ligament, at its pubic extremity, spreads out so as to be inserted not only into the symphysis pubis, but also into the spine and body of that bone. The outer and lower edge of the ligament, as it turns doAvnward to effect this latter insertion, is called Gimbernat's ligament, and forms the inner border of the internal femoral ring; whose upper border is formed by Poupart's ligament; whose lower, by the os-pubis; and whose outer, by a portion of the fascia transversalis, which extends dowmvards from Poupart's ligament, and separates the artery from the iliac muscles. The external iliac vessels come down betAveen the iliac fascia fAvhich is only the iliac prolongation of the fascia transversalis of inguinal hernia,) and the peritoneum, and pass through the ring, the artery being on the outer side. As they pass through, the * Skey's Operative Surgery, Am. Ed., p. 454. E* 482 FEMORAL HERNIA. fascia transversalis from Poupart's ligament, and the iliac fascia from behind, fold downwards Avith them, and form the common sheath of the vessels, or the " infundibilar fascia" of some. This sheath continues downwards with the vessels, and, becoming per- forated by smaller veins and lymphatics, is converted into the " cribriform.fascia." Internally it is divided by a septum, which passes between the vein and the artery. The portion of the femoral ring which presents the least opposi- tion to the descent of the intestines, lies immediately on the inner side of the vein, between it and the curved border of Gimbernat's ligament. In health, this space is occupied by cellular tissue, and sometimes by one of the glands of the part. The hernia almost invariably escapes at this point. The peritoneum is protruded into the sheath of the vein, and the tumor lies on the inner side of this vessel. Descending in the femoral canal, it becomes covered also with the fascia lata of the thigh; and, escaping from under the "falciform process" of the fascia lata, or the fold of this membrane which passes from the sartorius muscle to the pectineus, it lastly receives an investment from the superficial fascia, and the skin. From the greater laxity of the parts at the upper portion of the thigh, the tumor does not descend the limb; but, as soon as it escapes from beneath the falciform process of the fascia lata, or, as it is expressed by others, as soon as it passes through the outer ring of the femoral canal, it curls upwards, and sometimes even folds over, and rises above Poupart's ligament. In such cases it may be mistaken for inguinal hernia, unless care be taken to see that the neck of the tumor lies beneath the ligament. This femoral canal, is merely the space in which the femoral A-essels lie, till they pass through the oval opening in the fascia lata formed by its fal- ciform process. It is about an inch and a half in length, and passes along the surface of the pectineus muscle, enclosed betAveen two layers of the fascia lata. The relations of the hernia to the vein, to the epigastric, and obturator arteries, and to the cord, must be fully appreciated in order to operate with safety. The vein is directly on the outer side and will not be in danger, except in very ignorant or careless hands. The epigastric artery, arising from the femoral artery quite near Poupart's ligament, and inclining inAA'ards as it courses up, lies on the outer side, and above the neck of the hernia; nor is there much risk of its being Avounded. The obturator artery is the one most frequently injured, from the EXTERNAL FEMORAL HERNIA. 483 fact that its origin is quite uncertain. Its normal origin is gener- ally considered as that from the internal iliac; but there are so many exceptions to this rule, that one writer (Chelius,) affirms that its origin is "almost more common from the epigastric." It may also arise from the external iliac, or the femoral. When springing from the internal iliac, it is out of the way; when from the epigas- tric, it generally arises from this vessel quite near its own origin ; in which case it passes down between the vein and the hernia, and therefore to the outer side of the latter; and, as the stricture is to be divided inwards or upwards, there is no risk of wounding it. But sometimes it does not spring from the epigastric, till this ves- sel has passed some little distance on its upAvard and inward course ; in which case it may pass down on the inner side of the neck of the hernia, and is very much exposed to injury during the opera- tion. If it arises from the external iliac or femoral, it pretty gen- erally passes on the outer side, and is out of the way of injury. It is fortunate, that either the internal position is a rare one, or that, as observed by Erichsen, " Avhen it does occur, as it [the ob- turator artery] passes directly over that portion of the crural ring through which the sac would protrude, it necessarily strengthens this, and so diminishes the chance of rupture." This would seem, according to the researches of Cloquet, to be quite a common origin and course for the vessel to take. In two hundred and fifty sub- jects examined by him, one-half of whom were females, the ar- rangement was found to obtain in one-third of the cases.* There is another—but an exceedingly rare—form of femoral rupture, which is situated on the outside of the vessels, and which is therefore called external femoral hernia. It lies between the femoral artery and the anterior superior spinous process of the ilium, and, in its first stages, it is covered by the iliac fascia After a while, this fascia may be ruptured; and it is only when this oc- currence has taken place, that there is any appreciable risk of strangulation. When the fascia is entire, the base of the tumor is the Avidest part; but should this layer of fascia be ruptured, and the bowel escape from beneath it, the strangulation may occur at the orifice in the fascia. The tumor " is gradually developed, forms at the place men- tioned a moderately raised swelling, which, becoming narrower below, ascends, however, obliquely inwards, and terminates with * Smith's Operative Surgery, p. 438. 484 OPERATION FOR FEMORAL HERNIA. a blunt point in the region of the lesser trochanter. The finger cannot in the least be brought under either of its edges. If in its further growth the rupture overcome the anterior iliac fascia, the form and direction of the swelling is changed ; a new one is devel- oped beneath the old swelling, Avhich always extends further be- tween the fascia lata and the muscles of the thigh."* The cir- cumflex ilii artery passes over the mouth of the hernia, and may be wounded should an operation be necessary. Unlike inguinal hernia, femoral ruptures occur much more fre- quently in women than in men. They very seldom appear in childhood; and the few cases which do occur at this stage of life, very seldom become strangulated. The intestines in strangulated femoral hernia are more severely constricted than in any other form of rupture; and the operation, therefore, cannot be postponed as long as in other cases. As soon as the other measures for its reduction have failed, the operation should be immediately resorted to. The stricture, according to most authorities, is almost invariably situated outside of the neck of the sac. One German writer (Jaeger) even asserts—according to Chelius—"that no case of strangulation by the neck of the sac is known." The latter authority, hoAvever, very correctly denies the assertion ; Avhile South affirms that the stricture is, " almost invariably," in the neck of the sac. According to Sir A. Cooper, Erichsen and others, it is generally situated in the fascia that forms the sheath of the vessels, i. e. the fascia propria of the hernia. In many instances, it is situated in Poupart's, Gimbernat's, or Hey's ligament; or, as mentioned by Acton Key, in the tendinous bands joining " the fascia transver- salis to the posterior margin of Poupart's ligament ;""f- and some- times the falciform process is the seat of the constriction. The operation for the usual, or the internal, form of femoral her- nia, should vary someAvhat, according to the size of the tumor, and the intention of the operator in reference to the sac. When the tumor is small, and the patient is not very corpulent, a single straight incision Avill be sufficient; and this is ordinarily made directly over the tumor. But if it is not intended to open the sac, the plan, suggested by Gay and recommended by Erichsen, of making the incision on the inner margin of the neck of the hernia, may be adopted. By cautiously deepening this incision, layer by * Chelius' System of Surgery, Am. Ed., p. 337, vol. ii. f Idem, p. 335, vol. ii. OPERATION FOR FEMORAL HERNIA. 485 layer, the falciform process of the fascia latais found. The finger, or a broad director, must be insinuated between the edge of this fascia and the hernia; the hernia-knife must be introduced; and the constricting vein of the fascia must be divided for about the sixth of an inch, in a direction upwards and inwards. Reduction is now to be attempted, and if there is any difficulty in effecting a return, the neck of the tumor must be examined, when some con- stricting bands will generally be found, running across it, and binding it. These being carefully divided upon a director, or with a scalpel and pair of forceps, the bowel can usually be returned without any further trouble. But should the hernia be a large one, or the patient be quite fat, a single straight incision will not enable the operator to obtain sufficient command over the parts. Under these circumstances, several plans have been recommended. That most usually adopted is, to cross the first straight incision at its base Avith another, so as to make the figure of a reversed letter T, (J.). Dupuytren ad- vised a crucial incision; and Erichsen recommends that an in- cision should first be made " parallel to Poupart's ligament, by pinching up the skin, and then a transverse cut from the centre of this and carried over the tumor, so as to present the following shape : > A." Mr. Lawrence prefers a single, but oblique cut, beginning one inch above the femoral ring, and running down- wards;* and he is supported by Skey;*who does not "see the necessity of a second incision at right angles, because there is no advantage gained by cutting on to the tumor, the contents of which, when exposed, may be drawn inwards in a line Avith the ring." A single oblique incision is advised by Chelius also, Avho says that it should correspond to Poupart's ligament, and extend "half an inch over the SAvelling towards the iliac spine and the pubic symphysis." In Avhich of these ways the operation is to be commenced must be determined, in some degree, by the particulars of each case. If the patient is quite corpulent, the single incision will not an- swer as Avell as either of the other three methods; while in those cases in Avhich the impediment does not exist in such excess, the single oblique cut recommended by Lawrence, or that advised by Chelius, would seem to be preferable. The other steps of the operation are to be conducted as in other *See Smith's Operative Surgery, p. 435. 486 OPERATION FOR FEMORAL HERNIA. forms of hernia. The superficial fascia is generally divided Avith the skin, as it adheres pretty closely to it. Sometimes the fatty and cellular tissue then reached, is quite thick, especially in cor- pulent subjects; while in other cases, it is scant and thin. It is to be carefully dissected through; and then the fascia propria, or distended sheath of the vessels, is reached. In old and large her- nia, this is apt to be so much stretched as to be quite attenuated ; while in some cases it has become very much thickened, Avhen it may even be mistaken for a mass of omentum distending the hernial sac. This condition is most apt to obtain in those cases in which the use of the truss has been long continued ; and it is to be distinguished by its even and hard surface, and by the ab- scence of the peritoneal vessels. After carefully dividing this structure, layer by layer,— for sometimes two or three of these layers will be found—the hernial sac will be exposed. If it is intended to open the sac, this must now be carefully effected, by lifting, Avith the forceps, the most dependant portion, cutting slightly against the points of the instrument, and then inserting a director, and slitting up the membrane to the length of the Avound. This stage of the operation must be conducted with especial care. As the fluid accumulation in the sac is generally quite small, and as there is usually hut little omentum involved in the hernial tumor, there is considerable danger of Avounding the intes- tine. The stricture is now to be sought for, and divided for but a slight distance, in a direction upAvards and inwards. This is the direction now generally adopted as the safest. The reasons for preferring it, are dependant upon the surgical anatomy of the parts. On the outer side, lies the femoral vein and the epigastric artery, the latter being above as Avell as on the outer side; and immedi- ately above, passes the spermatic cord. These relations are prettv nearly invariable : so that the inner side is the one most usually free from any important structure; though it must be remembered, that in some instances the obturator artery lies on this side of the tumor. The injury of this vessel may be avoided by using a rather dull knife, and by effecting the division of the stricture by pressure, rather than by a drawing motion. Nor need the incision of the edge of the stricture be carried but a slight distance; for if its sharp edge is simply nicked by a little pressure, the dilatation will generally be found to be sufficient to admit of the easy reduction of the hernia. "The use of a dull bistoury, and the direction of its edge upwards for merely a line, at several points of the ring UMBILICAL HERNIA. 487 as advised by Velpeau, no matter in Avhat portion of the circum- ference of the ring the stricture is most marked, will suffice for the relief of the constriction, as may be readily tested on any sub- ject."* The upward and inward direction of the incision for the relief of the stricture is preferred, not because the cut in this direction is safer than one made directly inwards, but because the cut into Gimbernat's ligament, which would be the part incised in the latter case, would not have so great a dilating effect upon the crural orifice, as a division to the same extent of the " ilio-femoral" liga- ment, Avhich is the part involved in the upAvard and inward in- cision, -f- After the stricture is relieved, the parts are to be exam- ined, and treated in reference to their condition ; and the subse- quent management of the case is to be conducted in accordance with the general principles already laid down. The operation for strangulated external femoral hernia consists, in carefulJy dissecting down to the tumor, and relieving the stric- ture by dividing, layer by layer, the parts that seem to produce the constriction; which is the only possible way, "according to Hesselbach, to avoid wounding the circumflex iliac artery, which always lies in front of the neck of the sac."J Umbilical Hernia. This form of rupture occurs through the umbilical aperture. It is sometimes congenital; and it very frequently appears in early infancy, before the changes in the umbilical cord have firmly blocked up the navel; the immediate cause, in such cases, being some violent fit of crying or straining, on the part of the infant. In adults, it is generally found on females Avho have been fre- quently pregnant, in those who are very corpulent, or after great distention of the abdomen by dropsical effusions. It is probable, that in most cases of true hernia of the navel occurring in adults, there has been a tendency to the affection from birth or childhood; for if the changes which normally occur in the structures about this orifice just after birth have progressed to a healthy termina- tion, it is difficult to perceive how so strongly fortified a position would give way sooner than other and weaker points. In child- hood, the hernia is readily cured by proper compression of the part, kept up for a feAV months. In some cases, a spontaneous cure ♦Smith's Operative Surgery, p. 438. fErichsen. JChelius. 488 OPERATION FOR UMBILICAL HERNIA. is effected. In adults, it is apt to attain a very great develop- ment, unless the bowel is retained in the abdomen, or supported, when irreducible, by means of a proper truss. An irreducible umbilical hernia is liable to both incarceration and strangulation; and it is sometimes difficult to say, Avhich of these conditions obtains in a given case. Under such circumstan- ces, the best plan to adopt, after haring tried the taxis, relaxants, depletives, &c, and after finding that the bowels continue in a state of inaction,—is, to treat the case as one of strangulation, and resort without delay to the operation. When undoubted strangu- lation is present, the knife should be early resorted to, as it is but seldom that the other plans succeed in effecting relief. The surgical anatomy of the parts concerned is simple. In most cases, there is no proper hernial sac, the peritoneal covering having become either adherent to the under surface of the superficial fascia, or perforated at an earlier stage of the affection. The intes- tine, therefore, has not as many envelopes as in femoral or ingui- nal hernia, it being only covered by the skin and the superficial fascia, with, perhaps, the remains of the peritoneal sac. In operating for umbilical hernia, various methods are recom- mended. The plan advised by Erichsen would seem to be the best, as it produces the least disturbance of the bowels. He recom- mends "a semilular incision five or six inches in length, by the side of the tumor," Avhich is to be deepened, by careful dissection, to the linea alba; Avhen a careful opening is to be effected in this tissue, "and a director having been passed doAvn toAArards the neck of the sac, under the stricture, the section should be made with a probe-pointed bistoury." If it is found impossible to divide the stricture by this plan, he then proceeds to lay the sac open, and to relieve the stricture from within. The incision, for this purpose, may be made Avithout any risk, in any direction around the navel, and should be from one-half to three-quarters of an inch long". It is to be made directly upAvards or downAvards, or both above and beloAv, if desirable.* The bowels are then to be examined, and if it is determined to return them, and there is any difficulty in effecting this object, it is suggested by Skey, that "the abdominal muscles may be raised by introducing the finger through the open- ing, and drawing them upwards, so as, in fact, to enlarge the cavity into which the intestine is to be returned." The after treatment must be conducted with a vieAv, if possible, *Skey, p. 460. THYROID OR OBTURATOR HERNIA. 489 to effect a permanent cure. An efficient and firm compress should be applied over the orifice, and the use of a proper truss should be resorted to, as soon as the Avound can bear it. Sometimes a large umbilical hernia is divided into several parts, by the unequal distension of its coverings; and, occasionally, the divisions between these sacculi, or lobes, are formed of constrict- ing cellular bands, Avhich require division, when the operation is undertaken. The strangulation of an umbilical rupture verv seldom occurs in a pregnant woman. Should a case present itself, however, in Avhich this condition obtains, the operation should, nevertheless, be performed, as it offers the only reasonable chance for life. Some cases of success, under these circumstances, have been recorded by reliable authority. The success of the operation for the relief of strangulated umbilical hernia would seem to be pretty fair, ac- cording to the statistical reports. Of seven cases, collected by Smith, from Lawrence, Scarpa, and Dessault, one proved fatal: of seventeen cases of femoral rupture, from various causes, only one was unsuccessful; while in forty-nine operations for inguinal her- nia, fourteen died, and one had artificial anus. From the investi- gations of Thomas Bryant, Esq., of 126 fatal cases, occurring in Guy's Hospital, one of the conclusions arrived at was, "that after operation, inguinal hernia Avas more fatal than femoral by 16.6 per cent."* Other forms of Abdominal Hernia. The other forms of abdominal hernia, are much less frequently met with than those already mentioned. In some, strangulation never occurs; in others, it takes place, and there is no prospect of the operation being performed with success; while in some of these forms of disease, the operation is practicable, with a greater or less degree of success. We will confine the rest of our remarks to this last class. Thyroid or obturator hernia has been operated on successfully, but only in two cases; one by B. Cooper, and the other by Mr. Obre.f The existence of the affection is very rarely discovered during life, on account of its deep-seated location. The intes- tine protrudes through the foramen in the obturator membrane through tvhich the obturator vessels pass, and is so covered *See New Orleans Med. and Sur. Journal, Vol. xiii, No. 5, p. 69S. f Erichsen. 490 VENTRAL HERNIA. up, and pressed upon, by the pectinous adductor longus, "the long and middle head of the triceps and the gracilis"* muscles, that it is prevented, in almost every case, from producing any perceptible prominence. Should an operation be determined upon, the same general principles must be attended to that have been already eluci- dated, theanatomyof the partsbeingthoroughlyappreciated. When the point of stricture is reached, an attempt may be made to dilate the orifice by means of a blunt hook, the traction being made in an outward and downward direction. If this plan fails, the knife must be resorted to, and an incision must be made, according to Sir Astlev Cooper, on the inner border. Ischiatic, or dorsal hernia may sometimes require the performance of an operation. It is generally too small to be discovered ; but, it occasionally attains considerable dimensions, contains a great quantity of intestines, and sometimes the Avhole bladder and even the Avomb. The rupture takes place through the ischiatic notch, " above the sacro-ischiatic ligaments and pyriform muscle, beloAV the gluteal muscle, and appears externally near the lower part of one of the lateral edges of the rump-bone, or coccyx."