i ■••NB-i. ^fz%&. ■ ?yy-'-**x?i. * "jWs ■. i '^^a^T Nbxft/ &^/y(£k/ XBoston , MedicXv Library AssociaMon, 19 BOYLSTON P^ACE Received' "Fhr: rfift- r*f SURGEON GENERAL'S OFFICE LIBRARY. Section, ,-------------------- X T M 1 ^yicl^x -K- U^&* Fig. 3. Fibro-plastic cells, of various sizes and degrees of development. Fig. 2. Cells which are de- veloping into fibres. Those marked X a, have been treated with acetic acid. Traced with the camera from actual specimens from granulations, healing wounds, and fibro-plastic tumors, magnified 200 dia- meters. The scale of .001 inch will give an idea of the real magnitudes. As their development proceeds, they elongate, and split up into fibrous tissue. The destination of the nuclei is uncertain. general doctrine of repair. 51 These cells will often be spoken of in the following pages as fibro-plastic cells. They are formed in abundance, as we shall presently see, in all the less perfect examples of repair. They are found as some of the commonest results of inflammation. They constitute granulations. They also consti- tute the basis of most tumors and morbid growths. They are liable to de- generate into pus. And when diseased or perverted they may be supposed to constitute the material of cancerous tumors. But be it observed that although these cells are evolved under certain conditions out of the exudation which takes place during inflammation, yet that the absence of inflammation is essentially necessary before they can assume their full degree of development into tissue. Blood organizable, yet not the ordinary material of repair.—In a less perfect state of knowledge it was supposed that the blood was the common medium of reparation. We now know that this is not the case; that effused blood is a hindrance rather than a help; that the clot which is effused from an injury is absorbed before the work of repair is perfect; and that if clots of blood be present in large quantity they are apt to lose their vitality, and to cause suppuration. Yet it is quite true that thin clots of blood, under certain circumstances, are capable of undergoing a change into a fibrillated material similar to the nucleated blastema, and of receiving bloodvessels. Mr. Prescott Hewett showed, some time ago, that thin layers of blood effused into the cavity of the arachnoid may become vascular; it was also proved by Hunter, Macartney, Kiernan, and Dalrymple, that clots are capable of receiving bloodvessels.1 Formation of new vessels.—Twenty years ago, nothing was supposed to be organized which had not bloodvessels : and to become vascular, and organized, were used as convertible terms. Now, however, we know, as, in fact, was known but not reflected on before, that bloodvessels play a sub- ordinate part; and that organization proceeds to a certain point before they appear on the stage: yet that they are necessary at a certain epoch, in order that the material for fresh growth may be brought within reach. The readiest way for the student to watch the formation of new vessels will be to examine the lymph found on the edge of a placenta. There he may see the results of the process described by Paget, the budding out of branches from the nearest capillaries, which branches enter the developing lymph, and inosculate with each other, so as to form loops: from which, again, fresh loops are directly given off in like manner. The time within which repair is effected varies as greatly as the nature of injuries and of ages and constitutions. But vascularity, or propulsion of new bloodvessels into a new fibrinous exudation, may occur certainly in less than forty-eight hours, whilst in the progress of granulation, the layer of lymph effused in one day appears to become vascular by the next. Conditions favorable for repair, and the reverse.—1. In the first place, bearing in mind what has been said of the exhaustion of power of develop- ment it is evident that, cseteris paribus, the younger the system, the more capable is it of repair. 2dly. The state of the blood may be so poor as not to yield the necessary material; or it may be so overloaded with ill-assimi- lated material, or so poisoned, that the lymph effused is ill capable of de- velopment, and runs into degeneration. 3. Local conditions may be such as to afford mechanical or chemical complications. The effused matter if disturbed may perish, or if exposed to air or to poisonous influences, may undergo degeneration into pus, which may infect the whole blood. In i VidP Palmer's ed. of Hunter, vol. iii.; Catalogue of the Hunterian Museum, vol. i.; Carswel, op. dt. Macartney, op. cit. p.' 51; Home, Phil Trans. 1818; Wardrop on Siin the Cyclop. Pract. Surgery; Dalrymple, Med. Chir Trans, vol. ix.; P. Hewett^id. vol. x.; see also Lancet for 1845, vol. i. p. 219 ; Paget's Lectures, vol. i. 52 inflammation. general terms, whatever favors inflammation is hostile to repair, and the converse. Injuries with wound of skin, and without.—Here we are discussing gene- ral principles; in their proper place we shall say more of the specific instances of repair. Meanwhile we may divide cases into two great cate- gories—those attended with wound of skin, and those without; and state how infinitely more dangerous and difficult of repair the former are, as evidenced by compound fracture and dislocation, and by wounds of the great visceral cavities, compared with the severest bruises and simple fractures. The reason of the difference is the fact, that exudation exposed to the air and contact of the outer world is more liable to perish, and, having perished, to run into unwholesome changes, which may spread over the whole internal surface injured. It is a principle derived from this fact, that wounds of the skin are to be avoided when possible, and, when unavoidable, are to be as limited as possible : and that the subcutaneous method originally used for the division of tendons should be extended to every case admitting of it.1 In other parts of this work we describe the repair of abscesses and ulcers by granulation and cicatrization; the repair of wounds, of fractured bones, and of divided tendons. CHAPTER VI. inflammation. section i.—introductory. Definition.—A perfect definition of inflammation is at present impossi- ble, forasmuch as we are ignorant of many of its conditions, and are not even agreed upon the processes which shall be included under the term. Perhaps we may say that it is "a diseased process, including hyperaemia, stagnation of blood, and exudation." It is a very complex process, in which the state of the constitution, and of the blood, and the state of the part affected, require to be carefully analyzed in their relations to each other. Symptoms.—The classical symptoms are four—pain, heat, redness, and swelling; to which ought to be added, impaired function of the part in- flamed. Besides, there is feverishness with every true acute inflammation. section ii.—analysis of local symptoms. 1. Pain or dis-ea.se is sure to ensue when anything in the animal economy goes wrong, and the varieties it presents in inflammation require careful study. Thus (a) it may vary with the local cause which has produced it: thus patients talk of cutting, burning, stabbing pains. Every idiopathic inflammation also has its own kind of pain. The exudation of boil or car- buncle causes a different pain from that of phlegmon. 6. Then the pain will vary with the part inflamed; for each part has a set of sensations peculiar to itself; the bones and ligaments ache ; the skin smarts or burns; an inflamed pleura, when stretched, feels as if, torn or stabbed ; the inflamed ear hears unnatural sounds. 1 Sketch of Subcutaneous Surgery, by W. Adams, F. R. C. S. Lond. 1857. Refer to Tenotomy, False Cartilage, Bursae, and Hernia. [See also Gross, op. cit. vol. i. chap, xvi.] inflammation. 53 c. Inflammatory pain is aggravated by preternatural irritability, or re- ceptivity of impressions ; thus tenderness is created :—unusual reflex actions also are excited by impressions conveyed to the spine, and spasms are ex- cited, which are so painful a feature in conjunctivitis, croup, and dysentery. d. The intensity of the hyperaemia causes the throbbing of the vessels to be painfully felt; particularly in inflammations of dense, unyielding parts, or of parts confined by fascia. e. Distension by exudation causes intense pain in the like cases. f. Pain may be felt at a distance, along the course of nerves irritated. Thus the testicles ache in irritation of the bladder. Similarly, pain may be felt along the course of lymphatic vessels and glands if they are impregnated by the inflammatory exudation. g. Lastly, pain may be absent in slight cases. Moreover, it must be re- membered that pain is a subjective symptom, and exists in the consciousness of the patient; and though the conditions for it exist, it may not be felt if the nerves ar» severed, or the brain stupefied by disease, alcohol, or narcotics. 2. The heat of inflammation is a direct consequence of hyperaemia. It is in great measure a sensation, and chiefly felt in inflammations of surfaces; but (as Hunter showed) as an inflamed part receives more blood, so it is hotter than other parts; but yet it is not hotter than the mass of the blood. 3. The redness is another conseguence of the hyperaemia, and its appear- ance depends, in some degree, on the natural arrangement of the vessels of the part; thus, inflammation of the conjunctiva differs in appearance from that of the sclerotic. But it is still more influenced by the cause of the in- flammation : thus the vivid blush of phlegmon, gradually fading into the natural hue, differs materially from the abrupt red, dusky patch of erysipelas. Moreover, the color is often modified by blood exuded into the inflamed part, as in boil and erythema nodosum; or by a peculiar condition of surface, as in syphilitic lepra : so that almost every inflammation has its own color ; and one—the phlegmasia alba dolens—is remarkable for having no color at all. 4. The swelling is caused first by the hyperaemia, then by matters exuded into the inflamed tissue. These may be hard and brawny as in carbuncle, or soft, so as to allow the pressure of the finger to make a pit. 5. That inflammation must impair function is obvious. Motion is difficult or impossible ; sensations exaggerated ; and secretion diminished, and mixed with serum or fibrine. section hi.—analysis of constitutional symptoms—traumatic, or symptomatic fever, or feverishness. The word fever is now so wedded (although very improperly) to certain species, as typhoid and typhus, that perhaps it is better to use the word pyrexia, or feverishness, to express the sum of the constitutional symptoms attending acute inflammation. The relation of the constitutional symptoms to the local may be one of these three i__ 1. The constitutional symptoms may precede and cause the local: as in common idiopathic inflammations, erysipelas, pleurisy, pneumonia, &c. 2. The. constitutional symptoms may follow and be caused by the local; when the blood circulating through an injured part becomes contaminated by decaying animal matter, or by the irritation of the nerves ; as in the case of acute inflammation following an ill-closed and irritated wound. 3. The constitutional having been caused by the local malady, may again be the cause of other local diseases elsewhere—as in pyaemia, and secondary suppurations. , Fever consists, as may be proved by experiment and by reason, (1.) in a 54 INFLAMMATION. change of the blood : (2.) in a series of operations for purifying the blood so changed ;—by increased oxygenation—by increased secretion—and by exudation—or by all three. Symptoms.—1. The first in order of time is shivering ;—trembling of the muscles, sensation of cold, and, in severe cases, blueness, and shrinking of the features, and the other signs of abstraction of heat from the body. Its real nature is unknown ; but the student will do well to regard shivering as a most important symptom at any stage of any disease, inasmuch as, to use Hunter's words, it surely indicates "some new action set up in the blood." Vomiting is sometimes combined with it. 2. The pulse is raised to 100, 120, or more. In some cases it is hard and wiry ; in others soft and jerking. 