-\ In operating, the utmost caution must be observed in the dissec- tion ; the vessels must be tied as they are cut; and, if the dilation with the blunt hook fails to relieve the stricture, the incision must be made directly forwards. According to Chelius, one authority (Seller) "considers it absolutely necessary in dividing the mouth of the sac, to cut layer-Avise from Avithout inwards." Perineal rupture, in some very rare cases, may require the per- formance of the operation. The usual course of proceeding is to be adopted; and the constriction Avill generally be easily relieved by a slight incision into the edge of the hernial sac, "from beloAV upwards obliquely towards the side. (Scarpa.)"f Ventral hernia, or hernia through various portions of the abdom- inal wall besides those particular localities already mentioned, may sometimes become strangulated, and may require a resort to the knife. The omentum may be alone implicated, or the intes- tines, bladder, womb, &c, may be involved. These ruptures are of various forms and sizes, and are situated in various localities. Their neck is generally oval; and, in most cases, the orifice through which they have escaped becomes so dilated as pretty nearly to obviate all risk of strangulation. Sometimes, Avhen *Lawrence. fChelius. PROLAPSUS ANI. 491 situated near the navel, they are mistaken for umbilical hernias; and, vice versa, these latter are occasionally thought to be ventral. They are sometimes met with in the lumbar region; and in many cases, they are the results of traumatic injury. In these cases, if the wound has penetrated or seriously injured the peritoneum, the hernia may have no sac; and this fact should be borne in mind, Avhen operating on a case which has so originated. The operation is similar to that for umbilical hernia. It Avill generally be prudent to open the sac, if one exists; and the stric- ture should be divided in an upward direction, with due regard, always, to the anatomy of the particular locality in which the her- nia may happen to be. S. L. ESSAY No. 9. DISEASES ABOUT THE ANUS. Prolapsus Ani—Piles—Polypus Ani—Stricture of Anus and Rec- tum—Fistula in Ano—Recto-vesical and Recto-vaginal Fistulae— Congenital Malformations. A great deal of pain and discomfort is sometimes the result of a relaxation and falling of the rectum to a greater or less extent. This affection may arise from a prolapsed condition of the mucous lining membrane of the rectum; or it may consist in a descent of the entire tube. The latter, hoAvever, is of very rare occurrence, but is a much more serious affection than the first. The cause of prolapsion is generally, a relaxed state of the tis- sues about the anus, resulting from a state of general weakness and relaxation from bad health. The disease may, however, also arisejfrom constant irritation of the parts: as from tenesmus accom- panying dysentery, or the great effort necessary on going to stool after an attack of costiveness. The affection may also arise from, or accompany, stone in the bladder, stricture, or any disease that shall render the passage of urine difficult, and hence cause effort or straining to be necessary. Piles, too, are a frequent cause of prolapsus: the latter affection, in such cases, being generally cured as soon as the former one is removed. The symptoms of this complaint are too evident, for a mistake in 492 TREATMENT OF PROLAPSUS ANI. diagnosis ever to occur. A tumor is found occupying the region of the anus—if recent, red, smooth, and polished; or darker, and inclined to be turgid and swollen, if of longer duration. This tumor is found on examination, to be continuous with the mucous membrane of the interior of the rectum. The swelling generally first appears after some violent exertion in emptying the bowels. It is at first easily returned, gives no trouble, and does not again descend for some time. Gradually the descent becomes more and more frequent, until it occurs on every attempt at going to stool, and on taking any severe exercise, as riding, Avalking or standing for any length of time. When the disease becomes fixed, the tumor is always down, and cannot be returned Avithout difficulty; and Avhen returned, it immediately comes down again. The treatment of this troublesome affection must depend very much upon the length of time it has existed, and the extent to which it has gone. If recent, and only of occasional formation, the tumor should be at once returned beyond the sphincter, a compress, supported by a T bandage, applied over the anus, and astringent injections frequently used. The boAvels should be kept in rather a loose state, by the use of such food as Avill tend to keep them free and by aperients—if necessary. The bowel having been reduced, the patient should be put to bed, and kept for some time in the horizontal position. The easiest method of reducing the bowel is, to oil the index finger well, and then cover it Avith a well oiled and soft rag, and proceed exactly as though the object was to examine the upper portion of the interior of the rectum. The finger should be passed as high as possible; then with the finger and thumb of the left hand pressing firmly around and against the sphincter, and causing that muscle to grasp the fino-er in the rectum tightly, this should be gradually and slowly with- drawn, leaving the cloth, Avhich surrounded it, behind. When the finger is completely withdrawn, the cloth should in like man- ner be carefully removed. This will be found a simple and effec- tual method in all cases. After the tumor is reduced, astringent lotions, as above directed, should be used, and if the patient be a female, a pessary should be worn in the vagina. As an injection, solution of sulph. of iron has been recommended—of the strength of three grains to the ounce of water—and is perhaps as goodTas any of its class. When this—which is known as the palliative treatment—fails, recourse must be had to some operative proce- dure. OPERATION FOR PROLAPSUS ANI. 493 The operations for prolapsus ani have been divided into two classes, each having reference to the parts in Avhich it may be performed. In one class—that in which the operation is exter- nal—the object is to close the anus more thoroughly, by inducing greater contraction of the sphincter. This operation is based on the fact, that in every case the tissues around the anus are in a relaxed state, and the skin loose and Avrinkled; while the sphincter remains so much relaxed that the anus is but slightly closed. In the second class, the prolapsed mucous membrane itself becomes the seat of operation. The object is to prevent the return of the tumor, by causing sufficient contraction in the mucous membrane to prevent its falling. The patient should be placed so that the tumor shall be fully exposed : he should lie upon a bed on his belly, with the feet and legs hanging over the ends, so that the buttocks shall rest just over the edge. The surgeon then takes his position behind the patient, and the thighs are drawn apart by two assistants, while he seizes, with a pair of forceps armed with large teeth, in succession, tAvo, three, or more folds of the anus, and removes them with a pair of scissors curved on the flat. These incisions extend to the verge of the anus, or beyond it, according to the amount of relaxation to be overcome. This oper- ation is said first to have been performed by Hey, but is generally known as Dupuytren's. It is best adapted to those cases that are attended by prolapsion of both the muscular and the mucous coat of the rectum. Several methods of operating Avhen the affection is included in the second class, as above mentioned, have been advised; all of these, however, have as their object, the production of contraction in the rectal mucous membrane. It has been proposed to lift the most prominent part of the tumor with a pair of forceps and remove it by the bistoury, or with a pair of scissors; the rest of the tumor being then returned above the sphincter. The membrane should not return until all hemorrhage has ceased, as the bleeding is sometimes profuse. To prevent this risk of hemorrhage, Ricord is said to tie each artery as it is divided, and to divide the tumor slowly, with successive strokes of the bistoury, stopping to tie each artery, and not proceeding until the bleeding has ceased in that part of the wound. Erichsen, on the contrary, advises that the use of cutting instruments be done away with, and the ligature substi- tuted. He advises that the "ligature be applied in the following way: the patient having had the bowels freely opened on the 494 PILES. preceding day, and an enema of tepid water on the morning of the operation, should be directed to sit over a pan of hot AA'ater, in or- der to make the prolapsus descend ; it may then be seized with a pair of broad-ended forceps and drawn Avell fonvards. The base must then be firmly tied with a strong piece of Avhip cord, and a similar process repeated on the opposite side of the anus." Should it be difficult to apply these ligatures, he advises the tumor to be transfixed by an armed hermorrhoidal needle, and the ligature tied on either side; the use of the needle, however, must be avoided if possible. The ligatures being cutoff short, the entire protruded mass should be pressed above the sphincter, the external flaps of skin cut off, and a pill of opium given, to allay peristaltic action. If the Avound heals slowly, touch it lightly Avith the nitrate of silver, once or twice if necessary. This operation is said to give but little pain, and always to effect a complete and permanent cure. It has recently been advised to paint the protruded membrane over its entire surface with nitric acid, and then pass it above the sphincter. This is said to give rise to little or no pain, while the cure is certain and lasting. I will only add, upon this subject, that the use of chloroform in these operations has been recommended by some surgeons, and eschewed by others. It appears most advisable to avoid its use in the early part of the operation, Avhen the tumor is to be seized and drawn as Ioav as possible, and the assistance of the patient, by voluntarily bearing doAvn, is required; but as soon as this is ef- fected, and previous to ligation or the use of the knife, the anaes- thetic should be given to prevent pain; Avhile, by relaxing- the sphincter, it will also facilitate reduction. In cases in Avhich the bowel has become strangulated, every exertion must be made to reduce it early. Chloroform should be freely o-jven the taxis carefully resorted to, and if these measures fail, the sphincter muscle must be divided to a sufficient extent to relieve the bowel and admit of its reduction. Piles. Some difference of opinion exists, as to what a pile or hemor- rhoidal tumor really is. There are surgeons who regard this as a tumor formed by the rupture of one or more of the small veins of the part, and consequent extravasation of blood in the cellular tis- sue between the muscular and internal coats of the rectum. Most EXTERNAL PILES. 495 generally, hoAvever, piles are regarded as the result of a varicose condition of the hemorrhoidal veins. The rectum, from the very nature of its office in the economy, is so formed, that it may be very much dilated, and avi'11 immedi- ately contract again. The result of this is, that the internal or mucous coat of the bowel, Avhen not distended by the contents thereof, is very lax, and falls in folds around the interior of the tube. The muscular coat, on the contrary, is then firmly con- tracted. Thus the blood-vessels passing between these layers are constantly pressed from without, while all support is removed, at times, from their inner sides; nay, this is generally their condition. The veins from this part too, are not supplied with valves, and hence the blood by its own weight tends to produce distention of the hemorrhoidal veins. Every effort of the abdominal muscles too, has the same effect; while the passage of the feces through the bowel tends mechanically to force down and retain the blood in the hemorrhoidal vessels. Under these circumstances, it is not at all surprising to find the coats of the veins yielding becom- ing more or less distended and producing tumors of greater or less extent. Piles have generally been divided into the internal and the external. The first generally remains above the sphincter, while the second are below it. The internal piles have again been divi- ded into the bleeding and the blind, as they generally bleed at intervals, but do not always do so. The affection, in each of its forms, may consist of a single tumor of small or large size, or the growths may be so numerous as com- pletely to fill up and close the rectum or hang in clusters around the anus, while between these two extremes every grade in num- bers may present themselves. The internal pile is of a pale bluish or purple color, and is covered by a very thin layer of mucous membrane, so thin sometimes that the contained blood may ooze through it, and very often, under the pressure of the hardened descending feces, this thin covering gives way, and profuse hemorrhages occur. This form of pile arises within the sphincter, and is never covered by the skin. The external variety, on the contrary, arises Avithout the sphincter and is covered by the skin, which is generally thickened, hardened, and sometimes of a warty character. This form of pile never bleeds unless from the application of violence, but is very painful if pressed upon. Like the internal form, it is apt to cause a sensa- 496 TREATMENT OF PILES. tion of heat and discomfort, often amounting to pain, in the tumor itself; the pain often darting upwards, affecting all the neigh- boring organs, and being frequently increased by standing or walking. The internal pile sometimes descends, and is prevented from re- turning by the closure upon it of the sphincter ani ; becomes strangulated, and, if not relieved, will inflame, die, and slough away. Indeed, the disease is sometimes cured by this accidental process. In its first stage, this disease may consist simply of a varicose condition of the veins, causing longitudinal swellings along the surface of the bowel, and giving a knotty feeling to the interior of the rectum. These knots or bulbs soon enlarging, form soft and compressible tumors, at times increasing, then again diminishing in size, and easily emptied by pressure. Soon they become more decided, extend either longitudinally or in a spherical manner, and become firmer and firmer, by the increase of their cellular material and the deposition of plastic matter, until they resemble a sponge filled Avith blood. An artery is often found passino- di- rectly into the centre of the tumor. In the external pile Ave are apt to find, that, from the amount of plastic deposit, the tumor has lost its cellular character in a creat measure, and has hence become a tough, indurated mass, supplied with veins and having an artery passing into its centre. With regard to the causes of piles, I will only observe that they are apt to result from anything calculated to cause an eno-oro-e- ment of the abdominal vessels, particularly the portal system ; for as has been already observed, the superior hemorrhoidal vein is without valves, and so these vessels are obliged to act under the pressure of the entire column of blood in the portal system. Piles may arise, too, from any cause producing a certain habit, or a lax state of the muscles. Thus, luxurious or sedentary habits with little exercise, and high living, are frequent causes of the affection • and hence the wealthy and idle, and the studious but secluded, are alike sufferers therefrom. Sex appears to have no influence as a cause, it being found more frequent among young men than young women, but oftener with middle aged and old women than with men at the same time of life. The treatment may be divided into palliative and curative. Under the first head are included such measures as are calculated to pro- duce regularity in the portal system, and keep up a moderately REMOVAL OF PILES. 497 loose state of the bowels. Cooling and astringent lotions and in- jections, as local measures, an I •.* hatever, as free exercise, &c, shall serve to improve the general health, will be found useful. The curative treatment consists in the complete removal of the disease, by the knife, ligature, or cautery. These measures Avere formerly applied indiscriminately to both forms of pile; modern surgeons, however, confine the use of the knife entirely to the ex- ternal form of the disease, the internal being only removed by the ligature. The use of the cautery is seldom resorted to, except to check hemorrhage after one of the other operations. Formerly these forms of the operation Avere resorted to in both internal and external piles; but the excision of the internal tumor is found so invariably to bef ollowed by severe hemorrhage, that it has been quite abandoned in this form of the complaint, and the ligature used in its stead. Just the reverse is true of the external pile. Here the hemorrhage is seldom of great amount, and can always be controlled with ease. Hence the knife is preferred as more expeditious than any other method, and " it may be laid down as a rule in surgery that ail external piles should be cut off,. and all internal piles tied." (Erichsen.) In operating for external piles, the patient should be placed on the side corresponding to that on Avhich the tumor to be removed is, and an assistant by lifting the opposite buttock brings the hernorrhoides at once and plainly into view. The surgeon then seizing the tumors one by one with a pair of hooked dissecting forceps, and draAving them outward, divides their base or pedicle, and so removes the tumor. Should hemorrhage follow, it can easily be checked by torsion of the bleeding vessels, or ligation of them if necessary. Where the pedicle is narrow it will be most convenient to divide it Avith a pair of strong scissors, curved on the flat; but Avhen the base is broad, the bistoury is more con- venient. Perhaps the best method is to combine the use of the ligature with that of the knife thus.—A needle armed with a double liga- ture is passed through the center of the pedicle or base of the tumor, as near its attachment as possible : the two ends of the ligatures are then tied on either side, and the section of the tumor made just outside of them. After the tumor is removed, simple dressing is all that will be required; the patient being kept quiet, and in bed, until the wounds heal. When the piles are internal, the bowels having been well washed 498 REMOVAL OF PILES. out by an enema, the patient is caused to sit over warm AA'ater, that the parts may be as much relaxed as possible, and then placed in the same position as for the above operation. The surgeon then takes his position, and the patient is directed to bear down as if at stool: the tumors are thus brought plainly into view; and being seized Avith the forceps, are drawn doivn as far as possible ; a needle armed with a double ligature is passed through the base of the tumor, if it be broad and flat; and each segment is tied separately. When the base is not very Avide, or the tumor is pediculated, each pile being in succession drawn forward should be tightly ligated, with silk or whip cord. The tumors being all tied, or as many as can be reached, the ligatures should be cut off short, the entire mass passed above the sphincter, and the patient kept quiet in bed, until the piles have sloughed away; Avhich generally occurs be- tween the sixth and ninth days. At the end of forty-eight hours, if the bowels have not been acted upon since the operation, a little castor oil may be given. After the tumors have sloughed, the small ulcerated surfaces thus left will soon heal and cause no trouble. Metallic ligatures have been frequently substituted for the silk or whip cord, thin and very flexible silver or steel Avire being used. This is applied around the tumors, and the ends are tightly tAvisted. The metallic ligature has the advantage of being tightened from day to day by twisting of its ends, and thus causes the tumor to slough in a shorter time. The ends of the Avire, howe\-er, must be left out of the anus, and they often cause considerable irritation : in other respects the use of the metallic ligature differs in nothing from the same treatment with silk, &c. Good, strong, but moder- ately small Avhip cord is generally preferred. After the pile is tied, irritation about the neck of the bladder sometimes arises. This will generally be relieved by a warm hip bath folloAved by an emollient application over the pubis, and a full dose of anodyne. Erichsen recommends hyosciamus and nitric ether. In cases in which the pile is too high up to be ligated, or is of a granular nature, or where the tumor is broad and flat, it has been advised to apply nitric acid to the surface of the tumor, care being taken that the acid touches no part but this. To effect this, a cylindrical speculum ani Avith an oval or oblong opening near its extremity is used. This being introduced into the rectum, the pile is made to fall into and protrude through this opening, and the acid is applied through the speculum on the protruding part. The part should immediately be cleansed by lint saturated with a POLYPUS IN ANO. 499 solution of prepared chalk, and the speculum removed. The eschar, and consequent contraction, is said sometimes to effect a cure. If the acid is prevented from coming in contact with any other part, the operation will cause no pain. In cases of internal pile hanging very low, or in what some sur- geons call enter o-external piles, as well as in very vascular external ones, a combination of the ligature and excision is often resorted to. The tumor being transfixed by a needle with a double ligature, is tied around its base as above described, and then divided by the bistoury just outside the ligature, Avhich is left to slough off. If undisturbed, piles sometimes become cured by an atrophy of the sac after being ruptured ; or the tumor may slough and ulcer- ate ; and the ulcerated surface, by healing and contracting, may prevent a return of the disease. Under other circumstances, the ulcer grows deeper and deeper, and the contents of the rectum are from time to time lodged therein, until at last, a fistula in ano is formed. These cases, hoAvever, are exceptions to the rule; for generally, if not treated, piles will gradually increase, grow worse up to a certain point, and then for years remain apparently stationary, only causing trouble by the local irritation and pain to Avhich they give rise. Polypus in Ano. Pol vpi are sometimes found growing from the mucous membrane of the rectum, being most frequently observed just within the sphincter. They may be removed by the ligature or excision, and caustic also has been used with success. The bowels having been emptied, as in the operation for piles, the patient by a voluntary effort forces the tumor down, and the suro-eon seizes it Avith a vulsellum, or hooked forceps, and draws it steadily down until the pedicle can be easily reached. Around this, the ligature should then be tightly applied, the ends cut off, and the mass returned at once above sphincter, and left to ulcerate and fall off. When excision is preferred, the tumor is drawn forci- bly down, as in the preceding case, and its pedicle divided by a pair of scissors curved on the flat. The after treatment differs in no respect from that for piles. Perhaps it Avould be best to combine the use of the ligature Avith that of the knife, ligating the tumor first, and then cutting it off. In this case, the bistoury should be passed sufficiently far from the ligature to ensure the remaining of the latter in its proper position : 500 STRICTURE OF ANUS AND RECTUM. if passed too near, the ligature will fall off on the contraction and shrinking of the tissues after the section has been made. Stricture of the Anus and Rectum. As the result of healing after extensive ulceration, or the con- traction of the cicatrix after burns or wounds, the sphincter ani sometimes becomes so much contracted, as materially to lessen the size of the anus. Under these circumstances, all that can be done is carefully to dilate the anus, by the persevering and continued use of masses of lint, gum elastic bougies, sponge tents, &c. Stricture of the rectum may be the result of a closure of its calibre by a simple fibrinous deposit, or from malignant cancerous disease of the rectum. The simple form of this disease may occur at any part of the rectum, in either sex, or at any age. It is, however, most commonly found from tAvo to six inches above the anus, and in females rather advanced in life. The stricture may consist of a membrane apparently stretching across the tube on one side, and thus narrowing it; or it may ex- tend quite across the rectum, leaving only a slight opening, which resembles a hole through the membrane at its centre. Again; the stricture may result from the coats of the bowel being, as it Avere, drawn in towards each other, and approaching some- times so near that only a very small opening, or passage betAveen them, is left. The symptoms of stricture are the same as those accompanying constipation from any other cause : but that Avhich points most forcibly to this as the disease, is, the gradual and constantly in- creasing difficulty in defecation. At first some effort on going to stool is necessary, but with a little exertion the feces are passed, somewhat flattened, perhaps, and it may be slightly stained with blood. At each successive motion the effort necessarily becomes greater, and the amount of feces passed groAvs less, until extreme exertion is required, and only a few very hard scybala are forced aAvay. Occasionally a slight Avatery diarrhoea may exist. The case thus grows worse and worse, until it must either be relieved, or it causes death. Two methods of treatment are recommended ; dilatation, and the knife. The first can be resorted to in all cases,—the last, only when the stricture is low down, and can be easily reached by the finger. TREATMENT. 