3. The respiration is also increased—to 25 or 30 in adults : in children to twice that number. 4. The heat is raised to 102—104 degrees ; in some cases probably higher. 5. All the watery secretions—of skin, mouth, and urine—afe suppressed. Food is loathed, but acids and water craved for. 6. Headache, wandering at night, and lassitude, testify to disorder of the nervous system. T. The urine shows remarkable changes. Before an idiopathic inflamma- tion it is often pale, and during the height it is usually scanty and high- colored—at the close, copious, and turbid with sediments of lithates. * There are some exceptions to this, inasmuch as the increased excretion of lithate may begin before the disease, and cease earlier. During the height of acute inflammation, it is often albuminous—it contains serum from congestion of the kidneys, and tubular casts. Speaking generally, the uric acid, extrac- tive matters, and specific gravity of urine are greatly increased during acute inflammation. The sulphates are at or above the usual average: the chlo- rides greatly diminished. The diminution of the chlorides in the urine, which had long been known on the Continent, was introduced to the English profession, and the amount of facts greatly increased, by the researches of Dr. Lionel Beale, who has shown that every process of rapid development by cell growth in health or disease requires the presence of large amounts of chloride: (the ash of a foetal thigh-bone, for example, contains much more per cent, than that of an adult) ( and that when any diseased process of exudation and cell growth is set up, the salt is withdrawn from the blood and urine, and is present in the infiltrated tissue.1 8. That the state of the blood is peculiar during acute inflammation is proved by the fact that when drawn its surface is almost immediately covered with a bluish layer, like size : whence inflammatory blood was formerly called sizy. So soon as the blood has coagulated, this layer is visible as a yellow- ish-white stratum on the surface of the red clot; and as it generally contracts so as to make the upper surface of the clot concave, the technical terms buffed and cupped have been applied to this kind of blood. Various theories have been proposed to account for this: for example, slow coagulation, so that the red particles have time to sink and leave the upper surface of the clot colorless ; and increased attraction of the red particles for each other, so that they form themselves into a network of rouleaux, and sink with unusual rapidity: this is the view of Mr. Wharton Jones. Slow coagulation undoubtedly exists in most cases of inflammatory blood, and on Dr. Richardson's theory* that ammonia is the solvent of fibrine 1 Franckel und Ravoth, Uroscopie, Berlin, 1850; Beale, Med. Chir. Trans. 1852; Simon, Animal Chemistry, vol. ii. 2 See W. Hewson's Works, a medical classic that well deserves study; Wharton Jones, Guy's Hosp. Rep. vol. vii. N. S. ; Richardson on Coagulation of Blood. Lond. 1858. INFLAMMATION. 55 in blood, the slow coagulation may depend on excess of the solvent, or on slow evolution thereof. Besides, there may be an absolute excess of fibrine: and it must be remembered that, besides fibrine, the white particles of the blood sometimes constitute a great part of the buffy coat; and that the fibrine is supposed to be in a highly oxidized state—deutoxide or tritoxide of protein. The chemical composition of inflamed blood differs, according to Ancell, Simon, Becquerel, and Rodier, from that of healthy blood, in a diminution of the red particles and an increase of fibrine ; which last condition is now commonly designated hyperinosis, which signifies over-fibrination. Bec- querel and Rodier state, that in the phlegmasiae the fibrine is increased invariably ; that the increase begins with the beginning and lasts to the end, and is proportionate to the intensity of the inflammation; that it is present whether inflammation be the sole disease or be an accidental complication; that blood-letting does not lessen its over-proportion. Most authorities agree, too, that the hyperinosis is in some way connected with excessive oxidation of the blood; although Becquerel and Rodier believe it to be produced by an oxidation of the albumen; and Simon by an oxida- tion of the blood corpuscles. Hyperinosis is, as a rule, present in all acute inflammations; everything that ends in itis—bronchitis, pneumonia, carditis, peritonitis, and the like ; in acute rheumatism, especially; also in erysipelas, puerperal phlebitis, phlegmasia dolens, tubercular phthisis, and in pregnancy. The proportion of fibrine may be increased from about 2.5, the normal proportion, to 5, 7, or 10 grains per 1000. In typhus fever, typhoid, and the exanthemata, an opposite state exists, called hypinosis. section rv.—minute anatomy of an inflamed part. An inflamed part has a large quantity of blood intruded into its vessels; and its tissues and their interstices are infiltrated with liquids which have exuded from those vessels. If examined after death, it is softer than a similar sound part, for the hardest tissues seem to lose some of their cohe- sion. It is also redder, although mere redness, post mortem, is no proof of inflammation, for it may be produced by congestion or by a staining of tissues with dissolved blood pigment which has oozed out of the vessels in incipient putrefaction. The tissues involved in an inflammatory exudation (as in cancer and every other exudation) always show signs of " fatty degeneration," inasmuch as their true structural markings are confused, and they are in- filtrated with minute globules of oil, and soon are Cable to be Fig. 4. liquefied and absorbed. In articular cartilage, the cells, as Dr. Redfern has observed, are enlarged, and the intercellular substance split up. Besides this, they are greatly influenced by the changes which take place in the exudation, whether towards development or degeneration. If a fibrinous exu- dation becomes organized, the proper tissue of the part is starved as vegetables are by weeds. If it soften into pus, they become liquefied with it. Microscopical Observations.—Many, attempts have been Porti0]1 of mus made to see the exact phenomena of inflammation, after they cleinvolvedinin. have been excited by irritants applied to the transparent parts flammatory exu- of animals__a thing difficult of attainment, because it must be dation; fatty de- difficult to distinguish between the chemical effects of an irri- generation of the tant on the blood and vessels, and the genuine effects of in- S^^J^ flammation. But the following particulars may be gathered plastic matter._ from the researches of Mr. Paget and Mr. Wharton Jones. From nature. 56 inflammation. 1. The primary effect of a slight stimulus applied to the bloodvessels, is a slight and temporary contraction, with a retardation of the current through them. If the point of a fine needle be drawn across a minute artery and vein three or four times, without injuring them or the membrane cover- ing them, they will both presently gradually contract and close. This con- traction is no doubt analogous to the speedy closure of the innumerable small vessels divided in a wound, which are made to contract by the very stimulus of the instrument which has divided them. 2. During this contraction, the blood moves more slowly, or perhaps does not move at all. But when the vessels dilate again, they acquire a larger size than they originally had, and the blood moves more freely and rapidly through them than it did before. And now the same stimulus that made them contract at first has no effect, or a very transient one ; a more power- ful stimulus, however, may make them again contract and close. On applying a more powerful irritant, such as a drop of tincture of capsi- cum, the preliminary contraction, if it occur at all, is so transient as to be hardly perceptible, but the phenomena of active congestion or determination of blood become instantly developed. The bloodvessels become rapidly dilated, lengthened, and tortuous ; sometimes even they display varicose or aneurismal excrescences; they are tensely filled with blood, containing a large excess of red globules, which is circulated with far greater velocity than is natural. 3. But if the injury inflicted be of still greater severity, as a wound with a red-hot needle, then in addition to the preceding state of active congestion, there follows, in the very focus of the morbid changes, a retardation, and, at last, a complete stagnation of the blood in the densely-crowded capillaries. "All round this focus the vessels are as full, or nearly as full, as they are in it; but the blood moves in them with a quicker stream, or may pulsate in the arteries, and oscillate in the veins ; yet farther from this focus the blood moves rapidly through turgid but less full vessels." The dusky color in the centre of a phlegmon; the throbbing; the red blush around; the gush of blood on cutting into it, are thus fully explained. The exudations which are poured into an inflamed part may be, 1, blood, by rupture of distended capillaries ; 2, liquor sanguinis, which then separates into serum and fibrine ; the fibrine being attracted to the focus of the inflam- mation, and the serum infiltrating the parts around; 3, serum alone; 4, fibrine alone. SECTION V.—PROGRESS AND TERMINATIONS. Inflammation, once established, may destroy life, either by impeding the functions of some organ necessary to life, as the heart, lungs, or brain ; or by quick exhaustion or syncope, as in inflammation of the abdominal organs; or by slower exhaustion, from suppuration. Or it may end in complete subsidence {resolution, as it is technically called) and recovery, provided that the blood be purified from all source of morbid exudation; and that local irritation be done away with. Then sleep, appetite, and moisture of the skin return ; the pulse becomes natural; and the urine deposits a copious brick-dust or lateritious sediment of lithate. As to local changes. The first effect of inflammation on the tissues is probably an exudation of serum. This is succeeded by liquor sanguinis, the fibrine of which becomes solid, constituting the material of the adhesive inflammation. Here one of three things may happen. (1.) The inflamma- tion may cease, and the exudation be absorbed ; or (2.) the exudation may remain and develop itself into fibro-plastic matter or adhesions; or (3.) it may soften into the liquid called pus. Thus we can understand the Hunterian theory of the different effects pro- INFLAMMATION. 51 duced by differences in the intensity of inflammation, which decreases as the distance from the centre increases. Thus at the outskirts of an inflamed part there will be a ring of serous effusion or oedema: within this a solid layer of fibrine, which forms a sac, within which is pus, formed by the soften- ing of the central fibrine. If to the serous effusion, adhesion, and sup- puration, thus present, we add hemorrhage (for there is always some, often much blood extravasated in acute inflammation), and gangrene, or the death of some of the tissues involved, and ulceration, or a process of disintegration by which pus is discharged, we have the six processes commonly called termi- nations, or effects of inflammation; although, be it observed, every one of them singly may occur quite independently of inflammation. SECTION VI.—CAUSES AND VARIETIES OF INFLAMMATION. The Causes are of two kinds—constitutional and local, of which the former deserve precedence, inasmuch as, without appropriate blood material, no inflammation can be perpetuated. 1. The constitutional causes may be of the most opposite kind, although they all have the common property of rendering the blood impure. Excess in meat, wine, and stimulating food ; and deficiency of food ; inactivity and respiration of close air; or over-exertion and fatigue ; imperfect action of the liver, kidneys, and skin; and great exhaustion of mind ; besides the poisons of decaying animal matter in various stages, and animal or zymotic poisons. Cold, continuously applied, may disorder the whole blood, and bring on an idiopathic inflammation, or may cause inflammation of the part chiefly subjected to it. 2. The local causes are injuries of all kinds, whether from within, as over- exertion and excessive wear and tear, or from without, as mechanical and chemical injuries of all sorts. But, as we have before said, injury is not of necessity followed by inflammation : on the contrary, repair may go on quietly, unless the blood of the injured person be in a state inadequate to furnish healthy reparative material, or unless the injury be such as to destroy the life of certain tissues (as poisoned wounds) ; or unless the processes of repair be rendered difficult by the kind of wound (as an open jagged wound that cannot be closed), or by ill treatment, such as interferes with the exuded matter and hinders its development. The Varieties of inflammation depend on the cause, and on the kind of constitution conjointly. Thus we read of Sthenic or active inflammation, which is the disease as it affects a vigorous person. Asthenic, or low, or weak, which is the disease of a weak, asthenic person: or which may be produced by certain causes of a lowering nature, as hos- pital air, and other poisons. It is more obstinate and less amenable to treatment than the active or sthenic. Common inflammation is that which may be produced by ordinary causes in most individuals. Specific inflammation requires a specific set of causes, chiefly animal poisons, or a peculiar state of blood. The chief specific inflammations are gout, rheumatism, syphilis, gonorrhoea, erysipelas, phlegmasia dolens, glanders, and pyaemia ; croup and diphtherite; boil and carbuncle; erythema nodosum, eczema, lepra, and most skin diseases. And every variety of cause produces its own train of consequences. This point is very clearly stated by Dr. Budd.1 Take inflammation of the knee- 1 On Diseases of the Liver, 2d ed. Lond. 1852, p. 65. 58 THEORY OF INFLAMMATION. joint for an example. If caused by a penetrating wound, with admission of air, rapid suppuration and destruction of the joint usually follow. If caused by the presence of pus or decaying fibrine in the blood, there will be little swelling, but suppuration so rapid as to encourage the belief that the pus, instead of being formed in the joint, is brought there. If caused by rheuma- tism, there is severe pain, and much effusion; but that effused fluid is never purulent, and is almost always absorbed as the patient recovers. If of gouty origin, there is more pain and considerable effusion, which is apt to leave particles of lithate of soda behind in the synovial membrane, and in the areolar tissue around. If a consequence of gonorrhoea, there is abund- ant effusion, and great swelling, very difficult to get rid of. Sthenic inflammation is generally circumscribed, and most intense at one central point. Asthenic inflammation, especially from poisons, is often dif- fused, i. e. wide spread, with no efficient boundary to the softened exudations. Moreover, every cause which produces inflammation through the blood, seems to have its own favorite seat; the poison which causes measles will not cause croup nor chicken-pox; gout affects the great toe by preference, erysipelas the scalp. Yet there are certain local predisposing causes, which, cseteris paribus, render some parts more liable than others to be the seat of inflammation. Thus if any joint have been injured or overworked it is more liable to be the seat of gout. There are yet some other classifications of inflammation with which the student ought to be familiar; for example : Acute inflammation is that which runs through its course quickly; subacute is a mitigated acute inflammation; chronic is less violent, and tends to last indefinitely. We read also of oedematous, adhesive, hemorrhagic, ulcerative, and gan- grenous inflammation, according as the disease tends to produce either of those effects respectively. Lastly, in the pathology of thirty years ago, it was customary to suppose that the effects of inflammation depended on the part affected ; thus we heard of mucous, serous, and fibrous inflammation; and much was made of an alleged final cause, in the fact that mucous membranes generally suppurate if inflamed, and that serous membranes generally adhere by lymph. This is true ; but it is not true that the exudation of lymph from mucous surfaces is impossible or rare, although the rapid production of fresh layers of epithe- lium or pus tends to cast it off and prevent it from becoming organized; and thus the obstruction of mucous canals is prevented. SECTION VII.--THEORY OF INFLAMMATION. Physicians have in all ages wished for such an intelligible conception of the process as would enable them to connect it with the other classes of facts of which they have scientific knowledge. But it is quite certain that we can have no clear conception of disease till we understand health ; and that all the theories of inflammation that have been framed are, for the most part, preconceptions in the mind of the theorizer, who merely applies to the phe- nomena such philosophy as he may have. Thus in the time of the ancients, when the arteries were believed to hold air, it passed for a decent theory of inflammation to assume that blood had found its way into them, as Celsus narrates. In the earlier humoral pathology, ill-humors of various sorts were supposed to fall upon the organs affected. The words defluxion, gout, and catarrh, are relics of this theory. Mathematical physicians of the school of Mead supposed the vessels obstructed by aberrant particles whose size and shape would not allow them to pass. Hunter and his school spoke of inflammation as excited action of bloodvessels. The earliest microscopists ACUTE INFLAMMATION. 59 of the present century, Wilson Philip and Hastings, saw in the dilated and gorged vessels nothing but relaxation, debility, and want of action. Whilst the doctrine of action of bloodvessels was prevalent, Gendrin, Mayo, and others showed elaborately how the successive stages of inflammation were so many mechanical consequences of different degrees of obstruction or re- laxation of bloodvessels. The school of Liebig saw in it increased oxidation. The modern explorer of the blood sees in it the results of hyperinosis, or other changes in that liquid. The modern microscopic physiologist sees abnormal conditions of nutrition and of attraction between the blood and tissues. Then it must be noticed, that the search for a theory has been like the search for the philosopher's stone, or for the Grand Arcanum; when found it was to be a key to all difficulties, and to show the right plan of treatment. He who believed increased action to be the essence of inflammation, of course drained the bloodvessels, starved the stomach, and used every poison capable of "lowering the heart's action." He who saw debility in the distended vessels proposed stimulants. He who sees oxygenation of the blood, pro- poses remedies calculated to diminish oxidation. One theorist proposes remedies that shall hold fibrine in solution, and so on of the rest. But each of these suppositions may be true to a certain extent: there may be increased action of the arteries, debility of the capillaries, increased oxygen- ation of the blood, and perversion of nutrition ; but yet these are but acci- dents and accompaniments of a process whereof we are not able to grasp the essence. He only who knows and sees all things can frame a perfect theory. Yet as a reasonable being can scarcely help framing to himself some ex- planation of processes which he sees (although to a wise man a theory is a thing to use, and abandon when worn out, not to be enshrined as an idol), so we may be expected to give some probable explanation; and the best we can frame is this :— Idiopathic inflammation is the formation of a temporary organ of elimina- tion whereby the blood separates from itself some noxious matter, which is poured into the inflamed part with the inflammatory exudations. The blood meanwhile undergoes a process of oxygenation, whereby spoiled material is reduced to a state fit for elimination by the liver and kidneys; and if that be quickly accomplished, local mischief ceases. Traumatic inflammation is caused by changes which take place in the injured part; the blood (perhaps unhealthy to begin with) becomes changed by decaying blood or exudation at the injured part, which has been incapable of, or prevented from, developing itself; or else through the operation of pain and irritation of the nervous system. SECTION VIII.—ACUTE INFLAMMATION. Definition.—Acute inflammation is that which is sudden in its origin, violent in its action, and rapid in producing some one of the so-called effects of inflammation ; and it is attended with fever. We may observe, at the outset, that the surgeon should always estimate the natural tendencies of the particular kind of inflammation, the cause that it depends on, and the organ which it affects. He should consider the necessity which there is in some cases, of immediate relief, in order to save life whilst in other cases the disease tends to run a certain course, and then decline of itself; and the possibility there is, in some cases, of removing the disease entirely, in others, of only mitigating it. Treatment —Generally speaking we should say that the indications are, 1 To remove the cause. 2. To eliminate from the blood the source of morbid effusion 3. To allay and .soothe the disturbance of vitality and 60 ACUTE INFLAMMATION. sensibility in the injured part. 4. To moderate the afflux of blood. 5. To hinder degeneration in the fluids exuded, and procure their absorption. We shall proceed to speak in this order of the means by which each in- dication may be fulfilled. 1. To remove causes.—The taking away of any irritating substances, such as thorns and splinters, and placing every injured part under such conditions that the reparative exudations shall not be disturbed, are so obviously necessary as to require no mention. 2. To purify the blood.—In most cases, and more especially if the com- plexion is muddy, the bowels confined, the tongue foul, the urine either loaded or preternaturally pale, a dose of from one to five grains of calomel may be given, and followed by black draught, castor oil, colocynth, or some other purgative, and repeated so long as the stools continue lumpy, dark, bilious, and offensive, or until they are inodorous and serous. In gouty cases, the acetic extract of colchicum may be combined with the calomel. See F. 33, et seq. The kidneys and skin may most usefully be made to perform their functions by warm baths ; by cold, saline, and alkaline draughts, F. 58, lemon-juice, Seltzer-water ; by small doses of antimony, or of colchicum, F. 68, 69, &c. 3. To allay the irritation of the affected part.—This is a most important indication in the prevention and treatment of inflammation. All pain and sense of injury should be tranquillized if possible. For this purpose, in most cases, warm fomentations are advisable, particularly if medicated with de- coction or extract of poppies, F. 121. Warm fomentations (96°—98° Fah.) relax the skin, soothe pain, and promote perspiration, and likewise hasten suppuration when that is inevi- table. They are especially indicated in inflammations of dense tendinous parts. But in every case the patient's feeling should be consulted, and the application be warm or cold according to his choice. Injured or inflamed parts should be kept at rest, in an easy position, and should be elevated slightly, so that the return of blood may not be hindered. To fulfil this indication, opium and other anodynes are of the greatest value. They should be given after injuries and operations, in such quantities as to keep the mind tranquil, and prevent the patient from concentrating his whole thoughts upon the part affected. They tend to diffuse the blood generally, and to prevent local congestion, and they save the exhaustion of pain and spasm. In most cases of acute idiopathic inflammation it will be expedient, before administering opiates, to take care that the blood is well purified ; and whenever bleeding is necessary, that also should be executed first of all. But in inflammation of the bowels, in which repose is essential, in low inflammation arising from morbid poisons, or in exceedingly debili- tated or exhausted states, with a soft, rapid pulse, it is of infinite service, and may be given at once. Henbane, hemlock, and the extracts of aconite and belladonna, are likewise of great use in many cases as anodynes, and though they have not the soporific virtues of opium, yet neither do they lock up the bowels. Vide F. 30, 32. 