501 In using dilatation there can be no difficulty, if the stricture can be reached by the finger, as a probe can easily be introduced thereon, and carefully insinuated beyond the stricture. Where the difficulty exists higher up and beyond the reach of the finger, the case is much more difficult; for the probe must then be passed alone, its course necessarily becomes uncertain, and the difficulty is increased by the point catching in the mucous folds of the intes- tine. When once passed, the probe should be retained for a short time and then withdrawn, and introduced again about every second day; the size being increased each time. As a modification of this method, it has been proposed, to intro- duce upon a probe a long narrow linen bag, until it has passed considerably beyond the seat of stricture; the staff or probe being then withdrawn, and the bag filled to distention with small pieces of lint, and so caused to dilate the stricture. Whatever may be the peculiar mode adopted, the principle of all these operations is the same. They all have as their object the dilating of the tube, and effect this by the introduction from time to time, of some form of instrument, Avhich is regularly in- creased in size. Where the stricture is treated by the knife, the finger well oiled, should be passed gently but quickly through the anus,and carried at once to the seat of stricture. A probe-pointed bistoury, guarded by linen to within a short distance of its point, should then be carried on the finger, as a guide, in to the stricture, and its point carefully insinuated through it; the unguarded cutting edge be- ing then brought to bear on the constricting surface, so as to divide it to a slight extent. This may be done only at the lower centre of the tube, or there and above, or above, beloAV, and on either side, as may appear to be necessary in each case. The knife should be AvithdraAvn on the finger, and a probe introduced. This should be worn for a short time, and withdraAvn, being sub- sequently introduced on every second day, until the parts are quite healed. The patient, during the operation, should lie as though undergoing perineal lithotomy. Erichsen recommends, that where dilatation is used, and the stricture yields sloAvly, being hard and indurated, the knife be in- troduced, and a notch made on the posterior surface of the stricture. A tent of compressed sponge should then be introduced, and worn for twelve hours, after which the use of the probe should be re- 502 FISTULA IN ANO. sumed. The two methods are thus united, and no doubt the cure is expedited thereby. If left untreated, stricture of the rectum may in a feAv rare cases be spontaneously relieved, or suddenly cause complete closure of the boAvel, and so produce death. Generally the constriction goes on gradually increasing, until after some time total occlusion takes place. Abscess sometimes forms above the seat of stricture, de- scends, and bursts in the vagina; or it points in the nates, or internally in the pelvis, causing a large discharge of pus, and rapidly producing hectic, which is soon folloAved by death. Life may also be destroyed by the supervention of peritonitis. This affection should then never be neglected, or its thorough treatment postponed, as its tendency most undoubtedly is to cause death. Fistula in Ano. There are three varietes of this affection; the blind internal, the blind external, and the complete. In the first two, or blind fis- tulas, there is but one opening into the sinus. In the blind inter- nal, this opening is in the interior of the rectum; whilst in the ex- ternal variety, the sinus opens externally, someAvhere in the neighborhood of the anus. In the complete, the sinus is open at both ends, one end communicating Avith the bowel, the other open- ing externally. These fistulae vary greatly in their extent, sometimes consisting only of a short sinus in the submucous cellular tissue about the anus, and only extending for a short distance along the course of the rectum. This form of fistula is generally the result of small abscesses forming about the part, and not being properly cured. In other cases, the disease consists of extensive burrowing sinuses, which reach to some distance from the sphincter, and run for an inch or more up along the rectum. In these latter cases, it will generally be found that stricture of the intestine exists. In the blind internal variety, the patient suffers from occasional burning and constant tenderness over the seat of the sinus. At longer or shorter intervals, there are discharges of pus from the anus ; and this discharge may be produced at any time, by pressing over the seat of the sinus. By introducing the finger and exam- ining carefully, the seat of the opening can generally be detected. In the external blind variety, the opening into the sinus is evident, TREATMENT OF FISTULA IN ANO. 503 and it will attract notice by the pain and discharge it causes. On introducing a probe, it is found only to penetrate to the bottom of the sinus, and not to enter the cavity of the rectum. In the com- plete variety, on the contrary, the probe, if introduced into the sinus through its external opening, can be readily passed into the rectum, and detected by the finger passed therein. In cases of blind internal fistula, it is advised to convert the blind into the complete variety, by opening into the sinus from without, after which the case should be treated as if originally one of that variety. In cases of blind external fistulae, Ave may resort to the use of caustic, dilatation, the bistoury; or Ave may convert them into the complete variety. When caustic is preferred, the interior of the sinus may be touched with lunar caustic, or pencilled Avith nitric acid. The lining membrane is thus destroyed ; and Avhen the sinus is small and superficial, it may effect a cure. When caustic fails, it has been advised to lay open the sinus freely, and produce a closure thereof by granulation. Where these methods fail, the only sure plan is to convert the fistula into a complete one, and treat it as such. For this purpose, a piece of round, hard wood, having on one side a deep groove ending abruptly near its point, should be passed into the rectum as a sound. This must be passed up the bowel until the end of the groove is above the spot at which the internal opening is to be made. A pointed bistoury, long, narrow, and slightly curved, should then be passed, with its cutting edge turned doAvmvard, through the sinus, until its point reaches the rectum; through the walls of which it must then be forced, and its point lodged in the groove of the Avooden director or sound. This will be easily ef- fected, by pressing the point of the knife slightly against the sound and at the same time turning the latter, until the point of the knife is felt to slip into the groove. The operation may then be com- pleted at once by simultaneously withdrawing the knife and sound together, the handle of the knife being elevated, Avhile its point is kept firmly pressed into the groove of the sound. All the tissues betAveen the sinus and rectum are thus by one stroke divided, and the sinus and rectum converted into one. The after treatment is the same as that after the similar operation for the cure of complete fistula. For the cure of complete fistula, two methods of operating have been proposed and practiced; by the ligature, and by the knife. 504 TREATMENT OF FISTULA IN ANO. The first is very tedious, and should only be resorted to Avhen, from the fears of the patient or some other cause, the knife cannot be used. The operation consists in passing a ligature of silk or me- tallic wire through the sinus from the external to the internal opening; its end in the rectum is caught by the finger passed up the tube, and brought out at the anus. If the ligature is of silk, its ends are tied; if of wire, tAvisted slightly together; and it is tightened from time to time, until it cuts out. This is a very pain- ful and slow process ; indeed, so painful does it become when the skin only remains, and is pressed upon by the ligature, that the operation is often, at the request of the patient, brought quickly to an end, by dividing this Avith the knife. W7hen the knife is used, the patient should lie on his side in bed near the edge, or may rest on his knees in a chair, Avith his arms over its back; indeed, he may be placed in any position that shall fully expose the rectum to the view and manipulation of the sur- geon and his assistant. A very convenient plan—and one with which I have succeeded Avhere the involuntary actions of the pa- tient (a muscular negro fellow) could by no other means be over- come—is to spread a blanket over a long narrow table, and cause the patient to lie on his belly thereon, the feet and legs hanging over one end, and the buttocks resting near the edge. The patient is then directed to grasp the table Avith his arms, and an assistant on either side places one hand on the shoulder, and the other on the buttock or loin, and so easily controls the patient's movements. The surgeon then, standing behind the patient, passes a probe- pointed bistoury through the sinus, until its point enters the rec- tum; and the right index finger is then passed up that tube until it reaches the point of the bistoury, over which it should be hooked. The handle of the knife being then pressed firmly upAvards to- Avards the buttocks and the point simultaneously draAvn downwards by the finger in the bowel, both are brought out together at the anus. The sinus and rectum are thus laid into one, by the sever- ing of all the structures between them. When the internal opening is near the anus, a convenient method will be, to use, as has been advised, a very flexible silver director, as a probe ; and this should be passed through the sinus into the rectum, where its point must be caught by the finger forcibly bent downwards, and brought out at the anus. The ends of the director should then be-drawn forcibly fonvards and the structures, thus elevated, divided by a short, straight, and Avide- RECTO-VESICAL FISTULA. 505 bladed bistoury. The cutting out of the director ensures the per- fect division of all the fibres, and hence the opening of the sinus to its full extent. The wound should be filled from the bottom, with lint well oiled, and caused to heal by granulation. Great care must be taken to prevent the sides of the wound from coming in contact, healing, and so leaving a cavity below. Simple water dressing is all that is required. The operation over, and the wound dressed, the patient should be put to bed, and kept perfectly quiet. Opiates should be given to restrain the action of the bowels until about the third day, when a mild laxative may be given, if neces- sary. The first action of the boAvels will generally empty the wound ; and it should be dressed again from the bottom, care being taken to prevent its healing first above. A very good method of effecting this is, to introduce a probe daily to the bottom of the wound, and to move it gently from side to side. Should hemor- rhage follow the operation, the rectum must be tightly plugged with lint. After the wound has healed, the only inconvenience that may remain, is an incontinence of the watery and gaseous contents of the bowels, which sometimes occurs. In some rare cases, even fecal matter escapes. This difficulty results from the angles of the wound through the sphincter muscle projecting slightly, and so causing a small opening; but this difficulty will wear away after a short time. WThere there is but one external and several internal openings from the sinus, or Avhere, with but one external and one internal opening, several sinuses exist, running along the course of the rectum* the case should be reduced to one of simple complete fis- tula (by laying the several sinuses open into one,) and treated ac- cordingly. Recto- Vesical Fistula. This is fortunately a rare affection; occurring, generally, as the result of a malignant disease or of a Avound. The symptoms of the complaint are marked, and cannot be misunderstood. The urine escapes from the rectum in greater or less amount, as the opening between the viscera is larger or smaller; and where the fistula is very extensive, especially if the result of cancer, fecal matter may escape from the bowel to the bladder, and be dis- charged through the urethra with the urine. The constant drip- ping" away of the urine is very apt, too, to excoriate the parts 506 VESICO-VAGINAL FISTULA. around the anus, and so cause much suffering; Avhile the constant wetting of the cloths by that liquid causes the patient constantly to be annoyed by an unpleasant urinous odor. Where the first symptom above mentioned exists in combination with the others, or alone, the nature of the disease can scarcely be doubted, but will be easily rendered certain, by an examination of the rectum, with the finger or speculum. The treatment of this form of fistula is always tedious and un- certain; but when the opening in the viscera results from cancer, a cure cannot be hoped for, and all that can be done is, by the use of anodynes, and a strict attention to cleanliness, to detract as much as may be from the patient's sufferings. If the fistula is the result of some other cause, and is small, it Avill frequently yield under the use of nitrate of silver, carefully ap- plied around its edges through a speculum. The similar use of a Avhite hot wire has also been recommended. If these methods fail, or are not thought advisable, it has been recommended to introduce a grooved staff through the urethra into the bladder, and to divide the sphincter and tissues thereon, so as to convert the fistula into a perineal one, which should be healed, by granulation, from the bottom. Jrcsico-Vaginal Fistulae. These generally result from long continued pressure upon the parts, by the foetal head during labor, or from the unskilful use of obstetrical instruments. The affection may, hoAveA'er, result from accident or disease. The urine is found to drip away through the vagina, and upon examination by the touch or with the speculum, the fistula is observed. Of the several methods proposed for the cure of this melancholy accident, not one can be with certainty relied on. The most successful means, however, are afforded by caustic and the use of sutures. Malgaigne also speaks with favor of Dessault's method, which is to keep the lips of the fistula in close contact, by passing a cylindrical plug into the vagina so as to press the anterior edge of the wound against the posterior, a sound hav- ing been previously placed in the bladder and kept constantly there, to prevent any accumulation of urine. The sound should be kept in its position by means of a "curved metallic support at- tached to a truss, and the end of this support pressed on the vulva receives the handle of the catheter in a hole made on purpose." (Malgaigne.) OPERATIONS OF M. JOBERT. 507 Where the injury is recent and of small extent, cauterization, first recommended by Dupuytren, appears to offer the best means of relief. Either the actual cautery or caustic substances may be used ; but care should be taken in using either, so to apply them along the edges of the fistula, that no slough may be formed; for if sloughing should occur the operation will do harm. Where caustic is used, the nitrate of silver is generally preferred. This should, with an ordinary pair of forceps, be carried through a speculum, and applied over the entire edges of the Avound, the caustic being placed at right angles Avith the blades of the forceps. Should the opening grow smaller after the application, it may be repeated as soon as the effects of the first appear to have Avorn off; but should the wound grow larger, the caustic should be discontinued. Attempts to cure this affection by the use of sutures, have so generally failed, that it is unnecessary to do more than allude, in general terms, to the method in which they are performed. Two distinct steps mark the operation. The first consists in the paring off of the edges of the fistula, so as to convert them into raw sur- faces. The second step includes all measures used to bring these together by the application of sutures. Malagodi, Roux and others have devised various measures for accomplishing the one, while the ingenuity of Ludzinsky, Beaumont, Naegele, and many more, has been taxed in vain, to discover an efficient method of effecting the other. At present, the operations of M. Jobert are resorted to Avith the greatest prospect of success. In the one of these, a flap is cut from the labia majora, and the fistulous edges having been pared, it is turned thereinto by twisting its pedicle, and secured in situ with sutures. The opening is thus plugged up, and as soon as the flap becomes fixed, by healing, the pedicle is divided. Should this method fail, M. Jobert resorts to his second operation, which con- sists in making a semilunar incision over the anterior surface of the cervix uteri Avhere it joins the vagina, and dissecting a flap up- Avards; Avhen, by draAving the anterior portion of the vagina down- ward, the end may be fixed by suture to the edge of the fistula, and so close the opening. Under any circumstances, these autoplastic operations" of M. Jobert furnish the most hopeful resource; but where there has been much loss of structure, and the opening is very large, they furnish the only means by Avhich a cure can possibly be effected. 508 NARROWING OF THE ANUS. The use of the uniting apparatus, obliteration of the vagina and several other methods have been proposed for the cure of this af- fection ; but they are noAV regarded only as matters of surgical history. Recto- Vaginal Fistula. By long continued pressure during labor, or perhaps from some other cause, the septum betAveen the vagina and rectum is some- times destroyed, causing a recto-vaginal fistula. Here the open- ing may be closed by paring its edges, and using sutures to secure them in contact; or the same plan may be adopted as in the former affection. After the operation, the sphincter ani should be divided, and the patient put to bed ; an opiate should be given to prevent the action of the boAvels, and the patient kept perfectly quiet for several days. If the bowels have not acted at the end of three days, a very mild laxative may be given, or an oleaginous enema used. The sphincter ani should always be divided, and every exertion made to restrain or prevent any muscular action about the parts, until union has taken place. The urine should be draAvn off by the catheter, at least tAvice a day during the treatment. Should the operation only succeed partially, the opening still remaining, but of reduced size, the nitrate of silver may be gently applied around its edges, and closure thus induced. If this fails, we have only to wait until the parts have properly healed, and then to repeat the operation. This we should do again and again if necessary. The patient should never be left to her fate Avhile there remains a single chance or hope of cure, and as long as her health is good and the parts around the fistula remain sound and continue to heal kindly, Ave need not despair of eventual success. CONGENITAL MALFORMATIONS. Narroiving of the Anus—Closure of Anus—Absence of Rectum. Infants sometimes suffer from symptoms of violent constipation soon after birth, and, when examined, are found to suffer from one or other of the above malformations. When the anus is narrowed, the meconium is observed to ooze through a small opening at the usual seat of the anus, through Avhich a probe may easily be passed into the rectum. CLOSURE OF THE ANUS. 509 This narroAving of the anus is generally caused by a thin mem- brane, passing more or less across it. Under these circumstances, a probe-pointed bistoury should be introduced through the orifice, and the membrane divided by a crucial incision. The angles of the membrane should then be removed with a pair of scissors, and the anus dilated by a niche of lint or piece of compressed sponge, a bougie being afterwards introduced, from day to day, to prevent any subsequent narrowing or contraction of the opening from occurring. In other cases, the anus is completely closed, by a thin mem- brane stretching entirely across it, and preventing the slightest escape of meconium. Generally there is, in the place of the anus and marking the centre of the membrane, a small bluish or dark looking spot, at which the membrane appears thinner than else- where, and Avhere fluctuation can be felt. A small sharp-pointed bistoury should be introduced at this spot, and the membrane com- pletely divided by a crucial incision. The angles of the membrane should then be cut away, and the patient treated as in the former case. It occasionally happens, that an infant may suffer from most ob- stinate constipation, and yet the anal orifice appear perfectly nat- ural and sufficiently open. In these cases, very careful examina- tion should be made, as it sometimes happens, that, though the anus is perfectly formed, yet the rectum is closed by a septum passing completely across it some distance Avithin the anus. This malfor- mation can only be detected by introducing a probe or perhaps the end of the little finger into the rectum, and actually feeling the membrane. A small trocar should be carefully passed through the membrane, and the opening thus made dilated by the use of niches of lint, sponge, tent, or bougies. A much more serious malformation is where the anus is entirely wanting, and the rectum terminates in a cul-de-sac some distance above its usual outlet. Here we should make, just in front of the end of the coccyx, an incision about an inch long. This should be verv carefully deepened, the curve of the pelvic axis being kept in mind and followed, and the end of the rectum sought. When found this should be punctured, and its mucous membrane care- fully drawn down and fastened by sutures to the orifice of the ex- ternal Avound. The opening thus formed should be carefully kept open, by niches of lint, sponge tents, or bougies. These should be 510 HYDROCELE. perseveringly introduced daily until all tendency to narrowini: has been overcome or destroyed. If this precaution is neglected, the artificial passage will gradually contract until it becomes nothing more than a fistulous opening. Great importance is attached to bringing down the mucous mem- brane of the rectum, and causing the artificial tube to be lined therewith. Thus the alvine discharges are prevented from caus- ing the irritation Avhich they certainly would produce if they passed freely over a raw surface surrounded by cellular tissue. The operation is said frequently to have failed and death resulted, only because this precaution was omitted. By far the most serious malformation that may befall an infant, is that in which the intestines appear to have been arrested in their development, and end in a slight bulb or distention at the extremity of the colon, both the rectum and anus being quite Avant- ing. In these cases surgery offers but one resource, and life can only be preserved by the formation, as already described, of an artificial anus. T. S. W. LECTURE LXV. HYDROCELE--ITS VARIETIES--CONGENITAL HYDROCELE--CAISES OF HYDROCELE--DIAGNOSIS--TREATMENT--HYDROCELE OF THE CORD--ITS TREATMENT. We have this morning, gentlemen, to enter upon the subject of hydrocele. This is a watery tumor within the scrotum ;—a collection of water in the tunica vaginalis testis. Throughout our whole country there is perhaps no more common affection than this, and though it does not endanger life, it, nevertheless, causes great in- convenience. I have stated that hydrocele is a collection of water in the tunica vaginalis; but when we consider it in all its various phases, Ave find that, though this is its most common seat, there are cases in which its position chancres. It becomes necessary, there- fore, to enter into a consideration of these varieties with some detail. There are cases in which the cellular tissue of the scrotum is the seat of the effusion, sometimes in the form of cells, and sometimes in isolated cysts. Where the collection is in the tunica vaginalis, CONGENITAL HYDROCELE. 