4. To moderate the afflux of blood.—Since the determination of a large current of blood to the affected part, and its stagnation therein, are leading phenomena in acute inflammation, it cannot be wondered at that means for controlling this afflux are of the very highest consequence. First among these stands— Bloodletting.—A measure life-giving in its proper use, and deadly if abused. Its benefits may be explained on any theory. By diminishing the mass of blood, it lessens the labor of the heart and lungs, and allows the remaining blood to be" oxygenated and purified by natural influences. It diminishes the rush of blood to the inflamed part, and allows distended ACUTE INFLAMMATION. 61 venous capillaries to empty themselves. It decreases the specific gravity and increases the absorptive power of the blood; it promotes the action of the skin and bowels; and it imitates the spontaneous hemorrhage by which nature often gives great relief. Manner of Bleeding.—General bleeding should be executed in such a way as to cause slight faintness as quickly as possible. For this purpose the blood should be drawn as quickly as possible, from a large orifice ; and, above all, the patient should sit or stand upright. For if the blood is drawn slowly, so that the vessels have time to adapt themselves to their diminished contents, or if the patient is lying down, so as to assist the flow of blood to the brain, the bleeding may be continued almost to death without the occur- rence of faintness. Quantity to be taken.—As a general rule, the blood should be permitted to flow till paleness of the lips, lividity about the eyes, sighing, nausea, fluttering pulse, and relief of the pain, indicate the approach of faintness; but full faintness should always be avoided. The quantity required to produce this effect, on a healthy adult, was ascer- tained by Marshall Hall to be about 15 oz.; but in robust adults affected with acute inflammatory or congestive attacks of the head or viscera, a greater quantity may be taken. - The class of patients whom it is allowable to bleed, as a general rule, are the robust with red lips, firm muscles, rustic open-air occupations, firm pulse, and rigid fibre. If the lips and conjunctiva are pale, showing de- ficiency of blood; if the patient is bulky, soft, and flabby; if there is any weakness or degeneration of heart; or if there is any continuous disease of assimilation—scrofula, Bright's disease, or the like—bleeding can scarcely be thought of. The class of inflammations in which bleeding is permissible are those of sthenic inflammation of vital organs. It is not allowable, as a rule, in the hypinotic class of maladies, nor in erysipelatous diseases; nor in the case of injuries requiring great constitutional efforts for their reparation, as com- pound fractures; nor if the disease be advanced towards suppuration or gangrene ; and very seldom indeed in the case of any zymotic disease, or inflammation having a natural tendency to recovery. Local Bloodletting.—Whilst it must be admitted that in a past gene- ration general bloodletting was carried to an injurious excess, in the present day it is to be feared that local bloodletting is too much neglected. It is a most obvious, rational, and mild process; and it imitates and seconds the efforts of nature by removing some of that blood which may be assumed to be impure, and by taking it from the part where it is in excess. The local means of abstracting blood are leeches, cupping, and scari- fications In order to apply leeches, the part should first be washed, and if they wiU not stick, a little milk or blood should be smeared on it, or some small punctures.should be made with the point of a lancet; and the leeches should be well dried in a cloth. The best plan of stopping hemorrhage from leech-bites is to dip small pellets of lint in the tinct. feci sesqui- chloridi and press them on the holes for a few minutes. Other plans are to pinch up the skin and insert a finely-pointed pencil of lunar caustic into them to touch them with a red-hot knitting-needle, or to stitch them up with'a very fine needle and silk, or to apply a small piece of matico leaf. But in order to prevent the very serious consequences that sometimes hap- pen from this source to children and delicate persons, directions should alwavs be given that the bleeding from leech-bites should be stopped before the patient is left for the night. Moreover, it will be prudent-to apply them over some bone, so that the pressure may be applied effectually. Again leeches if they stick too long, should be removed by touching them 62 ACUTE INFLAMMATION. with salt, and should not be pulled off forcibly; nor should they be applied to the eyelids or prepuce, otherwise they will probably be followed by oedematous swelling. [In the last American edition of this work, the editor, Dr. Sargent, here calls attention to the fact, that the bite of the American leech is less severe than that of the Spanish and Swedish leeches, and pro- tracted bleeding is less likely to follow it. As a general rule, therefore, the American leech is used on children, and on those surfaces from which the blood flows freely and abundantly. Six American leeches are supposed to abstract an ounce of blood, while the same quantity will be drawn by two, or at most by three, of the others.] Cupping, when it can be adopted, is a more active measure, and relieves pain sooner than leeches. Punctures are of use in superficial inflammations of the skin; incisions are of use when inflamed parts are covered with a dense unyielding fascia, as in whitlow; or when there is great tension, as in phlegmonous erysipelas; or when the inflamed part is infiltrated with an irritating fluid, as in extravasation of urine, or with unhealthy matter, as in carbuncle. Cold applications are valuable means of diminishing afflux of blood, relieving morbid sensation of heat, and causing contraction of the capil- laries ; but they should be applied continuously, otherwise the pain will be aggravated when the heat returns. They should be applied by means of a single piece of thin linen frequently changed ; and care should be taken that the vapor may pass off freely, otherwise the cold lotion will soon be converted into a hot fomentation. In some severe cases, ice or frigorific mixtures (F. 114) may be applied in bladders. The following very effectual means of applying a continuous degree of cold is recommended by Dr. Ma- cartney. The inflamed limb is to be placed in a trough or piece of oilcloth, with a piece of lint on the inflamed part. A large vessel full of cold water being then placed on a table by the bedside, one end of a broad strip of cloth should be dipped in the water, and the other end (which should be cut to a point) laid on the lint; and so the water will be carried in a constant gentle stream down the cloth to the inflamed part. When cold is not agree- able to the patient, tepid or warm applications should be substituted. [The surgeon may also, occasionally, derive benefit from the careful administration of medicines known as arterial sedatives, such as digitalis, aconite, and veratrum viride, which, by diminishing the force and rapidity of the heart's action, diminish the afflux of blood to the parts inflamed. The tincture of the veratrum viride, particularly, is a powerful and reliable means of con- trolling the activity of the circulation. ] 5. To control changes in the exuded fluids.—There are some remedies which are believed to have the power either of destroying or removing that element in the blood which is the cause of disease, or else of so acting upon the morbid effusions as to cause their dispersion and absorption. Mercury is the chief remedy of this class; and the popular doctrine is, that, in acute inflammation, especially of serous or parenchymatous structures, mercury causes absorption of lymph, or of the effused fluids; and that for this pur- pose it should be administered in repeated doses, with sufficient opium to prevent it from running off by the bowels, and that it should be continued till the mouth is affected. F. 62—6T will show the common mode of administration. But the author does not hesitate to say that except in syphilitic inflam- mation of the eye, this absorbent power of mercury is grossly exaggerated; and he would advise his readers, if they still choose to produce salivation for inflammation, at all events to observe the following rules:—It should never be -resorted to till after such purgatives and other eliminatives, and bleeding, local or general, as shall be deemed necessary, shall have been used. The effect should be produced by the smallest doses given continu- CHRONIC INFLAMMATION. 63 ously at regular intervals. F. 63, 64. All salivation is an unnecessary evil. In the case of children, calomel should be given in continuous doses, till it causes green, chopped-spinach-like stools. Tartar emetic may be used either in nauseating doses, F. 68, to depress the heart's action and cause perspiration, or else in emetic doses, to purify the blood by vomit and stool and promote expectoration; or it may be combined with purgatives, of which it greatly increases the action, F. 40, or with mercury, F. 62, or lastly, as a direct antiphlogistic, after the man- ner invented by Marryatt, and detailed under F. 68 in the Appendix. Antimony, like bleeding, is best adapted for the early stage of inflamma- tion, before effusion has occurred. Stimulants, and astringent solutions, are of great service in inflammation of mucous membranes, by decomposing and washing away their irritating secretions, and inducing contraction of the capillaries. Counter-irritants.—Blisters are the best form of counter-irritants in recent inflammation ; but they should never be applied too near the seat of an acute disease, and never till its activity has been subdued by previous antiphlogistic measures. Diet.—The diet in acute inflammation should, as a general rule, not be of a stimulating nature. But the starving system must not be indiscrimi- nately applied to children, or the old or debilitated ; or, in fact, to any patient whatever: on the contrary, the strength should be supported, and the waste of illness be mitigated throughout by mild fluid nutriment, milk, arrowroot, veal or chicken broth, &c. In most cases there comes a time when the pulse gets soft and fast; and the cheeks, or hands, or feet chilly ; and when warm wine and water is of great service; or even is absolutely essential to keep up the heart's action. Regimen.—There must be a total avoidance of everything that would irritate mind or body. Perfect rest in the recumbent posture, and in a position as easy as it can be made,—cool air,—a quiet and darkened cham- ber,—with mental consolation, to allay doubts and fears and inspire resigna- tion and cheerfulness, are most potent aids to medical treatment, which without them would often be utterly fruitless.1 SECTION IX.—CHRONIC INFLAMMATION. Definition.—Inflammation is said to be chronic when it is slow in its pro- gress, and tends to last long, or even indefinitely. Pathology.—It consists in permanent local hyperaemia, with exudation into the interstices of the part affected, or from its surface ; if that be a mucous membrane, the secretion is probably mixed with pus. Causes.