511 instead of forming one large sac, this cavity may be divided by it into various cells, some communicating Avith their neighbors, others not, and all filled Avith a limpid fluid. This is celhdar hy- drocele. Again: hydrocele, instead of occupying the tunica vagi- nalis, may be developed along the course of the cord. This form of hydrocele is, under ordinary circumstances, nothing more than an encysted tumor, composed of serous cysts, Avhich are formed either at the expense of the cellular tissue of the cord, or from the portion of peritoneum Avhich is pushed before the testicle in its descent. To enable us to understand the leading characteristics of hydro- cele, as it generally falls under our observation, it is necessary to understand the relative arrangements of the tunica vaginalis and the testis, as it will also be necessary to understand the different relations of the peritoneum with the testis, during the first fouj- months of foetal life, and subsequently. During these first months, we find the testis in the cavity of the abdomen beloAV the kidneys, on each side of the vertebral column, and if we make a vertical section through the body, we see the testis in the lumbar region, the peritoneum, instead of passing behind, being reflected over it in front. This is the position of the testis in the four first months of utero-gestation. After this, owing to causes which act upon the testicle, and particularly owing to the gubernaculum testis, this organ descends towards the groin; and, when it arrives there, being still acted upon, it engages in the ring, and ultimately descends completely into the scrotum. Thus, in the primary condition of these parts, there is a perfect communication between the cavity of the peritoneum and that of the tunica vaginalis; but the cord eventually becoming adherent to the peritoneum at the ring, the connection between the cavities is entirely obliterated. Now, it is in this cavity of the tunica vaginalis, that the accumulation of Avater takes place. It consists, at first, of the natural serous se- cretion, but gradually goes on increasing, until it forms a large tumor. In some cases, however, we find hydrocele under different cir- cumstances; as, for example, where there is a free communication between the cavity of the. tunica vaginalis and that of the perito- neum. A child, at birth, may present a hydrocele of this kind; as may be inferred from the circumstance, that when placed on its back the tumor disappears, its contents being acted upon by the influence of gravitation. Sometimes this condition becomes per- 512 TREATMENT OF HYDROCELE. manent, so that the individual has a congenital hydrocele. This form of hydrocele may also occur Avithout there being any com- munication between the two cavities at the period of birth. What, in the next place, are the causes of this affection? As you will readily perceive, any thing which may cause inflamma- tion of the tunica vaginalis, as a Avound, a bloAV, inflammation,.pi the testicle, &c. But by far the most frequent.cause-of-hydrocele is, inflammation of the urethra. Let us see what is the reason of this. We have, passing from each testicle, its proper excretory tube, or vas deferens. Now this vas deferens is lined by a mucous membrane; and when inflammation attacks the mucous membrane about the urethra, it extends along the vas deferens to the epididy- mis, and thence to the tunica vaginalis. I would say from my own experience,, that perhaps nine out of ten cases of hydrocele, owe their o'rrgin to inflammation about the prostatic portion of the urethra. As analogous to this, I may remind you, that from an attack of gonorrhoea a person will frequently suffer from orchitis. This proceeds from the same cause, and extends through the same channel. As regards the diagnosis, I need not say much ; for, in my remarks the other day on hernia/ I alluded to most of the symp- toms. First, we have the pyri-form shape of the tumor; secondly, its fluctuation; and thirdly, its transparency. These are the prin- cipal symptoms. And let me advise you, gentlemen, always to darken the room, Avhen you Avish to examine the transparency of the tumor; when, taking a candle, and shading the eyes, you will find, in hydrocele, that the Avhole tumor transmits the light, except the back and upper portion, which is occupied by the testicle. This is generally the case. But I should remark, that the position of the testicle varies, and that it is sometimes found in front. There is another circumstance to which I Avould allude. It gen- erally happens, that, Avhen hydrocele has existed for a length of time, all of the structures of the scrotum become so much thick- ened, that it may be impossible for light to be transmitted through them. But here, if yon take into consideration the fluctuation in the tumor, and its Aveight Avhen compared to its size, you can easily distinguish it from cancer of the testicle, or from orchitis. With regard to hernia, the gurgling noise made on its return, and the different shape of the tumor, fender it easy to be distinguished. But not to dwell longer on this subject, let us pass on to the treatment of hydrocele. We find laid down in the books, tAvo chief methods; the palliative, and the curative. The palliative consists TREATMENT OF HYDROCELE. 513 merely, in emptying the sac from time to time. This is done by a simple puncture with a lancet, or a trocar. You may draw off the water, by holding the tumor in the palm of the left hand, draw- ing the integuments tight, with the thumb and finger, and thrusting in a trocar, in such a manner that the point shall pass obliquely upAvards. Or you may make a simple puncture with an ordinary lancet. All that this method can accomplish, is to relieve for a tew days. The disease will sooner or later return. Another palliative means, which has been recommended where ordinary stimulating lotions fail, is acupuncture. By this means, however, we do not simply draw off the water, but cause, in addi- tion, a sufficient degree of inflammation to procure an obliteration of the sac by adhesion. This method, therefore, belongs properly speaking, to the list for effecting a radical cure. With regard to the means for accomplishing this object, there are many expedients. One method is, by the use of a seton; ano- ther is, by incision; another, by incision and excision—that is, by laying open the sac, and cutting out a portion of the tunica vagi- nalis; another is, by incision with the use of a tent—that is, by lay- ing open the sac, and placing in it a piece of lint, called a tent; another is, to insert a bougie through the puncture; and another, to puncture Avith a trocar, and throw into the sac some stimulating lotion. When we come to revieAv all these plans, we find that we have a very wide field for choice. As a general rule, when the sides of the sac are not too callous for adhesion to be procured the method by injection is the best. It is less painful; keeps the patient laid up a shorter time; and does not expose him to the risk of inflammation or gangrene. But when the structures are so much thickened, and have become so callous, that this fails, we must fall back to the operation by incision and excision. We shall there- fore, at once describe this operation. Having placed the patient on his back Avith his lower limbs drawn up, seize the tumor in the left hand, and carry an incision from its apex to its base, extending through the integuments of the scrotum to—but not through—the tunica vaginalis. Having dis- sected back the integuments on either side, and opened the tunic cut out the whole or a part of the membrane thus exposed tak- ing care not to go too near the epididymis. Having thus excised a portion of the sac, fill the cavity with oiled lint, and draw the edges slightly together. Keep in the lint until granulation, or incipient suppuration, comes on; and then remove the lint, and 514 TREATMENT OF HYDROCELE. apply light dressings. When the Avound heals, the sac will be entirely obliterated; and thus all re-accumulation of Avater will be prevented. When the operation is by incision only, the incipient steps are precisely the same. Having laid bare the sac, cut into the tumor, let out the water, and then fill up the cavity Avith lint, as in the preceding case. There are two methods of operating by seton. In the first and most usual, having punctured the tumor Avith a trocar, we pass in a seton, and leave it in situ for a sufficient length of time to produce adhesive inflammation. Another method is to use but a single thread. Both act in the same Avay. Being foreign bodies, they cause inflammation ; Avhich results in the ob- literation of the cavity by adhesion. This is the object of all these operations. The operation by seton is only applicable to small and recent cases. In these, it may bring about such inflammation, as shall cause a radical cure. But by far the best means of procuring this result is the method of puncturing with a trocar and throwing in an injection. We have a great variety of substances recommended for these injec- tions. When the operation Avas first performed, it Avas recom- mended to use one part of wine, and two parts of Avater. The red wines were generally preferred. Port wine, tinct. of myrrh, warm wine, diluted alcohol, all have the same object in view; and cures have often folloAved the use of each of them. Where they fail, it may be because the trocar has slipped out, and its point has been left between the integuments and the tunica vaginalis; from Avhich cause, the injection has been thrown into the cellular tissue, and not the cavity of the tunica vaginalis. This accident, as you will readily perceive, will soon give rise to extensive sloughing of the integuments of the scrotum; and, what is worse, after all this, the hydrocele will not be cured. It will soon return, the same as be- fore. At the present time, all these injections are pretty much abandoned by surgeons generally, and the injection of the tinct. of iodine is substituted. This practice was first adopted in India, and is one Avhich has been frequently resorted to by myself. I should state, that there is a difference of opinion among surgeons, as to the proper strength at Avhich the injection should be used. Some prefer a weak solution, which they allow to remain for a short time and then draw off; others use a strong solution, and allow it to remain. I prefer the latter plan, and seldom dilute the ordinary tincture more than one half. Throwing in from tAvo to four ounces I Avithdraw the canula, leaving the iodine in the cavity. It is soon CYSTIC DEGENERATION OF TESTIS. 515 carried off by absorption ; and I have yet seen no reason to believe, that any evil results follow this practice. I would say to you, therefore, use a third or a half proportion of water, and allow it to remain in the cavity. There is, howeA'er, one point to which I Avould call your attention. The object of this operation is to create an inflammation, the result of which is, that, in a few hours after the operation, the tumor will be as large as before it. When this inflammation runs too high, you must combat it by the usual anti- phlogistic treatment; and when, after several days, the fluid still distends the sac, and is not absorbed, you should puncture it with a lancet or trocar, and draw off the liquid. The lancet will be found the best instrument for you to use. During the inflamma- tory action, the patient should be constantly confined to the hori- zontal position, and the scrotum must be supported by a bolster. Some persons use a T bandage : but this, I think, is unnecessary. Cases may occur, in which the inflammation runs so high as to require the use of leeches : and, Avhen sloughing takes place, it must be treated by the ordinary rules. In cases of hydrocele of the cord, the operation by tent, or that by injection, will, either of them, do very well. But if the hydro- cele is congenital, I should be very unwilling to use the injection at all. Some recommend the use of the injection, in these cases but with the precaution of pressing on the ring, to prevent it from entering the abdomen. When it is necessary to operate in these cases, I should prefer the incision, with the use of a tent. We sometimes meet with cases resembling hydrocele, in which the wall of the tumor is formed by the proper membranes of the testis, instead of by the tunica vaginalis. The testis here forms a serous cyst; and no operation for hydrocele will be of any avail. Where you find this to be the case, you should, at once, resort to castra- tion; as there is no good to be gained by delay, and the organ is useless, even if left, being also very prone, under these circum- stances, to take on a malignant degeneration. At the next lecture, we shall go on to some other varieties of dis- ease of the testicle and cord. 516 VARICOCELE. LECTURE LXVI. VARICOCELE OR CIRCOCELE--ITS SYMPTOMS AND TREATMENT--OPERA- TION OF BRESCHET--METHOD OF WARREN—ENLARGEMENTS OF THE TESTICLE--CAUSES--HEMATOCELE--MALIGNANT DEPOSITES IN THE TESTICLE--FUNGUS IN THE TESTICLE--TREATMENT--CASTRATION-- TREATMENT AFTER THE OPERATION--RESULTS OF THE OPERATION-- DISEASES OF THE PENIS--PHYMOSIS--ITS RESULTS--ITS TREAT- MENT--PARAPHYMOSIS--RESULTS--TREATMENT. Varicocele. You will very often, gentlemen, meet with a pathological state of the veins of the cord, in Avhich their coats become very much distended, and which may cause them to form a tumor of such extent, sometimes, as to hang half way down the thigh. To this condition of the cord, we give the name of varicocele, or circocele, from its knotty feeling. Where it is of limited extent, it is a mat- ter of little importance; but where it continues for many years, and the valves become unable to resist the gravity of the blood, the patient is exposed to great inconvenience; and, from the cir- culation being impaired, the testicle may sometimes, though not often, lose its functions. This circocele, in infants, is a matter of very little consequence; for, after a short time, it disappears spontaneously. When it does not do so, use a supporting bandage, and moisten it Avith some astringent lotion. When the varicocele has been of long standing, it may be neces- sary to resort to more potent means. A variety of expedients have been proposed from time to time. Most of them have the same object in view, viz : to destroy those parts of the veins, which are most diseased. Some persons resort to the ligature of some of the veins. But, in consequence of the aptness of these veins to take on inflammation, and the proneness of this inflammation to extend and be increased by a ligature of the veins, I Avould not recom- mend this plan. Another expedient is, to obliterate the veins by pressure. • This method is recommended by M. Breschet. He uses several small steel clamps. Having caused the patient to lie on his back he pinches up a fold of the skin of the scrotum containing the veins- taking care to leave the vas deferens behind—and then places TREATMENT OF VARICOCELE. 517 these veins, thus enclosed in a fold of the scrotum, between the clamps; which should then be tightened. One of these clamps should be fixed on the upper portion, and another near the base of the scrotum; and they should be left on for at least forty hours. When removed, the eschar will slough off, leaving an ulcer, which will soon heal. That part of the vein which was included be- tween the upper and lower clamps, gradually wastes away, and the disease disappears. This operation may succeed very Avell. But you Avill find, that, from the length of time that pressure, is kept up on the skin, inflammation and sloughing of this membrane is apt to occur; and this may extend to the scrotum. I would not, therefore, as an ordinary rule, recommend the operation of Bres- chet. Another expedient is, to use a needle, Avith the twisted suture; the vein and a fold of skin being included by it in a figure-of-eight. This operation, however, is quite too painful. Another, and far better method is, to pinch up a fold containing the veins, and then run a needle through beneath the veins, and pass a figure-of-eight suture over the vein and under the points of the needles. This is the best and safest method;, and, if properly applied, it will gen- erally succeed. I would, however, caution you, in this disease, ahvays to think calmly and well of the serious results that may follow even the simplest expedient. Another method, recommended by iEgineta, and frequently adopted by Warren, of Boston, consists in seizing a portion of the integuments containing the veins, and sweeping off veins, integu- ments, and all, stopping the hemorrhage by means of pressure. This is a very effectual method. But I will repeat, that, in the manage- ment of varicocele, you should not think of operating, except in very extreme cases. Dangerous results may follow even the most simple operation. I make this remark, from having had some experience of its importance. It has also been proposed, to excise a portion of integument from over the surface of the cord, of such extent, that, when the edges are brought together and cicatrized, the pressure on the parts beneath shall be sufficient to support the veins and prevent their over distension. This method has been generally ascribed to Sir Astley Cooper, but the priority of the operation is due to my friend, Dr. O. Broyles, of this State, whose claim dates back as far as the year 1821. I have seen the subject of his operation Avithin the last two years, who has been permanently relieved by it. 518 FUNGUS OF THE TESTICLE. Affections of the Testicles. In this connection, I wish to make a feAV remarks on some of the pathological conditions of the testicle itself. These are so numer- ous and diversified, that it Avill be impossible to do more than make a feAv cursory remarks upon some of them. We find, sometimes, that the testicle becomes very much enlarged and indurated, from an adventitious deposit. Noav, where this consists only of a simple enlargement or induration, some patients may wear such a testicle for years, without much inconvenience. But sometimes it is very painful, and may cause the individual to fall into very bad health. Here it becomes necessary to remove the gland. Again : in some cases of enlargement, we find, deposited in the gland, numerous cysts. Sometimes these are filled with serum, and sometimes they contain a thick and ropy mucus. Sometimes the enlarge- ment is scrofulous, and sometimes it is caused by entozoa. Cases have occurred, in Avhich all the elements of the embryo were found imbedded in the testicle. Now, where there is any danger of this enlargement being transformed into a malignant degeneration, it also becomes necessary to extirpate the gland. It sometimes happens, that, from a change in the textures of the testicle, its blood-vessels give way, and blood escapes and accu- mulates in the tunics. Thise scape of blood gradually increases, until a large tumor, quite void of transparency, is formed ; and the testicle becomes atrophied by the pressure it exerts. Here Ave have what is known as an hematocele, or a bloody tumor of the testicle. I have seen many such cases; and in several of them, I have com- menced to operate for old hydrocele. In such cases as these, again, the only resort will be, a removal of the gland. With regard to this hematocele, I Avould remark, hoAvever, that there is another variety; in which, the bloo'd is accumulated in the cavity of the tunica vaginalis. In this form of the affection, all that is necessary is, to lay open the sac, as in hydrocele, turn out the blood, put in a piece of lint, and heal by granulation. Besides these varieties of morbid states of the testis, there are others of far greater importance; as, for example, where there has been some malignant deposit in the body of the testicle itself. There is yet another morbid condition of this gland, of so much importance in the prognosis, that I deem it necessary to mention it also. At its commencement it is so similar to cancer, that it is im- possible to distinguish between them without the aid of the micro- CASTRATION. 519 scope. It is a fungous enlargement of the testicle, not at all ma- lignant in its character. This fungous growth gradually protrudes through its proper envelopes; and when it has once begun, it goes on increasing, until the tunica albuginea gives way; the growth protrudes directly into the cavity of the tunica vaginalis testis ; and, if let alone, it goes on increasing, until that cavity is enormously distended. The tunica vaginalis yielding, it reaches the integu- ments. These even may give way ; and a fungus of this kind may thus protrude externally. I have seen such cases. There is no malignity connected with this growth. There is a man in this city, for whom I was compelled to oper- ate, by castration, for a fungus on one side. He returned, some time after, with the other in a similar state. I was about to per- form the same operation; but he begged so hard, that I had to let him off. He got well, however; and I would remark, that, though the disease may not arrive at such a point as to render castration necessary, yet this operation will often be preferred by the suf- ferer. As regards cancerous deposits I would remark, that, though you may arrest the progress of the disease, for a time, by castration, yet, at some time subsequent, sooner or later, it will return in some other part of the body, and finally destroy the life of the patient. I have thus mentioned to you some of the circumstances, Avhich render it necessary for the surgeon to perform one of the most se- rious operations that he can ever be called upon to execute, for the deprivation of the testes seems generally to deprive life of every object. Where you have determined upon castration, there are several modes of operating presented for your choice. But I do not deem it necessary to dwell upon them all; and shall therefore explain to you at once, the one which I prefer. Seizing the tumor in the palm of the left hand, and draAving the integuments back, begin an incision below the inguinal ring, and carrying it down to the cord, let it reach as far as the lower portion of the tumor. Isolate the cord from the surrounding parts; take it in the fingers, and search for the vas deferens; which will generally be found behind, and which may be known by its hard feel. Having isolated this, take a curved needle, armed with a strong ligature, and plunge it between the vas deferens and the other structures of the cord. Enclose the latter in the ligature, and then divide the cord below 520 PHYMOSIS. the ligature; the loop of which ought not to remain longer than two or three days. By this expedient, you Avill avoid all risk of hemorrhage, and also the necessity of searching for the artery after the cord is divided; Avhen it becomes very difficult to find it, from its retracting into the gelatinous structures Avhich surround it. This operation can be accomplished in a very feAV seconds. In fact, I do not know but that the expedient of Koch is the best. He, having raised the cord above, Avith the integuments, SAvipes off all at once. After the testicle, is removed, we bring the wound together, and heal it, partly by the first intention, and partly by granulation. There is one condition, hoAvever, which sometimes results, and which also occasionally follows the operation for hydrocele by incision and excision. I allude to tetanus. After performing this operation, therefore, you should be ahvays very careful and watchful. We shall now leave the testicle for the present, and proceed to a kindred organ, the penis. We find that this organ is remarka- bly prone to take on some diseases, which are also common to other organs. Here, in the first place, let us speak of tAvo affections of the pre- puce. The first of these is Phymosis, An unnatural elongation and contraction at its orifice, which be- comes so small and rigid, that the prepuce cannot be draAvn back. This gives rise to great inconvenience, for two reasons : first, be- cause the secretions, being retained, become so acrid as to cause inflammation, ulceration, and sometimes even sloughing of the prepuce; secondly, because the orifice becomes so small, that the urine cannot flow freely out. This distends the prepuce like a sac, or bag, and may give rise to great uneasiness. In a case of phymosis, then, it is necessary that the surgeon should attempt some relief. Several operations have been pro- posed. The simplest is, to make several incisions on the inner surface of the prepuce from within outward, not extending through the skin. Another method is, to introduce a grooved director, on the median line, between the prepuce and glans penis, and carry it back till its point reaches the end of the cul-de-sac formed by the mucous membrane; then to pass a sharp-pointed bistoury along the groove, to its end, bringing the point of the blade through PARAPHYMOSIS. 