—Its causes may be local or constitutional. Thus it may in the healthiest subjects be caused by any slight and continued irritant;—or it may be the sequel of acute inflammation. But more frequently it is the local manifestation of some constitutional disorder, such as general de- bility,__or over-stimulation and plethora,—or disorder of some important organ, as of the stomach, or liver, or kidney,—and consequent impurity of the blood. Treatment.—The indications are, to remove all constitutional disorder, to allay local irritation, and to restore the tone of the distended vessels. Constitutional Treatment.—On this part of the subject, our space forbids us to do more than make a few remarks on the most obvious forms of con- stitutional derangement, which accompany chronic inflammation, and on the remedies that are known by experience to be most useful as alteratives. 1 [Gross, op. cit. vol. i. p. 118.] 64 MODIFIED INFLAMMATION. (1.) If the patient is bloated and plethoric, with red lips and conjunctiva, and a full hard pulse, and indulges freely in stimulating food and drink, and has unimpaired digestive organs, so that blood is constantly formed in too great abundance, the diet must be lowered and restricted chiefly to fish and vegetables ; free exercise should be taken in the air ; the bowels should be actively purged with calomel and black draught; and then a course of alter- ative medicine should be commenced in order to increase the various elimi- native secretions. Mercury, given in small doses at bed-time with saline aperients in the morning, deserves to be mentioned first: Plummer's pill, in doses of gr. v. every night, is an excellent form, or F. 63, 65 ; taking care, however, to use the mercury in obtaining increased elimination by the liver, and not to cause salivation. Next to mercury, tartar emetic, given in very small doses, F. 68, is deserving of notice ; it is highly advantageous to com- bine it with mercury, F. 67. Saline and alterative medicines, F. 58, 61, will also be of great service. (2.) But if the chronic inflammation occur in an enfeebled and irritable, or scrofulous constitution, a nutritious and liberal diet must be adopted, wine, cod-liver oil, and tonics (F. 1, 2, 3, 9, &c.) should be administered in order to improve the digestion and vigor of the circulation ; irritation and pain must be allayed by sedatives and opiates; and the secretions of the bowels be maintained by the gentlest laxatives. (3.) If the complexion and eye are sallow, a few doses of calomel or blue pill, at night, or F. 63, with morning aperients, and the nitro-muriatic acid, F. 22, or dandelion, and colchicum, are indicated. (4.) In all cases the condition of the urine should be inspected, to ascertain whether albumen or blood disks,—indications of congestion or degeneration of the kidneys,—are present. In such cases, and in all others in which the skin is dry and harsh, it should be stimulated by exercise, by warm clothing, especially flannel, by the flesh-brush or horse-hair gloves, and by an occasional ten minutes' immersion in the warm bath ; 96°—98° Fah. Local Treatment.—This has for its objects, to remove exciting causes, to unload the distended vessels, and to make them contract to their natural calibre, and to exercise the part in its proper functions, so that it may gradually resume the actions and sensations of health. Local bleeding may be employed at intervals to unload the vessels, whilst they must be excited to contract by various stimulants and astringents ; such as the sulphates of zinc, copper, and alumina, nitrate of silver, salts of mercury, &c. The application of cold by pumping, or by the douche, is often highly serviceable. These or any other measures will be known to do good if they make the part feel stronger and more comfortable, although their first application may have been painful; but if they render it hotter and permanently painful, it is a sign that they stimulate too highly, and may thus be in danger of bringing on an attack of acute inflammation. Counter-irritants are more useful in chronic inflammation than in the acute, especially those which establish a permanent suppurative discharge. Pressure, if gentle, equal, and continuous, is of material use in many chronic inflammations, and even in acute inflammation of the breast and testicle, when its first violence has been diminished by leeches.1 SECTION X.—MODIFIED INFLAMMATION. I. In the two sections foregoing, we have described the treatment of inflammation in general, such as may be produced in all individuals : but, as we observed at p. 57, the course and result of inflammation are altogether [Gross, op. cit. vol. i. p. 134.] MODIFIED INFLAMMATION. 65 modified by the causes producing it, and so must the treatment be likewise; and the modifications resulting have been enumerated at p. 57, and will be found by reference to the Index. Here we may allude shortly to II. Outward Causes of Modified Inflammation.—We also showed, at p. 57, that some of the causes of inflammation are outward, and that others reside in the patients themselves. Of the outward causes, those which interest the surgeon will be discussed in the next part of our work; in which there will be described the various modifications of inflammation ensuing on cuts, blows, gunshot wounds, heat, cold, and poisons of various kinds. III. Inward Causes.—The inward causes consist in morbid states of the patient's blood. Under the head of scrofula and carbuncle will be noticed some of the modifications of inflammation arising in this way. It may not be out of place here to notice one or two others. 1. Gout.—It is out of our province to describe gout, yet, amongst the maladies commonly called surgical, are many distinctly gouty; such as severe inflammations of the eye and of the testis, severe eruptions of the skin, and irritable states of the kidneys, bladder, and urethra. The ehief marks that any acute or chronic attack is of a gouty nature are, that it probably arises quite suddenly; yet that the patient, if cross-questioned, admits that he has not been quite well for some time ; that possibly an aching in the great toe, or spot of psoriasis on the skin, or that some very anomalous symptom, cough, dyspepsia, or hypochondriasis, has existed for some time, and has gone off just before some more important part has suffered. The patient is probably either too florid, and has been living too well, thus producing what the writer calls high gout, or, on the contrary, has been exhausted by fatigue or anxiety, thus producing what we call low gout. The bowels are probably torpid ; the urine either very pale and copious, or scanty and full of litnates: gout probably also exists in the patient's family. The treatment of an acute attack will consist in active purgation, with calomel, colchicum, and alkaline aperients F 61 71, with warm baths, low diet, and saline draughts. In a chronic attack, the more cautious use of the same means, followed by bitter infusions with alkalies, and alteratives, F.72. Intense pain, and utter loss of function, followed by complete recovery, are characteristics of gouty innarn- ma2°Bheumatic Inflammations.—These, if acute, may usually be known by the intense aching aggravated by warmth, the profuse perspirations, and the tendencv of the malady to shift from one tendinous or muscular part to another If chronic, there is an obstinate aching, sometimes worse at night, sometimes relieved by the warmth of bed. For the acute, moderate purga- tives and alkalies, F. 65, 70; for the chronic, warm aperients and stimulants F. 7, 38, are indicated; and, in most subacute affections, the iodide of p0toaST™;eFare9ma9ny modified chronic inflammations difficult to describe or classify, yet easily recognized in practice, which evidently depend each on a partTcu ar blood-taint, and each of which is benefited by some special alter- Se In all cases it is right to begin with general treatment; that is, to rmprove the health, to see that the bowels, kidneys, and skin do their duty and that the diet is sufficient. Then if general treatment does not avail, ,onie specific remedy must be sought. First, we may mention, iodide of po- taslium whichhas the power of dissolving many old deposits in rheumatic, ton V scrofulous, and syphilitic cases, and of improving many skin eruptions, | 94 Secondly, the liquor potass*, F. 78, which, as Dr Parkes has shown, nnrlonbtedlv causes oxidation of some blood elements. It is indicated when Z ur nel 7r d and contraindicated in most cases of mere debility Besides these alterative, we must mention sarsaparilla, small doses of corrosive 5 6 6 EFFUSION of serum and cedema. sublimate in tincture of bark, F. 87, and arsenic, F. 97, which are also useful in certain chronic inflammations, especially of the skin. In many of these the real evil seems to be a want of vigor, through which the tissues in ques- tion seem unable to maintain their vitality. It is on this principle that mineral tonics, as arsenic, zinc, copper, and the mineral acids seem to do good, by giving a better quality to the materials assimilated. CHAPTER VII. EFFUSION OF SERUM AND CEDEMA. Effusion of Serum may be caused, 1st, by any circumstance which hinders the return of venous blood ; this is called simple cedema. 2dly. It may be caused by a depraved state of the blood, arising from disease of the kidneys, renal dropsy. 3dly. It may be an inflammatory exudation. In almost all cases of inflammation, effusion of serum is the earliest and most constant effect; the liquid being poured out equally into the areolar tissue—into the parenchyma of organs—from mucous and serous surfaces, and from the skin. If it is followed by any of the other effects of inflamma- tion, it is always more widely extended than they are. But it may be the chief or only effect of inflammation, as in oedema glottidis, and the so-called acute hydrocephalus; and some subacute inflammations of the serous mem- branes. In patients of a lax, flabby habit of body, and in parts of loose and cellular structure, as the prepuce, eyelids, and scrotum, inflammation always produces more of this effect than in those of a firmer texture. The serous liquid effused in consequence of inflammation is not, as Mr. Paget observes, the merely albuminous liquid which is commonly known by that name, and which is exuded in passive dropsy, but is in reality liquor sanguinis, and contains a variable quantity of fibrine ; as may be readily proved by the spontaneous coagulation which takes place in the so-called serum exhaled from the skin under a blister of cantharides. It is difficult to explain why the effusion remains within the body, as it may for many days and even weeks, without the fibrine separating and becoming solid. The so-called inflammatory serous effusion may terminate in four ways :— 1st. It usually becomes quickly absorbed; an event which is hastened by such purgatives and diuretics and tonics as tend to drain the blood of impure materials, and give vigor to the circulation, and by bandages and other means of local stimulation. 2dly. In some cases it resists absorption for a long period, or altogether; of which hydrocele, some cases of hydrothorax, hydrarthrus, and hydrocephalus, afford examples. 3dly. The fibrine may slowly separate from the serum, and solidify, causing a doughy indolent thickening of the cellular tissue, the treatment of which will be mentioned at the end of the ninth chapter. 4thly. The serum effused may distend the cellular tissue, so as to interfere with the nutrition of the skin; which may be remedied by making punctures with a needle, and allowing it to ooze gradually out. Of the manner in which serous effusion may prove fatal to life, in the oedema glottidis and hydrocephalus, it is not our purpose to speak at present. OEdema is the name given to the swelling caused by the presence of serum, whether inflammatory or dropsical, in the cellular tissue. It is a soft, ine- lastic, diffused swelling, which pits on pressure, that is, retains for a time the pit or mark made by the pressure of the finger. If oedematous limbs HEMORRHAGE. 6 7 become inflamed from any cause, the skin is exceedingly liable to ulcerate or slough. The causes of dropsical oedema, which most concern the surgeon, are the pressure of cancerous, aneurismal, and other tumors on the great veins of a limb, and obstruction of the veins by phlebitis. A raised position, moderate support by bandages, and punctures made with a common sewing-needle, to let the serum exude, are the most rational palliative measures. CHAPTER VIII. HEMORRHAGE. Hemorrhage, like serous effusion, may be a consequence, lstly, of inflam- mation or excitement; 2dly, of obstruction to the return of venous blood ; and 3dly, of structural weakness of the bloodvessels and thinness of the blood, as in scurvy and putrid fevers. The first form is called active, the last two passive. (1.) Active hemorrhage consists in an escape of arterial blood from the capillaries, when ruptured by the distension caused by acute inflammation or violent excitement; and more or less of it doubtless occurs in every case of violent inflammation. It occurs during the formation of abscess in the cellular tissue and in the liver. But the most common seat of inflammatory hemorrhage is mucous membrane, especially that of the lungs. The principal instances of it which fall under the surgeon's care, are epistaxis or hemor- rhage from the nose ; hasmorrhois or hemorrhage from the rectum ; hemor- rhage from the urethra during gonorrhoea; and from granulating wounds. It has also been known to occur from the conjunctiva ; and more rarely from the pleura, pericardium, and peritoneum. Sometimes the blood issues, not from the surface of the inflamed membrane, but from portions of adherent lymph, which have become vascular, and whose newly-formed capillaries have been over-distended and ruptured. Diagnosis.—Inflammatory or active hemorrhage is distinguished from that which is the result of congestion or debility, by the presence of pain, heat, and throbbing, and of a febrile state of the pulse and system generally. Treatment.—This form of hemorrhage is to be treated by bleeding, if it can be borne (and it may be observed that it is less debilitating to employ one full venesection, so that the cause may be at once removed, than to let the blood dribble perpetually away from the part in small quantities), and by purgatives and astringents, and opium (F. 34, 35, 75). Cold, if it can be applied, perfect rest, and an elevated position, are the local measures. (2.) In passive hemorrhage the blood which escapes is venous. The principal instances of it are hemorrhage from the nose in old subjects with diseased liver: melaena, or hemorrhage from the liver, and passive menor- rhagia and hasmorrhois. The chief remedies are, dilute sulphuric acid, sulphate of alumina, acetate of lead, catechu, gallic acid, and other vegetable astringents which increase the coagulability of the blood, and ergot of rye, which increases the contraction of the capillaries. F. 14, 186, 187, &c 68 exudation of fibrine and adhesion. CHAPTER IX exudation of fibrine and adhesion. Fig. 5. ® © We have already spoken of the exudation of fibrine, as the material by which repair is effected ; now we must speak of it as an effect of inflamma- tion, by which organized adhesions or bands of false membranes are formed ; cavities are filled up, membranes rendered thick, opaque and rigid, and the substance of organs infiltrated with solid deposits. The material is, so far as we know, the same fibrine as that which has been described under the head of repair. It may either set into fibres, or develop fibro-plastic corpuscles : or both modes may be combined to any degree. It may very soon become permeated by blood- vessels, which no doubt are outgrowths from the nearest capillaries. Specks of blood are often found in lymph, and it has been believed that they are new formations, and that vessels may be developed de novo, as in the incubating egg; but this hypothesis is not probable. When lymph is once effused, its destination may vary according to circumstances. (1.) It may be developed into any of the tissues capable of renovation : i. e., fibrous tissue, bone or epithe- lium, forming bands of adhesion, cicatrices, super- ficial deposits, and thickened membranes. (2.) It may undergo changes of a beneficial sort, which cause it to be rapidly absorbed ; that is, if the morbid state of blood which caused the exudation be relieved, the latter may undergo fatty degeneration, and either be absorbed or remain harmless, in the state commonly known as yellow-cheesy-tubercular. (3.) From a continuance of local irritation and afflux, the lymph may be compelled to soften into pus. In some cases, as of phlegmonous erysipelas, diffuse inflammation, carbuncle, and the like, the exudation is so aplastic and cacoplastic from the first as to be incapable of organization, and so poisonous as to be unfit for absorption, and it softens only into an amorphous puriform fluid. Examples of adhesion.—1. After wounds, in which the efforts of nature at repair have been frustrated, a certain degree of inflammation ensues, fresh lymph is exuded, and this, so soon as the inflammation abates, takes the form of granulations. These are composed of plastic cells, in every variety of size, shape, and development, mixed with filamentous intercellular matter. The deeper layers are, as to structure, converted into filamentous tissue, and as to chemical nature into gelatine, whilst the more superficial are still spherical and albuminous; and whilst the very surface degenerates into the creamy liquid called pus, which will be described in the next chapter. This is the mode in which open wounds (or wounds which the skin will not cover) generally heal in the human subject; but it is an imperfect mode ; because granulations are extremely liable to be diseased, because they entail a great 1. Lymph, with fibrils and cor- puscles ; 2. Pus; 2a. Pus acted on by acetic acid ; 3. Blood ; 4. Oil-glob- ules ; 5. Granular masses, i. e. plas- tic and other cells filled with oily and granular matter. exudation of fibrine and adhesion. 69 waste of material which escapes in the form of pus, and because the scar is always larger than in the case of a wound healing by the primary reparative process. When two surfaces covered with granulations are made to unite, the union is said to be by secondary adhesion or by the second intention. 2. A second example is furnished by the acute inflammation of serous membranes; as pleurisy, in which lymph effused under inflammation forms the adhesions which so commonly bind the lungs to the inside of the ribs. Under rheumatic inflammation, the heart may be glued to the pericardium; in syphilitic iritis the anterior chamber of the eye may be filled with lymph. After injuries, the adhesive tendency of inflammations of the pleura and peritoneum is of service in preventing the spread of exudation or ofextra- vasated matter. Mucous membranes, as we said at p. 58, are not commonly considered liable to adhesive inflammation, because the lymph effused is generally cast off, and does not become adherent or organized. But if two abraded and inflamed mucous surfaces are placed in apposition and left undisturbed, they may adhere ;—as sometimes happens in the vaginas of female children ;—in the os uteri and Fallopian tubes of prostitutes, and in the ureters and biliary ducts when abraded by the passage of calculi; and Mr. Hancock has shown the existence of organized lymph in the canal of the urethra, in cases of stricture. 3. When a natural reparative process has failed, the surgeon often ex- cites adhesive inflammation, in order that the lymph exuded may serve as the basis for another effort at repair. (See False Joint.) It is sometimes excited, likewise, in order that the tissue of a tumor may be starved and atrophied. 4. Separation of fibrine may take place within the vessels as well as into the tissues. Granulations, if healthy, and proceeding towards a cure, are small, pointed, and florid ; they bleed if wiped, and are not very tender. But they are subject to many disorders; being sometimes pale, bloated, and (Edematous; sometimes degenerating into a pseudo-mucous membrane; sometimes breaking up suddenly, and being dissolved into a sanious fluid. When, however, the case proceeds favorably, the undermost are developed into fibro-cellular tissue, those on the surface form themselves into cuticle, and so the wound is healed. . Cicatrization.—This process of healing, or cicatrization, is attended with an absorption of inflammatory effusion in the vicinity of the wound, and a contraction of its margin, so that the wound becomes much smaller before any new cuticle is formed. Its edge then begins to look smooth and bluish, and a thin pellicle of new cuticle gradually spreads from the edge in a con- verging circle till the wound is closed. The material that closes up the gap is called a cicatrix: it is a band of fibrous tissue covered with cuticle. It has no thickness, for granulations do not really fill up gaps, as is sometimes said and seldom form a layer more than £d inch thick; and in the case of an extensive gap the cicatrix is closely glued to the bone or fascia beneath. It afterwards shrinks, becoming paler and likewise looser, through atrophy of the deeper portions. Lymph whether reparative or inflammatory, may become the seat of hemor- rhage, oedema, inflammation, tubercular deposit, and many other diseased ° Adhesions and Cicatrices are extremely liable to shrink, and become atrophied Thus, the extensive cicatrices left after severe burns always contract greatly; and adhesions between serous surfaces may, in the course of time disappear entirely. After the liver or kidney has been infiltrated with fibrinous effusion the whole organ is liable to waste. During certain 70 SUPPURATION AND ABSCESS. states of constitutional cachexy (as the scurvy), old fractures have become disunited, and old cicatrices have broken out afresh into wounds; showing that the new tissue has less vitality than that of original formation.1 Treatment.—If it be wished to remove adhesions, or thickening, the re- sults of previous acute or existing chronic inflammation, the general rules must be attended to which were laid down for the treatment of chronic inflammation. Mercury has a reputation for removing induration : but, as we have before said, it should be used as an eliminative, and not to accumu- late and cause ptyalism. The local means that may be used to remove the thickening left by a quite subdued inflammation of any external part, are friction, stimulating liniments, F. 143, 150 ; ointments containing iodine, or mercury ; gentle exercise ; shampooing; pressure by bandages or otherwise ; cold affusion ; electricity and galvanism ; discutient lotions, especially those of zinc, F. 117, or muriate of ammonia, F. 118 ; blisters, or other counter- irritants—always taking care not to produce active inflammation by too violent stimulation. CHAPTER X. SUPPURATION AND ABSCESS. SECTION I.—SUPPURATION AND ANALOGOUS PROCESSES. Suppuration.—According to the doctrines stated in the preceding chapters, whenever effusion of fibrine is attended with a continuance of acute inflammation, or when there are certain defects in the composition of the blood, the fibrine softens down, and with the cells, which have undergone certain changes, becomes a creamy liquid called pus. 1st. In Abscesses.—When suppuration takes place in any cavity, or in the substance of the areolar tissue, or of any organ, an abscess is said to be formed. If the inflammation is of the variety called healthy or sthenic, and circumscribed, the centre only of the effused fibrine will probably soften ; the circumference will form a cyst, containing the liquid. If the inflamma- tion is low, or unhealthy, as in erysipelas and pyaemia, the whole of the fibrine will probably soften into a puriform fluid, to be presently described, and the abscess will be diffused. 2d. In open granulating Wounds.