521 the skin; and to slit the prepuce up, on the median dorsal line. Some prefer to use scissors. Should the simple incisions of the inner surface be preferred, just insert a director between the pre- puce and glans penis; pass in a bistoury, and scarify, through the mucous membrane, not dividing the skin. Repeat this all around the prepuce, and you will find that a slight force will carry it back over the head of the penis. Order the patient to use emollient fo- mentations, and to draw back the prepuce, from time to time; and, when the cuts have healed, he will be well. This operation will nearly always succeed: though you will generally find, that the mucous membrane, in the dorsal operation, will extend beyond the skin; which it will, therefore, be necessary to divide afterwards. The deformity, at first, will be great; but very soon it will disappear, and all will appear as though perfectly natural. Some surgeons recommend tAvo incisions to be made, one on either side of the fre- num, instead of one through the dorsum. This is not necessary, and only gives additional pain. The other plan is all sufficient. There are cases, however, in which, from pathological condi- tions of the parts, there will be no possibility of succeeding by the ordinary method. The reason of this is, that there is formed in the prepuce, and around the stricture, a hard and almost homey substance, Avhich prevents the success of the operation. Here the only remedy will be circumcision. There is also, in phymosis, another pathological condition. In this, the prepuce becomes adherent to the glans; and here it will be necessary, in addition to the main operation, to divide these bands of adhesion, and to prevent their reunion afterwards. The second condition of the penis to which I have referred, is the reverse of the first, and is called Paraphymosis. The prepuce, being draAvn back over the glans, becomes con- tracted ; the glans becomes enlarged, swollen, and very painful; and, if the patient be not relieved, inflammation and mortification will result. In various inflammatory conditions of the penis—from chordee in gonorrhoea, for example—the vessels become so dilated, that, if the parts "be not relieved from this constriction, they will speedily run on to inflammation and mortification. In ordinary acute paraphymosis, the mode of treatment is very simple. Hav- ing bathed the parts in Avarm Avater, so as to soften and relax the tissues, seat the patient before you, on a chair; then, press the 522 URETHRITIS. glans firmly, so as to squeeze the blood out of its vessels, and, forcing the glans back with the palm, draw the prepuce forward with the finger and thumb. In acute cases of paraphymosis, you will frequently succeed by this plan. In chronic cases, however, where the great enlargement of the glans prevents the possibility of emptying its vessels, you can relieve only by an operation. Take an ordinary curved bistoury; pass it back under the constric- tion ; and then divide it, taking care to avoid the corpus caverno- sum. If one incision is not sufficient, you may make two, or even more. ESSAY No. 10. DISEASES OF THE GENITALS CONTINUED--URETHRITIS--GONORRHOEA-- SEQUELAE OF GONORRHOEA--IMPOTENCE--ORCHITIS-- OPHTHALMIA--STRICTURE OF THE URETHRA-- DISEASES OF THE PROSTATE GLAND. Simple inflammation of the urethra, may result from several causes. In persons of Aveak and feeble constitution, or of stru- mous habit, very slight causes will give rise to it; as the passage of instruments, the presence of stricture, an unusually acid state of the urine, or perhaps sexual intercourse when the female is not in perfect health, though she may not be laboring under any ve- nereal contagion. The symptoms of this affection are, a burning or feeling of heat and distension in the urethra, followed by pain in making Avater, and a muco-purulent discharge, Avhich is sometimes profuse. The treatment should be moderately antiphlogistic. Saline pur- gatives, a bland diet, and strict abstinence from stimulants, will generally be all that is required; the disease subsiding in eight or ten days. As soon as the inflammatory symptoms begin to subside, soothing and mildly astringent injections should be used; solutions of opium, or of acitate of lead, will noAv give great relief. Should the affection become chronic, copaiba, used in small doses, has been highly recommended. When stricture exists in combination Avith urethritis, the use of the catheter should be avoided, if possible. Here, leeches should be applied to the perineum, opiates and saline purgatives given, GONORRHOEA. 523 and the warm hip-bath frequently resorted to; diluent or demul- cent liquids should also be freely drank. If abscess, either about the urethra, or in the perineum, should follow this disease, Avarm emollient poultices should be early resorted to and constantly used, and the abscess be freely opened early, from without. If permitted to break internally, it is apt alsoTo open externally, and so occasion fistulous openings, through which urine will constantly escape, and the curing of Avhich will give much annoyance. When the abscess is forming near the urethra, a sense of heat and pain, Avith slight swelling and redness of the part, soon fol- loAved by fluctuation, will sufficiently mark the seat of the collec- tion. If forming in the perineum, the abscess Avill cause a sense of heat, Aveight, and deep-seated pain just in front of the anus. Slight redness will be observed, following the course of the ure* thra; but no fluctuation will be perceived until the abscess reaches the scrotum. An early and free incision should be made, and if the pain and inflammation are great, leeches should be applied to the perineum. Should fistulous openings be formed, and communicate with the urethra, they avi'11 gradually close, if not accompanied by stricture. If they are not, their treatment should be the same as for fistula in the locality from any other cause. Urethritis is very apt to be mistaken for gonorrhoea, and great care should be observed to avoid such a mistake. Indeed, the differential diagnosis is in some instances extremely difficult. The history of the case, the less violent nature of the inflamma- tion, and the absence of all unpleasant sequelae, furnish our only means of deciding. Gonorrhoea. Gonorrhoea, in its attack and progress, has been divided into three stages: those of irritation, of acute inflammation, and of chronic inflammation. The symptoms of the first stage manifest them- selves generally between the third and eighth day after the conta- gion, though they sometimes are felt earlier, nay, in some cases, a moment or so after an infectious connection; this is, however, very rare. At this time a sense of heat and itching is experienced, followed by a peculiar sensation at the orifice of the urethra, which feels as though some small, hard body distended it. These sensations are soon folloAved by pain on passing water, and a red and swollen 524 GONORRHOEA. state of the tips of the urethra, the opening into which remains widely separated, or gaping. Indeed, the whole penis is slightly inflamed and sAvollen, and gives signs of irritation. At this pe- riod, if the course of the meatus be pressed upon, a little thin muco-purulent matter will exude therefrom. After a period, varying from twelve hours to three or four days, has elapsed, the second stage begins. The swelling, heat and pain of the parts now rap- idly increase; the discharge is rendered abundant, and becomes quite purulent, and of a green or yellowish green color; and the ardor urinse, too, is now intense. The inclination to pass Avater is constant; but the urine, though giving great pain, flows in dimin- ished quantity, and the penis, particularly over the urethra, is quite tender to the touch, and SAvollen. ^Vhen the inflammation reaches the bulbous portion of the tube, a feeling of uneasiness will be perceived in the perineum; and if the disease still extends and affects the prostatic region, a sense of heat and discomfort will be observed about the anus. From the excitement and ter- gescence of the parts, erections are apt frequently to occur, and they give great pain, as the membranous parts remain undis- tended, and the organ is hence twisted on its axis and bent forcibly doAvnwards, so producing chordee. This painful accompaniment of this stage is most apt to come on at night. Considerable con- stitutional irritation is also apt to exist at this stage. When the disease goes on, at the end of ten or tAvelve days, or, it may be, two or three AAeeks, the inflammation becomes chronic; and so the third stage begins. The discharge now becomes much thinner, and diminishes in quantity, Avhile all the inflammatory symptoms are lessened. This stage may run on for a fortnight or three Aveeks, and then, if not cured, terminates by all inflammation subsiding in gleet. This consists of a very thin discharge, of small amount, but constantly existing, which may be kept up for months, or even years, and is generally very difficult of cure. Surgeons differ Avidely in their views of the nature and tendency of gonorrhoea Some regard the affection as purely local, and argue that it tends, sooner or later, by exhausting itself, to a spon- taneous cure, and will hence get Avell, even if no treatment be pursued. Others contend, that, Avhile the disease is in its outset purely local, soon the constitution will be affected, and life be endangered by a constant impairment of health. There can be very little doubt that gonorrhoea, though altogether local at first, very soon becomes constitutional. How otherwise can Ave account TREATMENT OF GONORRHOEA. 525 for the peculiar eruption, the buboes, and other distinctly charac- teristic affections to Avhich it gives rise? The contagiousness of the disease, too, appears to point to something more than a local effect; while the constitutional irritation which it originates and keeps up, is too great to be accounted for by the local disease alone. There is also too strong and well-observed a tendency in the disease to return, after every local manifestation thereof, is no longer to be accounted for, save upon the idea of constitutional taint. Gonorrhoea is extremely contagious in each of its stages. Indeed, as long as there remains the slightest discharge fromjhe urethra, so long will the disease be certainly communicable. The treatment of this disease must vary with each of its stages. In the first or irritative stage, the local use of emollient and soothing remedies will be advantageous. I have found great re- lief to be afforded by the use of an ointment of hogs lard and sugar of lead, applied over the entire glands and inflamed orifice and lips of the tube, the ointment being pressed as far into the urethra as its swollen lips and gaping orifice will permit, without using any instrument. Laxatives should be used during the day, and anodynes at night, and, with a strict abstinence from ail stim- ulants, either as food or drink, will be all that is necessary or can be done in this stage. The method sometimes adopted, of attempt- ing, by violent applications, to check the disease in its very com- mencement, has so signally failed, that it is noAv very seldom or never resorted to. When the stage of acute inflammation has set in, the treatment, general and local, should be soothing and antiphlogistic. Purga- tives should be freely given, and alkalies resorted to, to render the urine less irritating. Warm soft poultices, with the frequent use of tepid hip baths, and total abstinence from stimulants, make up, with perfect rest, the sum of treatment applicable in this stage, unless the inflammation should run very high, when the local use of leeches to the most inflamed parts may be followed by some relief. Rest is of the utmost consequence ; and the recumbent position should be, as much as possible, preserved; nothing, more than this, will contribute to a rapid recovery. In the use of pur- gatives, those should be preferred that appear to exert some pecu- liar influence over the genito-urinary organs. Hence cubebs and copaiba have always enjoyed the greatest confidence, and are universally employed. They should be so used as to act freely on the bowels, and have been recommended in several forms. The 526 GLEET. copaiba may be given in capsules ; but it is not then as efficient as when used pure in mixtures, or as an extract. In most cases, the copaiba should be preferred to the cubebs, because much less irritating. A very good and active method of using the copaiba is to combine it with burnt magnesia. This forms a paste, and, as advised by Erichsen, is thus prepared:—The magnesia is placed in a mortar, and rubbed up with as much oil of copaiba as will form a stiff paste ; of which, about one drachm, in the form of a bolus, should be taken thrice daily. The same author gives a very con- venient method of administering this oil writh cubebs, in the form of an electuary, Avhen it is desired to combine them. About half an ounce of poAvdered cubebs should be rubbed up with as much copaiba as will make a stiff paste; of this, the dose is one ounce three times a day. Combined Avith the internal use of these remedies, the local use of mildly astringent injections may noAA- be resorted to Avith advantage; such as a Aveak solution of acetate of lead, fol- lowed by one of the sulphates of zinc, and, as the inflammation subsides, the cautious use of nitrate of silver in solution; Avhose strength should not be greater than one grain to the ounce. These injections should be discontinued as soon as the discharge has ceased ; and great care must be taken, Avhile using them, not to injure the urethra. A glass syringe, with a very smooth nozzle, is the best for the purpose, and should be introduced gently and Avith great care. During the injection, the penis should be held up, that the injection may descend as far as possible into the ure- thra. Gleet, or chronic gonorrhoea, constitutes the third stage, and is decidedly the most obstinate and difficult of cure. This affection sometimes runs on, in spite of treatment, for years : appearing at intervals to be relieved, and breaking out again after some slight excitement or indulgence. Under these circumstances, the strong- est astringent injections should be used ; and as no one remedy will long continue to do good, the solutions of gallic acid, nitrate of silver, sulphate of zinc, tannin, vScc, &c, may in turn be em- ployed. The diet should be nutritious, but not stimulating; and it has been advised that all exciting drinks should bt avoided. In the treatment of gleet, however, this opinion appears to deserve some modification ; for I have found that in cases of long standing, where the patient is Aveakand enfeebled, the moderate use of those liquors which exert a strong influence over the kidneys, without producing great excitement generally, has rather a good effect GONORRHOEA IN FEMALES. 527 than otherwise. My sphere of observation, however, not having been great in this affection, it must remain for a more extended trial to determine whether the opinion be correct or not. The dis- charge certainly gives evidence of a want of tone in the parts rather than of sur-excitation, and there is no pain or other symp- tom of inflammation. Why may not the urine, by the use of whiskey or gin in moderate quantity, becoming increased in quan- tity and of stimulating quality, by washing and exciting the parts, cause a cure 1 In cases of very long standing it has been advised to introduce a full sized silver catheter from time to time. In one case of this kind that has come under my obseiwation, the disease, after resist- ing for several years every other treatment, yielded rapidly to the use of the catheter. A large sized instrument, being well smeared with mercurial ointment, was directed to be introduced every third morning. It was used but twice, Avhen the discharge ceased, and returned no more. In every stage of gonorrhoea, great care should be taken to avoid all causes of excitement, both bodily and mental; and ail sexual indulgence should be positively forbidden, as the slightest liberty in this respect will certainly augment the disease, or cause its return, if but recently removed. In the female, the course and treatment of gonorrhoea differ but little from those in the male. The disease is generally less vio- lent in women, simply because it is not so prone to extend along the urethra, and also because of the absence, in them, of the pros- tate, testis, &c; inflammation of which organs, in the male, is the greatest cause of difficulty. With women, the greatest source of difficulty exists in deciding upon the nature of the disease. When in the acute stage, the orifice of the urethra is seen to be inflamed, and also the entire mucous membrane of the labia: there is pain on making water; and the discharge is observed to proceed only from the membrane of the vagina. When the disease has become chronic, however, the case is very different; and it then becomes impossible to declare positively that any disputed case is or is not one of this disease. Under these circumstances any declaration of diagnosis should be very guarded. The treatment should consist of injections of astringents, as ad- vised for the second stage of the disease in the male; and, unless the urethra becomes inflamed, no constitutional treatment need be 528 IMPOTENCE. adopted, beyond keeping the habits regular, and avoiding stimu- lants. It is seldom that the urethra becomes much affected; but when this is the case, copaiba or cubebs, and the same course as recommended for gonorrhoea in males, should be resorted to. Hemorrhage from the urethra, phymosis, abscesses, &c, &c, which sometimes accompany or result from gonorrhoea, are to be treated upon the same principles, as the same affections from other causes. Some of the consequences or sequelae of this affection, however, require a more particular notice. SEQUENCES OF GONORRHOEA. Impotence—Orchitis—Ophthalmia. One of the most serious consequences of gonorrhoea is that feeble state of the generative organs, so often found existing after a severe and prolonged attack, tvliich causes seminal tveakness or impotence. This affection, Avhile resulting from debility, is also accompanied, in most cases, by a diseased and irritable state of the prostatic por- tion of the urethra. Those suffering thus, find themselves totally unable properly to consummate sexual intercourse, and are hence ahvays of a melancholy turn of mind, indeed often hypochondri- acal ; and, in some instances, the mind has become so much af- fected that suicide has been the result. The treatment of impotence may be divided into the general or constitutional, and the local. The constitutional treatment will consist in the use of such agents as shall give tone to the system and improve the general health. For this purpose the different preparations of iron furnish perhaps the best means care being taken to render the diet as nutritious, and the habits of the patient as regular, as possible. The local treatment should consist in the early use of the cold hip bath, both in the morning and at night. Too much impor- tance cannot be attached to this as a remedial means, for there is perhaps no agent that will assist more in giving tone to the affected organs, and restoring them to strength. To relieve the prostatic portion of the urethra Avhen diseased, the use of the nitrate of silver becomes necessary. Several methods have been suggested for conveying this salt, or its solution, to the seat of disease, but decidedly the most convenient and safest is that recommended by Erichsen. This instrument consists of a silver ORCHITIS AFTER GONORRHOEA. 529 catheter of full size, the end of Avhich is pierced by a dozen or more small holes, and a stylet, the lower end of which is expanded to fit the tube of the catheter, and has a small piece of soft sponge attached to it. When the caustic is to be applied, the solution should be poured upon the sponge, which should then, with the stylet, be oiled and passed into the catheter. The catheter being then introduced into the urethra and carried down to the diseased part, should be carefully held there, Avhile the stylet is pressed firmly into it, so as to squeeze the sponge and cause the caustic liquid to be pressed through the openings into the catheter, and reach the urethral membrane. This operation generally causes great pain and a good deal of local irritation. It should not, therefore, be repeated oftener than once in eight or ten days, or until the irritation it caused, when previously used, has entirely subsided. In addition to these means, every effort should be made during the treatment, to keep the patient cheerful and to divert his mind from his disease. To effect this, lively company should be sought, relief spoken of as certain, and all sexual excitement or indulgence scrupulously avoided. An inflammation and enlargement of the testes, sometimes occurs as a sequence of gonorrhoea. Sometimes the disease attacks one, sometimes both; but most generally one at a time is affected. It has been supposed that the gland on the left side is most liable to this in- flammation, but more careful and extended observation proves that the disease attacks one gland just as frequently as the other. " Consecutive orchitis is generally supposed to occur more fre- quently on the left side than on the right, but statistical enquiries show the fallacy of this opinion," says Curling, in his work on the " Diseases of the Testes." The same author then gives an account of one hundred and thirty-eight cases, from different sources, of which seventy-eight were confined to the right side, and only forty- nine to the left, thus proving exactly the reverse of what was formerly believed. The symptoms, course and treatment of the disease, differ in no respect from those of orchitis from any other cause, and shall not therefore be further noticed in this place. " The swelling of the testicle which occurs in gonorrhoea has nothing specific in its na- ture, nor is the constitutional influence of mercury necessary to its cure, &c." (Sir Astley Cooper on the Testes.) The disease may occur at any period after the setting in of a gonorrhoea, but is most frequently observed between the third and sixth weeks. H* 530 GONORRHEAL OPHTHALMIA. Perhaps the most serious affection that can folloAV a gonorrhoea is a severe and destructive ophthalmia, which sometimes occurs as the result of gonorrhoea! conjunctivitis. This affection—fortu- nately a rare one—consists of a violent specific inflammation of the conjunctiva, extending rapidly to the cornea and globe of the eye, and resulting generally in the total loss of vision, the escape of the humors of the eye, and shrinking and collapse of the globe, caused by the sloughing of the cornea. The symptoms are those of a most violent purulent ophthalmia, accompanied by a profuse discharge, and somewhat increased swell- ing of the conjunctiva of the globe. This maybe distinguished from the purulent ophthalmia, by the very contagious nature of the latter, and from the fact of the former occurring in persons affected by gonorrhoea. From the rapid and violent progress of the disease, it seldom comes under the care of a surgeon, until the eye has been irretrievably injured. It may almost be said that an attack of gonorrhoeal conjunctavitis is necessarily folloAved by loss of vision ; for this is so generally the case, that a recovery forms rather an exception than the rule. The reason is, that, before aid is sought, the inflammation has generally reached the cornea, and the cure being at an earlier period difficult and doubtful, becomes then im- possible. " Our prognosis will principally turn on the state of the cornea; if that should possess its natural clearness, the eye may be saved. If it should be heavy and dull, and more particularly if it should have assumed a Avhite, nebulous appearance, conse- quences more or less serious, will inevitably ensue." (LaAvrence on the Eye.) The disease generally attacks but one eye at a time, and, if the other becomes also inflamed, is apt to be less violent and more readily cured in the second than the first. So severe is this affec- tion, that but few recover perfectly after a violent attack, and the mildest forms, if not promptly treated, are folloAved by serious results. Lawrence mentions fourteen cases, in all of which vision Avas either lost or impaired. In nine, sight was lost, and the remain- ing five, only partially recovered. There is some difference of opinion among surgeons with regard to the cause of this affection ever being a constitutional one, some contending that it always originates from the local application of infectious matter directly to the eye; whilst others maintain, that it may originate from a gonorrhoeal taint existing in the constitution. There can be no doubt, however, that gonorrhoeal matter applied to the eye Avillgive TREATMENT. 531 rise to this affection; and great care should be taken by those attending cases of gonorrhoea, and those suffering therefrom, to avoid the possibility of any discharge coming in contact tvith the eye, through the linen used, or from the hands. Neglect in this respect, has caused the loss of many an eye. The treatment of this form of ophthalmia should be strongly anti- phlogistic. Blood should be drawn from the arm freely, and its local abstraction pushed as far as possible. Locally, a solution of nitrate of silver should be used. Much difference of opinion exists, as to the strength of the solution that should be preferred. Lawrence advises the solution to be not stronger than four grains to the ounce of Avater ; and Erichsen also prefers this method of using the caus- tic; Avhile Heys and others advise a much stronger solution, or even the solid stick. Such is the treatment to be pursued in the first stages of this affection. But Avhen the cornea has sloughed, and the violent inflammatory symptoms have subsided, or the patient is weak and feeble, suffering perhaps from exhaustion, it becomes necessary to moderate this plan, or, in some cases, even to resort to a restorative and tonic treatment. Every thing, however, must depend upon the stage at which the disease is first combatted. If taken in hand early and promptly treated, a fair share of success may be calcu- lated on; but if permitted to run on for forty-eight hours, or more, the most judicious management will generally fail to produce a cure. With regard to the simple local applications for the removal of pain, perhaps those that will give most relief will be the cooling or cold lotions. Warm applications are preferred by some, and will often be found more soothing to the patient. So little impor- tance should be attached to this, however, that the patient may be permitted to choose for himself, and sometimes the cold, at others the warm will be preferred. As soon as active inflammation has been subdued, it may become necessary to change the treatment somewhat. Should the patient be weak and pale, and the discharge still profuse, generous diet, tonics, and the local use of astringent lotions, solutions of alum, nitrate of silver, diacetate of lead, &c, &c, will now be found ad- visable. It has been proposed to relieve the chemosis in this affection, by making incisions through the sclerotic conjuctiva. This, the me- thod of Tyrrell, is thus described by Lawrence, who quotes Mr. Tyrrell. " The patient was seated on a low chair and I stood be- 532 STRICTURE OF THE URETHRA. hind him, so as to receive his head, Avhen inclined backwards, against the lower part of my chest; I then carefully, and with as little force as possible, elevated the superior palpebra with the point of the fore-finger (as in the operation of extracting a cataract.) having the finger covered with a piece of fine linen to prevent its slipping; one of my pupils depressed the lotver lid : next, with a fine cataract knife I divided the conjunctiva and the subjacent cellular membrane from the margin of the cornea, in a direction betAveen the attachment, of the recti muscles; making two inci- sions in each of these positions, or eight in all; in passing the knife, its point was made to penetrate the membrane, just over the junc- tion of the cornea and sclerotic, and the back or blunt part of the instrument Avas opposed first to the cornea, and afterwards, as the incision was extended, to the sclerotic." The object of this opera- tion is, to relieve the distended conjunctival membrane, and though the theory upon tvhich it was founded has been much con- tested, yet all alloAv that its practical effect is exceedingly bene- ficial. A mild form of gonorrhoeal inflammation of the eye, accompanied by bright redness and increase of the mucous secretion, is some- times observed. This affection may be so mild as scarcely to cause any pain or difficulty; or it may be so severe as to resemble the purulent ophthalmia. In the milder cases, the local use of astringent solutions, particularly of the nitrate of silver, will be all that is required. In the severer cases, antiphlogistic measures become necessary; and where the inflammation progresses to such an extent as to resemble purulent ophthalmia, the same treatment will be advisable as is recommended for that affection. Gonorrhoeal inflammation sometimes occurs in the external tu- nics and iris. Here the parts are seen to be inflamed, the Aoav of tears is increased, and there is great intolerance of lio-ht. When the inflammation reaches the iris, that membrane becomes hazy specked, or thickened in appearance, and may sooner or later become so much impaired as to destroy sight. General and local antiphlogistic treatment should be pursued, until the inflammation' is checked; when blisters may be resorted to with advantage and the local use of warm soothing applications be of service. Stricture of the Urethra. A narrowing, or partial closure of the urethra, by an approxima- tion of its walls, or the formation of adventitious membranes is SPASMODIC STRICTURE. 533 not an unfrequent affection—occurring sometimes from a pecu- liarity of constitution, but more frequently as the effect of long continued or severe attacks of inflammation. This inflammation may be the result of gonorrhoea or some other cause. Strictures have been divided into three classes; the spasmodic, the congestive, and the organic. To these some surgeons add a fourth class, comprising such cases as combine the spasmodic and congestive forms. Spasmodic stricture may result from constitutional predisposition or some inflammatory attack. As exciting causes of this disease, may be instanced all those conditions by which general relaxation may be produced or irritability increased, and particularly re- peated excesses in eating or drinking, or too free an indulgence of the passions. A stricture of this kind consists in the compression of the walls of the urethra, by the spasmodic contraction of the muscular fibres outside of its mucous lining. The affection super- venes rapidly after any exposure, or from either of those causes that are above spoken of as exciting; or it may accompany and increase a period of bad health. The symptoms come on suddenly, and as rapidly does the disease subside, under proper treatment. The peculiar treatment required in this form of stricture, con- sists in a frequent resort to the Avarm hip bath, and the internal use of some anodyne and diaphoretic preparation ; the Dovers powder in full dose is a very good one; and if the sufferings are great, enemata of laudanum, in some convenient vehicle, will afford much relief. All stimulants and exciting food should be carefully avoided, and the general health attended to; while the bowels should be kept open, and every exertion made to prevent an acid state of the urine. Should these methods fail, or appear only to give temporary relief, a silver catheter, of full size, should be intro- duced, and the operation repeated every third or fourth day, until the irritability of the urethra is relieved, and the spasm is cured. It sometimes happens, that the use of the instrument appears, even after having been several times used, to increase the urethral irri- tability. Under these circumstances, it should be dispensed with, and the constitutional treatment alone pursued. It is generally advised to use wax or gum bougies, in this affec- tion; but I have found, in all cases requiring the introduction of an instrument to relieve stricture, that a silver catheter, unless under peculiar circumstance, is more easily introduced, and causes far 534 ORGANIC STRICTURE. less irritation than a bougie; and in spasmodic stricture particu- larly do they appear to be preferable, as the spasms yield much more readily to the firm, constant, and gentle pressure of the catheter, than to the uncertain and wavering, or yielding pressure of an elastic and bending bougie. When the catheter is used, it should first be moderately Avarmed by immersion in warm Avater, and then Avell oiled. The existence of congestive stricture, in addition to the symptoms of stricture generally, is accompanied by SAvelling and redness of the lips of the urethra, a slight, thin, or perhaps a purulent dis- charge, and indeed by a genuine urethritis. The sufferings of the patient under an attack of this kind are truly severe, and fre- quently are enhanced by a sense of heat and discomfort in the perineum and much uneasiness when going to stool. Here, every thing should be done to improve the general health; the diet must be simple, the habits regular, and all excitement carefully avoided. Anodynes should be used, to allay irritation, as Avell as for their equalizing effect upon the circulation; and the urine should be rendered as bland as possible, by the free use of diluent liquids and alkaline preparations. Copaiba, too, in small doses, will be advisable Avhere the congestion is great, or urethritis exists. Under this course, the stricture will generally yield, but is extremely apt to return again ; indeed, it sometimes recurs from the slightest causes, after appearing to be perfectly cured. Where it does so return, the same course is to be repeated ; and when the inflammatory symptoms have subsided, the cautious use of the catheter should be resorted to, and persevered in for some time. Under these circumstances, the instrument should be very gently introduced, and all force strictly avoided, as the membrane is easily lacerated, and, even Avhen most carefully dealt Avith, is apt to bleed on the withdrawal of the instrument. Should the inflammation run very high, and great uneasiness about the perineum exist, leeches may be applied to that part, and great relief will be obtained from the frequent use of fumigations with warm vapour of Avater or where this is not convenient, the warm hip bath. Organic stricture consists in the closure of the tube bv adventi- tious formations. These may exist in the form of a membrane sometimes hard and cartilaginous, stretched across the canal, and having a small opening through it; or it may be composed of threads or organic fibres, stretching from one point of the tube to TREATMENT OF ORGANIC STRICTURE. 535 another, and generally lying obliquely. This affection results from long continued inflammation of the parts, and owns, as its most frequent cause, neglected or repeated attacks of gonorrhoea. This form of stricture generally comes on gradually, and Avhen once formed, the opening there-through becomes constantly smaller, until perfect retention of urine is produced. The symptoms,, at first, are but slight, and not generally noticed. A few drops of urine are at first retained; the calls to urinate become more and more frequent, and are increased at night, or after going to bed; some straining next becomes necessary; a slight discharge from the uretha comes on, and is soon followed by a sense of Aveakness. As the stricture increases, the urine, in passing through it, has its direction changed and its current divided, so as to assume different forms, and it may thus be twisted, scattered, or completely divided so as to flow in too distinct streams. The exertion necessary to force the urine away increases; the calls to pass it become more frequent, and the amount voided at each effort becomes less, till at last, Avith extreme exertion, difficulty and suffering, a feAV drops only can be forced to ooze through the stricture and drip away. When a stricture is suspected, its existence may at once be as- certained by passing a sound or catheter through the urethra, when, if there is a stricture, the instrument will be arrested thereby. Three methods of treating these strictures have been proposed; by dilatation, by caustic, and by division of the stricture. The principle upon which the first method—that by dilatation—has been adopted is, that while the stricture is temporarily removed by the introduction of instruments, and the patient thus quickly relieved from much suffering, the organic deposits are caused to be ab- sorbed, in consequence of the pressure exerted upon them by the instrument in the tube, and thus a permanent cure is effected. Some surgeons prefer the use of Avax or elastic bougies, and others resort exclusively to metallic sounds or catheters. For the above reasons it appears that metallic instruments are best, and the greater amount of pressure they must exert appears rather to in- crease their superiority. As large an instrument as can, without violence, be pressed through the stricture, should be carried to the bladder, permitted to remain there for about five minutes and then removed. At the end of about forty-eight hours, the same operation should be repeated, but with an instrument one size larger; and so 536 TREATMENT OF ORGANIC STRICTURE. on, every second or third day an instrument should be passed and retained for a short time, the size of the instrument being con- stantly increased till as large a one as the orifice of the urethra will easily admit, can be passed Avith ease into the bladder. The inter- val betAveen the operations may now be gradually increased, until they are completely discontinued. It will be advisable for the patient occasionally to use a full sized instrument for some time after his relief appears perfect, as otherwise the disease may grad- ually return after a long interval. It has been proposed, (and instruments have been invented for the purpose) to effect the perfect opening of the stricture promptly, by forced dilatation. This method, however, first advised by M. Mayor, is not generally approved of, and is now but seldom re- sorted to. The slow and gradual process by which the resistance of the stricture is gently overcome, appears far safer, and, in most cases, will prove more expeditious than the other; for, it must be remembered, that Avhile forcing instruments through the stricture, we are dealing violently Avith the urethra, the membrane of Avhich is extremely sensitive and prone to inflame, and that the superven- tion of even a moderate urethritis Avill protract the sufferings of the patient and enhance them, by increasing his stricture and render- ing it more difficult to cure. When the closure of the meatus is so nearly complete that neither catheters nor bougies can be made to pass the stricture, the use of caustic or incision remains. Several methods of applying caustic to the stricture have, from time to time, been proposed, and the " porte caustiques" of Ducamp, Heurteloup and Amussat, have had their various advocates, and are ingenious contrivances. They are, hoAvever, rather too complicated, Avhen the same object may be as well fulfilled by the much simpler method of Whately. A Avax bougie of full size being Avell oiled, is passed down to the stricture, and the surgeon with his thumb nail dents it opposite the orifice of the urethra. It is then AvithdraAvn, and another boutrie of like size and length, having a small piece of potassa fusa—about the size of a mustard seed—fixed in a depression at its end is similarly marked, and then passed quickly dotvn the urethra until the mark lies opposite the orifice of the tube, Avhen the bougie is firmly pressed against the stricture for the space of a minute and then removed. The operation ought to be repeated every third morning, until a moderately sized instrument can be passed when TREATMENT OF ORGANIC STRICTURE 537 the cure may be completed by dilatation. After each application of the caustic, a slight thin discharge is apt to occur, but it requires no treatment. The treatment by incision comprises two methods, one by divid- ing the stricture from within, Avith instruments passed down the urethra, and the other by incision from without, by cutting through the perineum to the seat of stricture, and through it. In the first method, few surgeons have ever operated with satisfaction, though numerous instruments for thus notching or cutting the stricture, have from time to lime been invented and recommended. All of these act upon the same principle : a cutting edge is, by means of a canula, carried through the uretha to the stricture, then protruded, and caused to act upon it so as to divide or notch its edge. The most recently invented of these instruments, and that at present most in vogue, Avas introduced by Dr. Pancoast. This consists of a curved canula, in which a cutting stylet, grooved on its back, fits. In using the instrument, a long fine piece of catgut is carefully insinuated through the stricture, into the bladder. The end of the catgut is then passed through the groove in the stylet, and hence through the canula. The instrument is then carried down to the stricture, (the canula gliding over the catgut,) and the stylet, protruded on the catgut as a director, is forced through the stricture, which is thus divided. WTheri the catgut cannot be got through the stricture, it is advised, to place the same in the groove on the back of the stylet, and then, drawing it within the canula, to pass the latter down to the stricture; when the catgut should be protruded and carefully insinuated as far into the stric- ture as it will go : the stylet is next to be carried cautiously for- ward on the catgut, and the stricture thus partially divided. The catgut and stylet are then retracted, and the same process repeated until the entire stricture is divided. After the division of the stricture, the cure is completed by the use of bougies, as in simple dilatation. The great difficulty in this operation is, that in cutting Ave are obliged to depend entirely upon manipulation, and are dealing with tender and sensitive structures lying altogether out of sight. The use of caustic, therefore, is now generally preferred; and where this fails, the external incision through the perineum becomes ad- visable. This operation is performed in two methods. The first, introduced by Mr. Syme, is applied to cases of long standing, ob- stinate, but pervious strictures, and consists in passing a grooved 538 TREATMENT OF ORGANIC STRICTURE. sound through the stricture into the bladder, and then making a section upon this from the perineum, down to the seat of stricture and through it. In the second method, Avhich applies to impervi- ous strictures, no sound or director is used, the surgeon attempting, without any such aid, to cut into the stricture, and beyond it, from the perineum. The first operation—urethrotomy, or perineal section—is performed in the folloAving manner.—A staff of medium size and grooved on its convex surface, is passed through the stricture, and the patient ly- ing as though for lithotomy, the surgeon makes an incision directly through the raphe or middle line, about an inch long, and just above the anus. The incision must be carefully deepened, by slight successive strokes Avith the point of the knife, until the staff is reached. The point of the knife should then be carried directly into the groove, and if possible behind the stricture; Avhich must then be divided, by carrying the knife forwards through it. When the knife cannot conveniently be placed in the groove of the direc- tor behind the stricture, it must be placed in front thereof, and it becomes necessary to divide the strictures carefully from before backAvards. When no instrument can be passed into the stricture, and the use of caustic fails, the only resource left the surgeon is, to cut into and divide it without a guide. Here he must rely entirely on his anatomical knowledge; and, under the most favorable circumstances, he will find the operation difficult, dangerous, and tedious. A large sized catheter should be passed doAvn to the stricture, and the patient lying as for lithotomy, the surgeon cuts into the urethra directly upon the point of the catheter, and then endeavors to cut through the stricture into the urethra beyond it. This is a bloody and extremely difficult operation, and one which is frequently found to be impracticable. It has been more than once commenced and left uncompleted, by expert and experienced surgeons. The stricture having been divided, the catheter is car- ried on into the bladder, left there for forty-eight hours, and then removed; to be introduced again every fourth day, until the parts have healed completely. In these external operations, after the stricture is divided, the perineal wound should be closed by straps, and union by the first intention induced, if possible. The cuts wi 11 generally heal kindly and give no trouble. The last operation Avill be very rarely neces- sary, as it should never be performed or attempted Avhile any other PROSTATITIS. 