—In the case of wounds and other injuries in which a portion of the tissues is left uncovered by skin, or of wounds which have not united by adhesion, the exposed surfaces, after bleeding has ceased, and a thin reddish serum has ceased to exude, become glazed over with a grayish or buffy coat composed of fibrine and the white corpuscles of the blood. Two or three days pass, more or less ; and the vicinity of the wound displays evidence of slight inflammation, and lymph is effused in thin layers. Of each layer a portion soon becomes vascular, and its surface is thrown up into little eminences called granulations, which secrete a fresh layer ; another portion degenerates into pus, forming a bland creamy covering for the granulating surface. 1 In examining the body of a madman who had stabbed himself in the abdomen fifteen different times during his life, the parts near the most recent wounds were found united by considerable false membranes ;—at the situation of some that were older, there were only a few thin cellular adhesions ; whilst at the oldest, there was no trace of adhesion or false membrane whatever. Andral, Anat. Path. vol. i. p. 486. [^ee Gross, op, cit. chap. iv. sect. ix. and x. 1 SUPTURATION AND ABSCESS. 71 Physiological Relations of Suppuration.—1st. Suppuration is essentially a morbid process ; yet as it may accompany other processes which tend to a beneficial end (such as granulation), so it is customary to speak of it when accompanying such beneficial processes, as healthy, and to describe the pro- duct as healthy pus. Moreover, though suppuration be a morbid process, it often takes the place of other processes infinitely more morbid. Thus, after a very severe lacerated wound, when the patient has passed through several days of fearful constitutional excitement; or after sloughing or rapid phagedasnic ulceration, nothing delights the surgeon more than the sight of healthy pus, because he knows that it announces at least an attempt at repa- ration, and the cessation of violent febrile excitement. 2dly. The formation of abscesses often seems to serve as a means for eliminating some noxious matter from the blood. 3dly. Suppuration affords a mechanical means of removing foreign substances impacted in the soft parts. Lastly, if too profuse, it may exhaust the vital powers, and bring on hectic fever. Healthy Pus.—Pus is a yellowish-white, opaque fluid, of the consistence of cream ; free from smell, neither acid nor alkaline, said to have a sweetish, mawkish taste, insoluble in water, although freely miscible with it, and very slow to putrefy. It consists of a thin serum, holding a vast number of globules in suspension. Its usual specific gravity is 1.021—1.040; heat coagulates the albuminous elements of its serum ; potass and ammonia con- vert it into a gelatinous mass. The most recent analyses1 show that pus contains water (86.1 per cent.), fat, extractive, and albu- men. It also contains about 0.8 per cent, of salts; chiefly common salt, and muriate of ammonia. Pus-Globules.—When these are examined under the microscope, they are found to be opaque spheri- cal globules, apparently granulated like mulberries, but in reality smooth, as may be known by exa- mining their circumference. They measure from l-5000th to l-2000th of an inch in diameter; some even are larger. They may be shown to consist of cell membrane, containing nuclei, ioil globules, and minute granules. If water be added, they imbibe some of it, and become larger, more transparent, and less granular. If acetic acid be added, it brings clearly into view two, three, or four nuclei; and renders the other parts transpa- rent, or so invisible, that they seem to have dis- solved. These central nuclei furnish the best means of distinguishing pus from other globules other smaller molecules are also found in pus in great abundance. Mucous Pus or Muco-purulent Matter.—Mucus consists of a viscid mat- ter coagulable by acetic acid and containing epithelium. The mucus yielded by every distinct organ differs in the shape and character of the epithelium contained in it; for example, mucus from the bladder is very different from mucus from the bronchi. Under inflammation, mucus may be mixed with albuminous or fibrinous exudation, and with pus, in any proportion. The real nature of any such matter is easily decided by the microscope. But the question of the diagnosis between pus and mucus is not of the same conse- 1 Vide Mayo, Med. Gaz. 19th Oct. 1839 ; Vogel, \iber Eiter und Eiterung, p. 35 ; Davy, op. cit. vol. ii. p. 468 ; Bonnet, Med. Gaz. vol. xxi. ; Gueterbock, de Pure et Granulatione, Berol. 1837. Fig. 6. The uppermost group gives a pretty accurate idea of the ap- pearance of pus-globules magni- fied 400 diameters. The middle figures represent globules treated with acetic acid ;—the lowest re- present the appearances when pus is partially decomposed or treated with liq. potassse. Drawn from nature by Dr. Westmacott, under the superintendence of Dr. John- son of King's College. Besides the globules, 72 ACUTE ABSCESS. quence now as it was at the time when pus was supposed to indicate the existence of an ulcer. Muco-purulent matter is pus mixed with mucus. Puriform Fluid is, as we have said, a fluid formed by the softening down of a fibrinous exudation, without the development of real pus globules. It constitutes the liquid yielded by carbuncles and un- Fig. 7. healthy abscesses, by spreading ulcers, and by the fibrinous exudations which occur in the lungs and elsewhere, when putrid fluids have found their way into the blood. It exhibits oil-globules, shreds and fragments of tissue, granules, and possibly abortive cell formations; smaller than pus-globules, less regu- lar, and not giving the characteristic reaction with _ .. fl ., , „ . acetic acid. See Pyaemia. Puriform fluid from a soft- •? . . ened lymphatic gland. Softening is a process analogous to suppuration, inasmuch as it is a degeneration and liquefaction of the affected tissue, and of any fibrinous exudation with which it may have been infiltrated, although without the presence of true pus. It is a condi- tion met with in the brain, either from disease of the arteries, or from a low degree of inflammation. Amongst the products of decayed exudations are the bodies known as compound granular cells. They were formerly called exudation corpuscles, because they were Fig. 8. found in inflammatory exudations; but they are by no means peculiar to these; on the contrary, they seem to be formed by a pro- cess of fatty degeneration of almost every primary cell, and thus may be found in any cell-growth, healthy or morbid. For in- 1, shows a ceii from a fibro-piastic stance, they may be found in the colostrum tumor; 2, from cancer; 3, from an ova- or milk first secreted after parturition ; in nan cyst, and from the decidua-aii the decidua; and in enchondromatous, fibro- loaded with oil-globules; traced by the , ,. j i i „j.i___ t. , ; i • v, *v. plastic, cancerous, and almost every other author from actual specimens, by the r "^ . ' mi i i camera. morbid growth. They are unaltered by water and acetic acid ; potass dissolves the cell-wall, and sets free the granules.1 In some cases these bodies consist merely of an aggregation of»fatty molecules. SECTION II.—ACUTE ABSCESS. Symptoms.—Acute abscess (which, when occurring in the subcutaneous cellular tissue, is called phlegmon) commences with the ordinary signs of acute inflammation—namely, inflammatory fever ; severe throbbing pain; bright redness; and much swelling ;—firm in the centre, and cedematous around. The occurrence of suppuration is indicated by an abatement of the fever, and a change in the pain—which is less acute, and converted into a sense of weight and tension. Then the tumor becomes softer, and loses its bright arterial color ; and as the quantity of pus increases, its centre begins to point, that is, to project in a pyramidal form, and fluctuation can be felt by alternate pressure with the fingers. After this, the parts between the abscess and the surface become successively softened and disintegrated. The tumor becomes more and more prominent; the centre exhibits a dusky-red or bluish tint, the cutis ulcerates, the cuticle bursts, and the pus escapes. Deep Suppuration.—But where pus is formed under fasciae, or deep in the mamma, or pelvis, and cannot quickly make its way to the surface, the pain is not relieved but often much aggravated by the increase of distension, and the constitutional symptoms are much more severe. See Hectic Hughes Bennett on Cancer, &c, p. 153. ACUTE ABSCESS. 73 Although abscesses may burst into serous cavities, or mucous canals if they happen to be near, still their general course is that which is least pre- judicial ; namely, towards the skin. Causes.—Acute abscess is mostly idiopathic, that is, depends on a dis- ordered condition of the blood, and is. a frequent sequel of fevers ;—it may, however, be caused by blows, ecchymoses, or by foreign bodies introduced into the skin or flesh. Treatment.—In a case of idiopathic abscess the indication always is to remove, if possible, the morbid state of constitution on which it depends, by purgatives, and to hasten the process of suppuration by warm poultices. In abscesses arising from local injury, all exciting causes, such as thorns, splinters, &c, should be removed. Poultices relax the skin, promote perspiration, soothe pain, encourage the formation of pus, and expedite its progress to the surface. They should be large, soft, and light, and may be made of bread and water, or linseed meal, or of chamomile flowers boiled till they are soft, or of bran sewed up in a flannel bag, which may be dipped into boiling water as often as it becomes cold (F. 152), &c. [When, as it not unfrequently happens, it is desirable that the poultice be very light, the powdered bark of slippery elm answers an excellent purpose. All poultices should be covered by oiled silk to pre- vent them from becoming dry.] The warm-water dressing—that is, a piece of soft lint, or folded linen dipped in warm water and covered with oiled silk to prevent evaporation, and the spongio-piline—are good substitutes for poultices in many cases, especially for irritable sores ; but when there is much pain, they are not so soothing as the large soft warm mass of a well-made poultice. Respecting the opening of abscesses, it may be laid down as a general rule, that if they point and become pyramidal, without enlarging in circum- ference, they may be left to burst of themselves; but that if they enlarge in breadth and circumference, without tending to the surface, they should be opened. In the following six cases, however, the surgeon's aid is impera- tively demanded :— 1. When matter forms beneath fasciae and other dense ligamentous textures, such as the sheaths of tendons. Because these parts are dense, and ulcerate with difficulty, the pus, instead of coming to the surface, will burrow amongst muscles and tendons, extending the abscess to great distances ;—producing extreme pain and constitutional disturbance, by its tension of the fascia? which cover it, and pressure on the parts beneath,—causing risk of extensive sloughing, and impairing the future motions of the part. Hence, as a gene- ral rule, all abscesses beneath fasciae [beneath the periosteum, if accessible], or among tendons, or under the thick cuticle of the fingers, should be freely opened, as soon as the existence of matter is suspected. 2. When abscess is caused by the extravasation of urine, or other irri- tant fluids; or when'it contains an unhealthy matter, which might diffuse itself and spread the disease : as in carbuncle. 3. When an abscess is formed in loose cellular tissue (as around the anus) which would readily admit of great distension and enlargement of the sac, and more especially if the cellular tissue is partially covered with muscles (as in the axilla), under which the matter might burrow. 4. In suppuration near a joint; or in the parietes of the chest or abdomen ; or under the deep fascia of the neck; lest the abscess burst into the serous cavities, or the trachea; or cause compression of, or burst into, the trachea, oesophagus, or jugular veins. 