539 means may succeed. Before operating, the patient should always be placed under the full influence of chloroform, as it will be found, that Avhile under the action of an anaesthetic, his stricture will of- ten yield, and admit of a medium or full sized instrument being passed into the bladder, when, a moment before, it had been com- pletely impervious to the smallest bougies or sounds. In speaking of external section Avithout a guide, Erichsen says: " Fortunately this operation is now scarcely ever necessary; with patience and under chloroform, the surgeon may almost invariably get a staff, however small, into the bladder; he then has a sure guide upon which to cut, and by following Avhich he must certainly be led through the stricture into the urethra beyond it. In all cases, therefore, urethrotomy should, if practicable, be substituted for the division of the stricture without a guide." Diseases of the Prostate. Inflammation of the prostate—prostatitis—is generally the result of long continued inflammation of the urethra from gonorrhoea. It is accompanied by a frequent desire to urinate and much pain on the passage of Avater, and there is deep-seated pain'and much un- easiness about the perineum. There is also considerable pain on the passage of fecal matter doAvn the rectum, from its pressure while passing over the gland. The finger, when introduced into the rectum, at once discovers the enlarged and tender gland, and so renders the diagnosis sure. The tendency of this form of inflammation is to the production of abscess, to prevent which, the treatment should be actively antiphlogistic. Cups and leeches should be applied to the peri- neum, Avarm anodyne fomentations used, and the warm hip bath frequently resorted to. Saline preparations and antimonials will also be found serviceable. When abscess forms, it will be accompanied by throbbing and rigors; and if the collection of pus is large, retention of urine will also be likely to occur. These ab- scesses most generally break into the urethra, though they may also open into the rectum, or point externally in the perineum. When the latter is the case, a dark brawny appearance, accom- panied by hardness, is apt to be perceived in the perineum. This should be cut into, even before fluctuation can be perceived, as it is of consequence to open these abscesses early. The incision should be made" directly in the mesial line, and if no pus can be found, the wound should be kept open by a dossel of lint, and 540 HYPERTROPHY OF THE PROSTATE. poultices applied, so as to cause the pus to be discharged through the wound. In this Avay, an opening into the urethra or rectum may be prevented. During an attack of prostatitis, retention of urine may occur, as the result of the enlarged and swollen state of the gland, or from the pressure of an abscess. Under these circumstances, it will be necessary to draw off the urine by the catheter. When using this instrument, let it be borne in mind, that the neck of the bladder may be very much elevated by the diseased prostate. A very long instrument should therefore be used ; and, in passing it through the urethra, its point should be carefully kept in contact Avith the upper wall of the tube, as otherwise the orifice of the bladder may not be entered. Inflammation of the prostate may also assume a chronic form. This is particularly apt to be the case in feeble or very debilitated constitutions, and, like the acute disease, is most frequently the result of gonorrhoea. In this affection there is, in addition to tender- ness on examination through the rectum, a sense of Aveight in the perineum, &c, and also a morbid secretion from the follicles of the gland, causing a discharge, from time to time, of thick, ropy- mucus. This viscid secretion may drip away, or be squeezed out during defecation by the matters descending through the rec- tum; or it may sometimes be throA\-n out, so as to resemble the ejection of semen. In such cases, leeches should be applied to the perineum, cups to the same, and the Avarm hip bath freely used. Where there is a chronic enlargement of the gland, and much pain in passing water, copaiba in small doses, blisters to the perineum, and the use of tincture of bark, combined Avith that of the tincture of hen- bane and the liquor potassae, have been highly recommended. Hypertrophy, or chronic enlargement of the prostate, is of very common occurrence among the middle-aged or old, but is gener- ally accompanied by such an enlargement of the urethra, and corresponding changes in the surrounding parts, as to produce no inconvenience, and, hence, really not to constitute actual disease. This, however, is not ahvays the case; the enlargement sometimes goes on to such an extent as completely to prevent the passage of urine, so as, if not relieved, inevitably and rapidly to produce death. The earliest symptoms of this affection are, the necessity of effort on passing the urine, and a lengthening of the period re- CALCULI IN THE PROSTATE. 541 quired to empty the bladder, whilst, after this is apparently done, an involuntary escape of a small quantity of urine occurs, on the first movement of the patient. Strings of mucus are next observed to be mixed with the urine, and this becomes dark-colored, and assumes a fetid, sour smell. If the affection be not relieved, the mucous membrane of the bladder will become inflamed, and the urine be rendered extremely offensive, and of a milky appearance, from being mixed Avith pus In examining by the rectum, the condition of the lateral lobes may be ascertained; while by the use of the catheter, the state of the urethra and middle lobe is dis- covered. In examining for prostatic disease, then, these tAvo methods of exploration should always be combined. In the treatment of this affection, such means must be resorted to as are calculated to allay irritation about the urinary organs. The urine should be rendered as bland as possible, by the use of diluents and alkaline preparations; and the use of henbane and copaiba, in small doses, wi 11 also be found advantageous. When retention of urine comes on, the catheter should be freely used; and, indeed, Avhere the instrument is with great difficulty passed into the bladder, it may be advisable to pass into that viscus a gum catheter, and retain it therein until an instrument can easily be carried past the enlarged gland. Great care should be observed, in passing the catheter, to keep its point against the upper wall of the urethra, as above directed; and the urine should be frequently drawn off, as it is apt, othenvise, to become putrid, and thus occa- sion fatal typhoid disease. Should the enlargement of the gland be so great that no instru- ment can be passed into the bladder through the urethra, tAvo methods only of preserving life remain—forced catheterism, and puncture of the bladder. Each of these have been elsewhere treated of, and will require, therefore, no further notice in this place. Calculi are sometimes found in the ducts of this gland. They generally exist in small numbers, and are of small size; though they sometimes attain considerable bulk, and have been found in great numbers. The disease is accompanied by a sense of heat, pain and discomfort about the perineum, and a discharge of mu- cus from the urethra. On introducing the catheter, it is felt to strike the calculus before entering the bladder. If the finger is passed into the rectum, and presses the gland upwards against the 542 URINARY CALCULUS. catheter, the stone Avill be more plainly perceived: indeed, it may sometimes be distinctly felt by the finger in the gut. When stone exists in this position, the patient should be placed as in cutting for stone in the bladder. The gland should then be cut down to, as in the lateral form of lithotomy, and the calculus removed with the scoop or forceps. The wound should then be treated as in cases of lithotomy. Malignant disease of the prostate occurs very rarely. It may be recognized by the syrmptoms of enlarged prostate being accom- panied by the escape of bloody mucus, mixed Avith cancerous debris, from the urethra. The hard tumor formed by the gland may be felt through the rectum, and the general systemic symp- toms of malignant disease develop themselves. The treatment, here, can only be palliative and soothing, as the disease must necessarily prove fatal. T. S. W. LECTURE LXVII. CALCULUS IN THE BLADDER--ITS FORMATION--SYMPTOMS--TREATMENT OF LITHOTRITY--THE INSTRUMENT OF AVEISS--THE INSTRUMENT OF JACOBSON. We design, this morning, gentlemen, to treat of calculus, or stone in the urinary bladder. This is a subject which has always been regarded as one of the most important to be found in the list of surgical records. The difficulties of the operation were at one time regarded as so great, that physicians deemed it their duty to warn their pupils never to undertake it. But, although this is still regarded as one of the capital operations, yet, so divested of its terrors has it become, that it may Avell noA\r be undertaken with as much collected calmness, and confidence, as an amputation of the leg. The truth is, that when it is knoAvn where and how to cut, the operation of lithotomy is as easy as many others, attending the performance of which there is not so much eclat. In my opinion, where the individual possesses the requisite qualifications of a sur- geon, the operation of cutting for stone is far less serious than is that of the extirpation of many tumors that are found about the FORMATION OF CALCULI. 543 neck. In cutting for stone, no important blood-vessels or nerves are destroyed, or severed. It is, then, only in the hands of the ignorant, and rash—those who cut in the dark, and are wanting in all preparatory knowledge; Avho, instead of entering the bladder, cut, helter-skelter, they know not where—it is only, I say, in such hands as these, that this operation becomes dangerous. But let us leave this digression, and return to an examination of the formation of calculus. Of what is stone, as found in the bladder, composed ? We find it made up of elements, all of which are found in the blood itself. But I do not intend to speak of the chemical constituents of stone. Upon that subject, I can safely refer you to your able professor of chemistry, for information. There are two seats of stone ; the kidneys and the bladder. The urine secreted in the kidney, from some derangement in the rela- tive proportions of its constituents, gives rise to various sediments: these crystalizing form gravel: this, passing on to the pelvis of the kidney, and there meeting a portion of mucus, or a clot of blood, concretes around it; and thus a nucleus is formed, around which the concretion of gravel continues, until we have a stone in the kidney. This, having attained a certain size, is pushed by the urine into the ureter, and finally passes into the bladder; some- times giving rise, on its passage, to excruciating pain, which comes on in paroxysms. If the calculus is large, it mav be arrested in the ureter for some time; but it will eventually be forced into the bladder; Avhere it either remains, and enlarges, or passes off by the urethra, and the patient is relieved. By far the greater num- ber of calculi arise thus. Sometimes they grow so large in the kidney, that they cannot pass through the ureter; and then they give rise to violent inflammation, and even sometimes to abscess. The other point at which calculi may be formed, is the urinary- bladder. Here also clots of blood or mucus may be the nuclei, around which the gravel, crystalizing, concretes to such an extent, sometimes, as to give to the stone an enormous size. In some cases, both in the kidneys and the bladder, some tAvo, three, or more of these stones are formed ; and instances have oc- curred, in Avhich several hundred have been found. This being the method in which calculi are formed, I might go on to speak of their causes. But time will not permit this. I would only remark, therefore, that, as a general rule, their forma- tion Avill be influenced by climate, water, the state of the atmosphere, mode of life, &c. Where water contains lime, it renders those who 544 SYMPTOMS OF CALCULUS. drink of it more liable to stone. This appears to be the result of universal experience. One circumstance, however, appears to contradict it. If we take the State of Maryland, Ave find that a great portion is of the primary lime-stone formation, and that a great portion is of the tertiary formation. Now, calculi are very common in that State; and about two-thirds of the cases come from the neighborhood of the tertiary formation, while one-third only are derived from the neighborhood of primary lime-stone formations. This is an apparent exception ; but it only serves to strengthen the rule; for, throughout its whole extent, this tide-water region ia underlaid by vast marl beds, from Avhich the water becomes strongly impregnated with lime. You may suppose that the same thing would hold good here. But remember, that so far as the geological structure of this State is concerned, there is very little of the pri- mary limestone formation, almost the Avhole country being of either the tertiary or granitic formation, so arranged in layers, that here and there it is underlaid by large beds of carbonate of lime. The water, hoAvever, is not generally impregnated with lime, because the springsand wells do not sink deep enough to come in contact with these beds of marl, and therefore remain unimpregnated by them. Hence, stone is of very rare occurrence in this State ; so rare, indeed, that a surgeon in a pretty large practice may have occasion to operate for stone but once or twice only in his Avhole lifetime; and in these cases, it will generally happen, that the stone is of oxalate of lime. The symptoms of stone may be divided into tAvo classes: the rational, and the physical. These should be considered separately. When a stone exists in the bladder, there are rational signs which almost always present themselves. There will be frequent calls to avoid the urine, this frequency depending on the amount of the irritation of the bladder. When it is not much irritated, the calls Avill be less frequent, and vice versa. After fatigue, after a debauch, or after any circumstance Avhich may determine the circulation to that part, the calls will be very frequent and urgent; so much so, that frequently they cannot be resisted for an instant. At particular times and under certain circumstances, these at- tempts to pass urine are attended by pain and effort. At first the urine Aoavs freely and without pain, but soon the stone falls into the neck of the bladder, and pain and difficulty of passing urine come on; so that, though the patient may begin to pass his urine freely and comfortably, he will end his evacuation with pain and effort. Sometimes, when the calculus is small, it completely closes SOUNDING FOR STONE. 545 the orifice; so that, after flowing freely for a while, the urine sud- denly stops, and the greatest effort cannot force away another drop. After awhile, the bladder is again distended by urine; the stone moves, and the patient can now pass his water. But he must go through the same ordeal again. The rough surface of the calculus, coming in contact Avith the delicate lining membrane of the bladder, causes great irritation, followed by the secretion of a thick ropy mucus, which passes off almost in a galatinous state; and, Avhere the irritation is great, pus may even be secreted, and it passes away, mixed, sometimes, with blood. The irritation may even be so great as to cause bloodv urine to be discharged. On account of the great amount of pain, the patient generally seizes the glans penis or prepuce, and forci- bly tugs at and pulls it. This is attributable to the fact, that wherever there is great irritation at one end of a tube, as at the neck of the bladder, or one end of the urethra, the pain will be felt at the other, as at the glans, or other end of the urethra. There are other rational signs, but I have not time to notice them all. I will add, hoAvever, that, even taking all of these signs together, they cannot give perfect certainty ; for the same pain in micturi- tion, the same sudden stoppage of the Aoav of urine, the same pain and tugging at the glans penis, may all be the result of other causes. So I repeat, that however strong the presumptive evi- dence from these rational signs may be, yet they leave us still uncertain, still in the dark. How then are we to be sure ? We can only be certain by studying the physical signs; by sounding the bladder—an operation, Avhich, if properly performed, clears up all doubt. Having placed the patient in a proper position, take an instrument known as the steel sound, oil it Avell, and introduce it through the urethra into the bladder, turning its point in every possible direction. Should there be a stone, the point will come in contact with it, and you will detect it at once by the grating, jarring feeling to which it gives rise. You will not always, how- ever, be thus readily successful. When you fail Avith your patient in the recumbent posture, cause him to stand up. Should you fail then also, oil the index finger of the left hand well, and passing it high up in the rectum so as to avoid the prostate gland, press the tip forward towards the pubis, and examine thus, with the finger in the rectum, and the sound in the bladder. But still we may fail to discover the stone. Then place the patient on his hands and knees, with the buttock upwards, and examine in this posi- i* 546 jacobson's LITHOTRITE. tion. Should you try all of these methods, and yet fail to detect the stone, Avhile you still have reason to suspect its existence, you must not desist after one trial only; but, making the ex- amination again and again, you will certainly find the stone eventually. There is one circumstance which may prevent you from detect- ing the calculus, and to which I will call your attention. Under the influence of forcible distention, some of the mesh-like cells or cavities on the inner membrane of the bladder maybe so enlarged, that the stone may fall into one of them, and thus be received into a little sac or diverticulum, leaving perhaps one portion still pro- jecting into the bladder; or it may be contained entirely in this little cavity. Generally, however, it has one portion left free in the bladder. When a stone is thus encysted, it is particularly hard to find it, and when entirely encysted it becomes impossible to detect its presence Avith a sound. Having discovered the calculus, the next question is, what must be done to give relief to the sufferer. Here we enter upon a wide field ; and, did time permit, it Avould be very interesting to consider the whole subject of the treatment of this infirmity. But I must forego this pleasure, and pass it rapidly over, only remarking, that so far as regards the removing of the stone, the method is twofold. One plan of proceeding is to crush the stone in the bladder into such small fragments that it ma)' be passed off through the urethra. This has been long regarded as the great desideratum, and many methods have been proposed, and various instruments invented, for this purpose. It was not, hoAvever, until the present century, that any of these have successfully accomplished this object; and however praiseAvorthy may be all of those who directed their en- ergies towards the attaining of this end, yet it is to Civiale that AA'e are indebted, for having first established the safety and success of the operation. I need not describe his instrument in detail. There are many others Avhich I might mention to you. All. hoAvever, act upon the same principle. Among them, I will mention the in- strument of Jacobson. It consists of a holloAV silver tube, contain- ing a steel loop Avorked by a screAv, and so arranged that Avhen the tube is introduced into the bladder, by turning the screAv, the steel loop projects from it. By turning the instrument about, the cal- culus finally falls into the loop; when, by turning the screAv in the reverse direction, the loop is drawn into the tube again, and the stone is crushed. The hardest calculi have thus been crushed, LITHOTRITY. 547 and a whole stone has been broken up at a single sitting. Take care, however, not to keep the instrument in the bladder too long, as inflammation of that organ may be the result. It might be ne- cessary to repeat this operation of lithotrity one, two, ten, or twenty times. I would mention, also, the instrument of Weiss. This, instead of acting by a loop, consists of two rods of steel, one gliding along a groove in the other. The ends of both blades are turned slightly up, and one is perforated by an oblong opening. The other is solid, and both are serrated. This instrument acts on the principle of a cog-power, the upper or male blade, being drawn back by turning a small handle, which acts as a cog upon the long rack attached to the blade. The stone falls betAveen the curved ends of the tAvo blades; .when, by the action of the cogs, it is crushed between them, the fragments passing through the opening in the lower or female blade, and thus pre- venting the risk of wounding the urethra, while withdraAving the instrument, by any fragments which may remain and stick out between the blades. I prefer the instrument of Jacobson. It is easier to find the stone with it, and it crushes it, when found, without any difficulty. There is no danger of its breaking, and even if it does, no difficulty will result from the accident. Being a closed loop, there is no risk of catching the coats of the bladder in it; while you might do so with the instrument of Wiess. It is neces- sary, in using both, to turn the instrument about, until the stone falls into it, being careful never to catch the bladder. As regards the condition of the bladder, whether it be empty or full, there is a great difference of opinion. Some request the patient to retain the urine for some time previously ; and if he has not done so, they inject warm water before operating. I think it a matter of no consequence. The removal of stone by the knife, or the operation of lithotomy, shall be spoken of in the next lecture. 548 LITHOTOMY. LECTURE LXVII1. LITHOTOMY--METHOD OF CELSUS--OPERATION OF FRERE JACQUES-- OPERATION AS NOW PERFORMED--CALCULUS IN THE FEMALE. It yet remains for us, gentlemen, in continuing the subject of yesterday, to speak of the second method of getting rid of stone. This we must do but briefly, as it Avould be impossible in one, or even in a dozen lectures, to discuss properly the various operations, or methods of cutting for stone. Perhaps the oldest method of performing the operation of lithot- omy, is that of Celsus. It is exceedingly simple, and in those classes to Avhich it is adapted, it is also effectual. It consists in cutting on the grip, as we say, and its performance is limited to cases occurring among children. The child is seated on the lap of an assistant, with the legs draAvn up. The index finger of the surgeon is then passed into the rectum, Avhere it reaches the calcu- lus, and bearing it down, causes it to press on the perineum, near the anus. Then, by a simple lunated incision in front of the anus, he cuts directly on the stone and turns it out. This operation is effectual; but there are cases, even among children, in which it will not do. It is rendered impracticable in adults, by the depth of the perineum. At a very recent period, there appeared in France a bold and daring monk, known as Frere Jacques, Avho operated freely for stone. He kneAv nothing of anatomy. His operation Avas as fol- lows.—Having passed into the bladder, an ordinary sound Avithout a groove, by a bold stroke on the left of the raphe, he carried the knife to the sound, and, guided by this, into the bladder. The stone Avas then removed by the forceps ; and this fearless felloAV, having gone thus far, would say to his patient that he had removed the stone, and would now leave the cure to God. It Avas doubtless this operation of Frere Jacques, that first led to the introduction of the grooved staff, Avhich has ever since been used. Having mentioned this piece of the literature of surgery, I Avould state, that, in cutting for stone, we operate on one side of the peri- neum, one side of the urethra, and one side of the bladder. Hence this is called the lateral operation. It is divided into two varieties ; the lateral and horizontal, and the lateral and oblique. The latter LITHOTOMY. 549 is generally known as the lateralized operation ; and it is the one Avhich 1 prefer. Before proceeding to discuss the manner of operating, I wish to lay down certain general principles, by Avhich you should be gov- erned in the lateral operation. First, your incision in the perineum should he full or large ; and, secondly, your incision in the prostatic portion of the urethra should be small, never extending through what is called the shoulder of the gland. The reason for this is, that in the natural state, a layer of fascia passes from the bladder to the pubis under the gland ; and if you divide through the gland, the urine passes to this fascia, and, infiltrating in the cellular tissue, gives rise to serious conse- quences. It is important, then, not to cut through the gland, and also that the incision in the perineum should be free and large. In making the first incision, you proceed as follows.—Place the patient on his back, Avith the feet in the palm of the hands, and the buttocks drawn to the edge of the table ; carry a sound into the bladder; and confide this to the hands of an assistant ; who, hold- ing the staff in the right hand, should, with his left, lift out of the way the scrotum, penis, &c. The surgeon, seated on a chair of convenient height, commences the first incision at the raphe, about an inch and a half below the pubis, and carries it obliquely down- wards and outAA-ards, to a point half way between the anus and tu- berosity of the ischium, and on a line terminating with the centre of the anus. Having made this incision, he passes the index fin- ger of the left hand into the upper portion, and seeks the staff; which will be easily felt through the thin membraneous portion of the urethra. Having found the staff, he feels with the finger for the groove ; and having found this, keeping the rectum down beneath the finger, he carries the scalpel above it, and piercing the mem- braneous layer of the urethra, places its point in the groove of the staff. Keeping the blade turned obliquely outwards and dowmvards, so as to avoid the rectum beloAV, and the internal pudic artery on the outer side, he then presses it firmly against the staff, and car- ries it into the bladder. Having laid doAvn these general rules, I proceed to speak of the different instruments for, and the leading modifications of, this op- eration. In skilful hands, the ordinary long scalpel is as good an instrument as any other. Various other instruments have been recommended from time to time. Among them is the gorget of Hawkins ; though this, however, has been almost entirely aban- 550 LITHOTOMY. doned. After the incision has been made, the stone is removed by a pair of forceps carried into the bladder for that purpose ; and I would here call your attention to one difficulty which may arise. The finger being kept in the bladder, the forceps passing on it as a guide, if carried too Ioav, may enter the pouch between the rec- tum and bladder. Take care, therefore, always to direct the for- ceps high up near the pubis. Besides this cutting gorget of Hawkins, we have a blunt gorget and shield ; as, also, another modification of the same instrument, by Physick ; Avhich has again been modified by Gibson. By either of these instruments, you may readily enter the bladder, but they have been almost entirely abandoned by modern surgeons. A far better instrument is that of Professor Smith, of Baltimore. Of all the methods proposed for entering the bladder byr the peri- neum, that of Professor Smith is perhaps the hest. His instru- ment is an exceedingly ingenious one ; yet I must confess, that I deem the cap and wire superfluous. The great advantage of this instrument is, that having adjusted it, and introduced the sound blade into the bladder, by bringing down the second blade, the lancet passes through the perineum directly into the groove in the staff. By introducing the knife into the groove of this staff, it will be carried directly into the groove of the main staff, and so into the bladder. It is almost impossible for any one to fail in enter- ing the bladder with this instrument. There is no danger of hem- orrhage ; and, in short, there is no instrument by Avhich the opera- tion can be more safely performed. Yet, for m\r own part, I think there are no instruments for entering the bladder for the removal of stone better than the common scalpel, and a sound with a deep groove. One aat1io is accustomed to operating can thus, Avith per- fect ease, carry the knife into the bladder. The chief danger in all these operations is that of opening the rectum. When you operate, you should always see that it is pre- viously emptied of its contents. I would here remark, that, if un- accustomed to operate, you may, after the first incision in the perineum is made, introduce a grooA-ed director, and carrying it into the groove of the sound, pass it thus into the bladder ; and then, introducing the knife into the groove, having Avithdrawn the staff, cut upon it, instead of on the main staff, thus using a straight staff The operation can be thus very easily performed, Avithout any risk of Avounding the rectum. Some are in the habit of using a straight staff; and, when this can be introduced, the plan is a LITHOTOMY. 551 good one. But there is difficulty in introducing it, and frequently it can not he done. All these methods of which I have spoken, propose to remove the stone by cutting first from without inwards. There are other instruments for this purpose, which cut from within outwards ; as, for example, the lithotome cache. When this instrument has been fairly lodged in the bladder, the staff is removed ; and the instru- ment being properly placed, the surgeon, by making pressure on the handle, causes the knife to leave its sheath, and makes the cut through the prostate by withdrawing the instrument. You may succeed very well with this instrument. It is proper to re- mark, however, that in some cases the calculus is so large, that the incision thus made will not permit it to pass. To prevent this difficulty, it has been proposed to make an incision on both sides, and so avoid dividing the entire gland, and yet give sufficient room. With this object in view, it was first proposed to use an ordinary gorget, made with two cutting edges instead of one. For this special purpose, Dupuytren was also led to invent the double lithotome cache. This instrument, being fairly lodged in the bladder, is turned so as to bring its convexity upwards, and then is withdrawn gradually, the hand being gently depressed, so as to cause the instrument to move in the segment of a circle. Here the incision is made on both sides, and thus more space is given for the removal of the calculus. I have used this instrument myself, and I have seen it used by others. There is one serious objection to it. The blades are very slender, and unless they are very sharp, they are apt to spring, and the incision will be too small. If proper attention be paid to this, however, you will suc- ceed very well with it. I might go on to mention to you a hundred or more different methods of cutting for stone. But time will not alloAv ; and I will only noAV remark, that it has been proposed to enter the bladder by an opening above the prostate gland,—or even through it, at the fundus of the bladder,—from the rectum. Noav, this opera- tion is exceedingly simple, more so than any other ; the removal of the stone by it is easier, and the danger to life is less. But here its advantages end; for after the stone is removed, you can not close or heal the wound, and the feces pass into the blad- der, and the urine into the rectum. Thus the patient will be ex- posed to more inconvenience, than if the stone had been left in the bladder undisturbed. Another method that I must mention 552 CALCULUS IN THE FEMALE. before I leave the subject, is the operation high up above the pu- bis. Some persons recommend this operation, and others condemn it. Though long opposed to it myself, I am free to confess, that from the very favorable accounts I have lately received concern- ing it, I give the preference to it over all others, when the subject is young. Having shaved the hair from the pubis, and having placed the patient upon his back on a table, and having passed a large curved sound to push up the fundus of the bladder, make an incision on the median line, extending from the pubis about an inch and a half upAvards. This incision should pass through the skin and cellular tissue, to the tendons of the abdominal muscles. Next, carefully divide the linea alba, to the peritoneum, taking care not to wound that membrane : then, carefully distending the Avound with flat hooks, plunge the knife, guided by the left index finger, directly into the bladder, at its anterior part; and, through the opening thus made, examine the bladder with the index finger, and remove the stone. Having done this, introduce a gum elastic catheter into the bladder ; bring the wound together, and heal it by the first intention. The catheter should remain until the wound has healed. The only objection to this method is, the possibility of the urine infiltrating into the pelvic fascia ; but, barring this, I must acknowledge, that this high operation demands preference over all others. WThen the stone is large, and can not be broken, this high operation is the only resource which is left us. In a case in AA'hich I had occasion, recently, to operate aboA'e the pubis, on account of the large size of the stone, the bladder was entered readily ; but the calculus being very friable, when seized in the forceps, crumbled into numerous fragments, Avhich occasioned much trouble. Infiltration, followed by sloughing and suppura- tion, took place, but the patient finally recovered.* CAI.Cl'LUS IN THE FEMALE. In the female, calculus is of very rare occurrence, and appears generally to re- sult from a deposite formed around some foreign body that has lodged in the bladder. When, however, females are found suffering from stone—the symptoms of which are pretty nearly identical with those accompanying the same afTection in the male—the calculus may be removed by extraction through the urethra, or by lithot- rity. In former times, when extraction through the urethra was decided upon, that tube was quickly and forcibly dilated, immediately before the extraction, by a small bivalved speculum. Great force was sometimes used, and where the stone was large, the mucous membrane was first notched or cut through, and the dilator then used. This proceeding was so generally followed by incontinence of urine, that it has been almost entirely abandoned ; lithotomy, even, being preferred. LITHOTRITY IN THE FEMALE. 553 Since the introduction of the lithotrite, however, it may be affirmed, that cutting for stone in these cases, is quite unnecessary, and should not therefore be resorted to in any form. The female urethra is short, almost straight, very dilatable, and bears the introduction of instruments, generally, without inconvenience. By the persevering and gentle use of prepared sponge, &c, the canal may be so dilated, that large sized calculi may pass without the use of any instrument. Should the stone not thus come away, a small pair of forceps may be passed through the urethra, after it has been thus gently dilated, and the stone caught and removed entire, if it is not too large 10 pass through the urethra without wounding it. If its size is such as to prevent this, the lithotrite should be introduced, and the stone crushed ; when the fragments will be easily removed. Let it be remembered, that the urethra may be so dilated without injury, in the female, as to admit of instru- ments being used of sufficient strength to ensure the easy crushing of the largest and hardest calculi. Lithotrity is performed in the same manner, and with the same instruments, upon the female as on the male, the only difference being, that, in operating on the former, the hips should be kept slightly elevated, that a sufficient quantity of liqu.d may be retained in the bladder. t,D" INDEX. A. Abdomen, wounds about. 428; tapping of, 434. Abdominal Aorta, ligation of, 338. Abscess, 12 ; varieties of, 20; lymphatic, 24. Air-passages, foreign bodies in, 418; abscesses about, 419; bursal tumors- near, 419. Amputation, generally considered, 244; specially considered, 263; of the fin- gers, 263; of the meta-carpal bone of the thumb, 264; at wrist-joint, 264; of fore-arm, 265; at elbow-joint, 265; of arm, 266; at shoulder-joint, 267; of the tarso-metatarsal joints, 26S; through the tarsal articulations, 269; at the ankle-joint, 270; of the leg, 271; of the thigh, 273; at the hip-joint, 274. Anastomosis, 302; aneurism by, 313; treatment of aneurism by, 344. Anchylosis, 215, 223; treatment of, 228. Aneurism, 310; varieties of, 310; aeti- ology of, 313; terminations and re- sults of, 315; spontaneous cure of, 316; treatment of, 317; by anastomo sis, treatment of, 344; arterio-venous, treatment of, 346. Ankle-joint, amputation at, 270; dislo- cation at, 211. Anthrax, 63. Antiphlogistics, 4. Antrum Highmorianum, diseases of, 404; opening into, 404; wounds into, 384. Anus, artificial, 439; fistula of, 502; stricture of, 508; congenital malform- ations of, 508; prolapse of, 491; poly- pus of, 4y9. Aorta, wounds of, 427. Arteria Innominata, ligation of, 325. Arteries, wounds of, 297; obliteration of, 299; collateral circulation in, 302; ligation of wounded, 305; application of ligatures to principal, 321; ligation of thyroid, 327. Artenio-venous Aneurism, 310; treat- ment of, 346. Artery, ligation of common carotid, 322; ligation of lingual, 328; of external carotid, 329; of external maxillary, 329; of subclavian, 330; of axillary, 332; of brachial, 334; of radial, 336; of ulnar, 337; of internal mammary, 337; of external iliac, 338; of com- mon iliac, 339; of internal iliac, 339; of femoral, 340; of popliteal, 341; of posterior tibial, 341; of anterior tib- ial, 342. Arthritis, from wounds, 214. 556 INDEX. B. Bedsores, 41. Bladder, calculus in, 542; formation of calculus in, 543; operations for re- moval of calculus in, 546; puncture of, 431. Bone Abscess, 238; treatment of, 243. Bone, atrophy of, 233; exfoliation of, 234; fractures of, 137; inflammation of, 231; tumors of,233; ulceration of, 234. Brain, compression of, 361; concussion of. 359; hernia of, 369. Bronchocele, 420. Bowels, obstruction of, 441; scirrhus of, 433; wounds of, 432. Bubo, 81. Bubonocele, 450. Buffy-coat, 2. Burns, 109. Bursal Tumors. 121. 419. C. Cesarian Section, 443. Calculus, 542; in the female, 552. Cancer, 127; alveolar, 129; colloid, 129; encephaloid, 128; epithelial, 129; me- dullary, 128; melanotic, 129; scirrhous, 128. Carbuncle, 63. Caries, 234; treatment of, 241. Castration, 519. Chancre, 66. Cheek, wounds of, 381. Chopart's Operation, 269. Circocele, 516. Cold, effects of, 112; local anaesthesia by, 114. Compression of the Brain, 361; epilepsy from, 367. Concussion of the Brain, 359. Cordee, 521. Corns. 123. Cranium, fractures of, 354; contusions of bones of, 353. D. Dessault's Bandage, 158. Dislocations, generally considered, 193; varieties of, ib.; treatment of, 195; of lower jaw, 198; of clavicle, 199; of humerus, 202; at elbow-joint, 203; at wrist, 206; of phalanges of thumb and lingers. 206; at the hip, 207; of pa- tella, 210; at the knee, 211; at ankle, 211; of the astragalus, 211; of the phalanges of the toes, 212; treatment of compound, 212. Ear, diseases of, 370; foreign bodies in, 373. Ecchymosis, 282. Ecraseur of M. Chassaignac, 125. Ectropium, 396. Emphysema, 424. Empyema, 425. Enchondroma, 136. Enterocele, 450. Entero-epiplocele, 450. Entropium, 396. Epiplocele, 450. Epistaxis, 391. Epulis, 406. Eresipelas, 54; vera, 55; pseudo, or false. 59. Eustachian Tube, catheterism of, 377. Exostosis, 233. Eyelids, wounds of, 3i>0; operations about, 395. F. Face, diseases, wounds, &c, of, 380. False Joints, 191; treatment of, ib. Femoral Hernia, 449; anatomy of, 4S1; operation for, 45S4; operation for ex- ternal, 487. Femur, fractures of, 174. Fingers, fracture of, 172; dislocations of, 206. Fistula, in ano, 502; mucous, 383; recto- vesical, 505; recto-A-aginal, 508; vesi- INDEX. 557 co-vaginal, 506: salivary, 381; intes- tinal, 473. Fore-arm. amputation of, 265. Fractures, generally considered, 137; treatment of, 145; of bones of the nose, 148; of malar bone and zygoma, 149; of upper maxillary bone, 150; of lower jaw, 150; of the vertebrae, 152; of the sacrum, 156: of the clavicle, 157; of the scapula, 160; of the hume- rus, 162 ; of the bones of the fore-arm, 166 j of the lower part of the radius, 169; of the bones of the carpus and meta-carpus, 171; of the phalanges, 172; of the os innominatum, 173; of the femur, 174; of the patella, 183; of the bones of the leg, 184; through the tarsal and meta-tarsal bones, 186. Fractures, compound, 1S7; comminuted, ib.; compound comminuted, ib.; treat- ment of compound, ib.; treatment of compound comminuted, 189. Frost-bite, 112. G. Gangrene, 31. Gastrotomy, 442. Gleet, 526. Goitre, 420. Gonorrhoea, 523; treatment of, 525; in females, 527 ; sequelae of, 52b. Gums, tumors on, 406 Gun-shot Wounds, 287; treatment of, 284. H. HEMATOMA, 123. Hare-lip, 398. Head, injuries of, 349. Heart, wounds of, 127. Hematocele, 518. Hemorrhage, treatment of, 302; treat- ment by ligature, 305; treatment by actual cautery. 309. Hemorrhoids, 494. Hernia, 449 ; causes of, 452 ; symptoms and diagnosis of, 554 ; reducible, 451; irreducible, ib.; incarcerated, ib. ; strangulated, ib.; internal strangu- lated, 452; differential diagnosis of in- guinal, 454; differential diagnosis of crural or femoral, 456; diagnosis of thyroid, 456; diagnosis of phrenic, ib.; general treatment of, 457; radical cure of, 459; symptoms of incarce- rated and strangulated, 460; treat- mentof incarcerated and strangulated, 462 ; operation for strangulated, 464 ; operation in general, ib.; special operations, 473 ; operation for ingui- nal, 474 ; operation for crural or fem- oral, 4^4; operation for umbilical, 489 ; other forms of, 490. Hernia Cerebri, 369. Hernia Pulmonalis, 425. Hip, disease of, 223; excision at, 227 ; amputation at, 275. Hospital Gangrene, 43. Humerus, fracture of, 161; dislocation of, 202. Hydrarthrosis, 216. Hydrocele, 510; congenital, 511 ; causes of, 512; diagnosis of, ib.; treatment of, ib. Hydrocele of the Cord, 512; treatment of, 515. Hyoid Bone, bursal tumor near, 419. Impotence, 528. Incised Wounds, 276. Inflammation, general consideration of, varieties of, &c., 1; products, conse- quences, &c. of, 9. Inguinal Hernia, 449 ; diagnosis of, 454 : operations for, 474. Intestinal Hernia, 450. Intestines, wounds of, 432; wounds of, in operation for hernia, 473; fistula of, after operation for hernia, ib. Iritis, syphilitic, 93. Ischiatic Hernia, 490. 558 INDEX. J. K. Jaw, excision of upper, 402 ; excision of lower, 406 ; fracture of lower, 150; immobility of lower. 401. Joints, diseases of, 213; wounds of, ib.; inflammation of synovial membrane of, 215; false, 191. Knee-joint, dislocations at, 211; exci- sion of bones at, 272; fractures involv- ing, 180. L. Larynx, wounds of, 414. Laryngitis, syphilitic, 91 ; treatment of, 103. Laryngotomy, 417. Leg, amputation of, 271; fractures of bone of, 174. Ligatures, 305. Lipomatous or Fatty Tumors, 126. Lips, affections, &c. of, 397. Lithotome Cache, 551. Lithotomy, 548. Lithotrity, 546 ; in females, 553. Lungs, wounds of, 424 ; hernia of, 425. Lymphatic Abscess, 24. Lymphatic. Tumors, 24. Malar Bone, fracture of, 149. Maxillary Bone, excision of superior, 402; excision of inferior, 406; disloca- tion of inferior, 198; fracture of infe- rior, 150. Meatus Externus, foreign bodies in, 373; occlusion of, 371. M. I Medullary Abscess, 234. 1 Morbus Coxarius, 224. Mortification, 31; varieties of, ib.; cau- ses of, 32; symptoms of, 33; treatment of, 36. Mucous Fistula, 383. Myringitis, 375. N. Njevi Materni, 313; treatment of,1 Nose, wounds of, 3S3: affections of, 344. | 385; polypus of, 3b»; correction of Necrosis, 235; treatment of, 241. deformities of. 393. Neuralgia of the Face, 382. | Nostrils, hemorrhage from, 391. Obstruction of the Bowels, 441. OZsophagus, wounds of. 415. Olecranon, fracture of, 166. Onychia, syphilitic, 103. Ophthalmia, gonorrhoeal, 530. Orchitis, 518 ; after gonorrhoea, 529. Oscheocele, 450. Osteitis, 231. Osteo-Chondrosis, 235 Osteo-Elkosis, 234. Osteo-Phyta, 233. Osteo-Pyosis, 233. Osteo-Sarcoma, 236. Osteosclerosis. 232. Osteo-Spongtosis. 232. Otitis, 370, 376. Otorrhoea, 370. Ovarian Cysts, 4. Ovariotomy, 4. Ozena, 385; syphilitic, 91. Palate, cleft, 411. Paracentesis, abdominalis, 434 : thora- cis, 427. Paraphymosis, 521. Parotid Fistula, 3*1. Patella, dislocations of, 210 ; fractures of, 1^3. Pelvis, fractures of bones of, 173 Penis, diseases, &c, of, 520. Perineal Hernia, 450, 490. INDEX. 559 Perineal Abscess, 523. Periostitis, 237 ; syphilitic, 92. Peritonitis, after operation for hernia, 470. Phrenic Hernia, 450; diagnosis of, 456. Phymosis, 520. Physic's Tonsil Clippers, 410. Piles, 494 ; treatment of, 496. Radius, fractures of, 166; fracture of lower portion of, 169. Recto-vaginal Fistula. 508. Sacrum, fracture of, 159. Salivary Fistula, 381. Sarcocele, syphilitic, 94. Sarcoma, 122. Scalds, 109. Scalp, wounds of, 349. Scapula, fractures of, 160. Scirrhus, 128. Scrotal Hernia, 450. Shoulder-joint, amputation through, 267; dislocations at, 202. Skull, collections on, 351; fractures of bones of, 354. Sloughing, 34. Snake-bites, 293. Spina-ventosa, 92. Starch Bandage, or the Immovable Ap- paratus, 186. Stings of Insects, 293. Telangiektasis, 313; treatment of, 344. Testicle, affections of, 518; operation for the removal of, 519; cystic degen- eration of, 515; syphilitic affections of, 94. Thorax, wounds, &c, of, 413. Throat, wounds of, 413; syphilitic affec- tions of, 90. Thumb, amputation of the meta-carpal bone of, 264; dislocation of phalanges of, 206. Thyroid Hernia, 449; anatomy of and operation for, 489. Tic Douloureux, 382. Polypus Ani, 499. Polypus Nasi, 384. Prolapsus Ani, 491 ; treatment of, 496. Prostate Gland, diseases of, 539; cal- culus in, 541. Ptosis, 397. Pus, 10. Pyaemia, 46. Recto-vesical Fistula, 505. Rectum, congenital malformations of, 508; stricture of, 500. Stomach, wounds of, 432. Stricture of Anus and Rectum, 508; of urethra, 532. Suppuration, 10; local effects of, 13. Sutures, 280. Synovitis, 215. Syphilis, 65; primary, 66; consecutive, 79; secondary, 84; in infants, 94; di- agnosis of primary, 69; treatment of primary, 70; treatment of consecu- tive, 80; diagnosis of secondary 86; aetiology of secondary, 95; prognosis of secondary, 99; treatment of second- ary, 101. Syphilitic, enlargement of the testicle, 94; eruptions, 88; iritis, 93; nodes, 92; periostitis, 92; onychia, 103; or- chitis, 92; osteitis, 92; sarcocele, 94; ulcers, 89; warts, 80, 89. Tonsils, hypertrophy of, 408; excision of, 409. Torsion of Arteries, 309. Trachea, wounds of, 414. Tracheotomy, 417. Trephining the Skull, 365. Tubercular Syphilitic Sarcocele, 94. Tumors, 112; innocent, ib.; adipose, 126; atheromatous, 117; bursal, 121; com- pound cystic, 122; encysted, 116; fat- ty, 126; fibro-cellular, 126; fibrous, 127; haematomatous, 123; mucous tu- bercle, ib.; pilo-cystic, 122; sarcoma- tous, ib.; warts, ib.; wens, ib.; ma- R. S. T. 560 INDEX. lignant, 127; alveolar, 129; colloid, ib.; encephaloid, 12S; epithelial, 129; medullary, 128; melanotic, 129; scir- rhous, 128; semi-malignant, 134; car-1 tilaginous, ib.; cheloid, ib.; enchon- dromatous, ib.; fibro-plastic, ib.; ma- lignant fibrous, ib.; recurrent fibroid, U. Ulceration, 24. Ulcers, 25; treatment of, 27; fungous, 29; catamenial, 30. Umbilical Hernia, 449; anatomy of, 487; operation for, 489. Union of Wounds. 277. Uniting Bandage, 167. Urethra, stricture of, 532; abscesses in, 523. Urethritis, 522. Urinary Bladder, calculus in, 542; punc- ture of, 437. Uvula, elongation of, 411; excision of, ib. Vaginal Hernia, 450. Varicocele, 516; treatment of, ib. I Ventral Hernia, 450, 490. I Vesico-vaginal Fistula, 506. W Warts, 122; syphilitic, 80, 89. Wens, 122. White-swelling, 216, 221. Wounds, 275; simple incised, 276; pro- cess of healing, 277; treatment, 279; contused and lacerated, 2b2; punc- tured, 285; tetanus from punctured, 2S»1; gun-shot, 2S7: treatment of gun- shot, 290; poisoned, 293; from rabid animals, 295; poisoned, from farcy and glanders, 297. Wrist, amputation at, 264; dislocation at. 206.