5. In suppuration of very sensitive organs, as the testis. 6. When it is desirable to avoid the scar which always will ensue when an abscess ulcerates spontaneously. 74 ACUTE ABSCESS. And in the first three of these cases it is much better to make an opening before matter has formed, than to delay it for one moment afterwards. Abscesses may be punctured with a large lancet, used as in venesection, or with the sickle-shaped bistoury, commonly called Syme's; or, if deep and [Fig. 9. Syme's abscess lancet.] extensive, by a straight-pointed, double-edged bistoury. Holding it like a pen, the surgeon should gently plunge it in at a right angle to the surface, till it has entered the cavity, which may be known by a diminution to the feeling of resistance, or by gently turning the instrument on its long axis, so that a drop of pus may well up by its side. Then the aperture may be enlarged sufficiently as the instrument is being withdrawn. The puncture [Fig. 10. Mode of opening abscesses.] should be made either at the most depending part of the abscess, or else where the matter points most decidedly and the skin is the thinnest; and a very fine strip of oiled lint (called a tent) may be gently introduced between the edges of the opening, and be allowed to remain for the first forty-eight hours to prevent them from closing again. No rude attempts should be made to squeeze out matter; but it should be allowed gradually to exude into a poultice or fomentation. The poultice may be continued till all the pain has subsided, and the cavity has begun to granulate ; b.ut not too long, lest the granulations become weak and flabby. And then the best plan is to apply a compress of linen, and a bandage. If the cavity does not contract speedily, it must be treated as a weak ulcer or fistula. If the suppuration continues profuse, tonics, change of air, and a good diet are advisable, in order to prevent hectic, and enable the constitution to repair the local mischief. Absorption of Pus.—It occasionally happens that acute abscesses are cured by the absorption of their pus. This is likely to happen when, after acute inflammation, the matter remains without tending to come to the sur- face, and without pain; the means best adapted to promote it are moderate pressure, purgatives, and tonics. HECTIC OR SUPPURATIVE FEVER. 75 By these means, in fortunate instances, the liquor puris may be absorbed, the pus-corpuscles undergo degeneration and disintegration, and after re- maining for some time as a fatty or cheesy mass, may pass again, in a mole- cular form, into the bloodvessels. SECTION III.—HECTIC OR SUPPURATIVE FEVER. Definition.—Hectic (a Greek word signifying habitual) fever is a re- mittent fever, marked by daily paroxysms. It depends on a disordered state of the blood, whether from obstinate malassimilation, or from severe local disease with suppuration. Symptoms.—The patient generally displays great loss of flesh and strength, the skin is muddy, and the eyes hollow. Usually every afternoon or evening he has a fit of shivering, more or less severe, followed by heat and thirst, which render the early part of the night restless; then sleep and profuse sour perspiration come on. The tongue is red, and there is a marked tendency to diarrhoea. The pulse above 80 and soft. If the hectic arise from a local disease, it may cease instantly, on the removal of the disease, by operation or otherwise. But if the causes continue, and the' malady increase, the diarrhoea and perspirations become more and more profuse and exhausting, and the patient sinks. Causes.—Hectic fever, more or less well marked, attends several of the great assimilative disorders of the blood, as diabetes. But that which interests the surgeon is its connection with suppuration; and there is no doubt that true severe hectic depends on the absorption of decomposing pus into the blood, and that the perspirations and diarrhoea are the means by which nature eliminates the poison. In the case of certain deep abscesses (the writer, from his midwifery practice, has seen it in the breast more often than elsewhere) there may be a daily attack of cold shivers, succeeded by heat and profuse fetid perspira- tion, and attended by great debility, red tongue, and diarrhoea; and these symptoms, after lasting for days, may be relieved at once by opening the o |"j c r» p o c It is often said that shivering is a sign of suppuration. This is not true absolutely, for pus may be formed without shivering. But shivering is a sign that matter, if formed, is beginning to be absorbed in a condition which renders it poisonous ; and the occurrence of it, especially if attended with the other signs of hectic, renders it the surgeon's duty to look for local Treatment.__The first indication is to remove the local disease if it can be done. The second is to support the strength. The third to treat symp- Tlie first may often be fulfilled by letting out pus, or cutting out a diseased part or such other operation as may suit the individual case. The second, by abundance of food, especially animal food, and good beer or port wine. Preparations of isinglass, or other fish or animal jelly, seem also to supply waste ; and there are some cases in which feverishness is so great that the patient can take only milk and farinaceous food, as arrowroot, The best tonics are bark and steel, especially the decoction of bark with nitric acid, F. 1 : and the Mixture of Moses Griffith, F 19. # Diarrhoea is best combated by pure meat diet and sulphuric acid, 1.24, 25 • with small doses of opium. Sometimes the old-fashioned soothing medicines chalk and bismuth mixtures, &c, are useful, and sometimes gallic acid Perspirations are relieved, also, by sulphuric acid, and oxide of zinc. 76 CHRONIC ABSCESS AND PUTREFACTION OF PUS. SECTION IV.—CHRONIC ABSCESS AND TYPHOID SYMPTOMS FROM PUTREFACTION OF PUS. General Description.—Chronic abscesses may be the result of an exu- dation produced by a low and unsuspected degree of inflammation, or of some non-inflammatory scrofulous deposit. They most frequently are the result of diseased bone. They are mostly lined with a thin, reddish-gray, distinctly-organized cyst;—there is little or no vascularity in the parts ad- joining ;—and the pus usually is thin and flaky. Symptoms.—When first detected, a chronic abscess appears as an obscure tumor, with a fluctuation more or less distinct according to its distance from the surface. It is free from pain, tenderness, swelling, and redness, unless far advanced, or accidentally inflamed. Progress.—These abscesses may attain an enormous magnitude, before the coverings ulcerate. When, however, from the increasing distension, or from some accidental irritation, this does happen, the skin reddens, inflames, and ulcerates, and so the matter is discharged. Terminations.—(1.) In slight cases the interior of the sac pours out granulations;—the reddened skin around the orifice ulcerates;—and the sore so formed may heal. (2.) If the restorative powers are weak, or the ab- scess is caused by a piece of diseased bone or some other source of irrita- tion which is not removed, one or more sinuses may remain. (3.) If, on the other hand, the abscess is very large, or if, after the admission of air, the pus have not a free exit, a most serious, train of consequences will ensue. The pus, exposed to the atmosphere, putrefies—the hydrosulphate of am- monia (the product of putrefaction) is absorbed into the blood1—and a train of typhoid symptoms comes on precisely like those which were produced by the air of a cesspool in Dr. T. H. Barker's experiments. There is hot and dry skin; dry and glazed tongue ; parched lips; the formation of healthy pus ceases; the pulse is rapid and jerking; there is low muttering delirium, and picking of the bedclothes, and jerking of the muscles of the arms and legs (subsultus tendinum) ; the bowels are paralyzed and tympanitic, or else probably there is offensive diarrhoea, and the patient, if unrelieved, sinks comatose. Prognosis.—Hence, the danger of these abscesses will be great, if the sac has attained a large size, and has advanced so far towards ulceration that a spontaneous and permanent aperture is inevitable, more especially if it is connected with diseased hip or vertebrae, which will keep up the secre- tion of pus. Treatment.—There are three indications: (1.) To amend the general health by the means detailed in the Chapters on Chronic Inflammation and Scrofula. If (as in the case of psoas and lumbar abscess) the abscess has been caused by some local disease, the latter must, if possible, be ascertained and removed by proper measures. (2.) To procure absorption of the matter, if possible. This may some- times be effected by stimulants, in cases not arising from diseased bone, applied to the tumor; or pressure; as the Emp. Ammoniaci cum Hydrarg.; or F. 160. (3.) But if the tumor continues to enlarge it cannot be opened too soon; —especially if there is any incipient redness of the skin. And a different proceeding is requisite in different cases. 1 It may be detected in the blood and urine. The blood in these cases is black, and refuses to coagulate ;—which is precisely the effect produced by adding the hydrosul- phate of ammonia to healthy blood. Vide M. Bonnet's Papers in the Med. Gaz. vol. xxi. ; Dr. T. H. Barker on Sewer Exhalations ; and Richardson on the Blood, Appendix I. 1858. CHRONIC abscess and putrefaction of pus. 77 If the abscess is superficial and small, a sufficient opening should be made with a lancet to let out the raspberry-cream-looking matter and the flakes of lymph floating in it; and some strips of adhesive plaster should be passed round the part, so as to keep the sides of the sac in apposition with a moderate degree of pressure. Thus, a free exit being provided for the pus, the opposing surfaces of the cavity will often granulate and adhere; then the external aperture heals, and the case is cured. If this adhesion does not take place, stimulating injections may be used, such as F. 117, diluted ; or the cavity may be slit up, and made to heal from the bottom. Large Chronic Abscesses.—If the abscess is so large that the exposure of its cavity would lead to the evil consequences that have been enumerated, or if it is connected with disease of the spine or other bone (as in the case of psoas abscess), the surgeon must take care not to let air into the sac; nor to empty the sac suddenly and leave its sides unsupported; else when the fluid pressure within is removed, blood will very probably ooze from the delicate vessels, and give more material for putrefaction. A small puncture should be made at the most depending part of the tumor. Mr. Vincent recommends a trocar. As much matter as flows spontaneously should be permitted to escape, the parietes of the abscess should be brought together by careful bandaging, and then the puncture should be carefully closed by collodion or plaster, and the patient be kept at rest till it is healed. During the flow of the matter, the greatest care ought to be taken to prevent the admission of air into the sac. At the expiration of ten days or a fortnight, when it is nearly refilled, a second puncture should be made (but not too near the former), and should be healed again in like manner. This opera- tion should be repeated at proper intervals, taking care never to let the abscess become so distended as it was before the previous puncture—and using moderate support by bandages in the intervals. Thus, in fortunate cases, these repeated partial evacuations, combined with proper constitu- tional measures, will cause the abscess gradually to contract;—so that it either becomes completely obliterated or degenerates into an insignificant fistula.1 Perhaps a still safer method is to pass a long narrow knife through the skin, at a little distance from the abscess; then under the skin into the sac, so that the pus may pass through a subcutaneous canal, that shall be tho- roughly valvular and exclude the air.a But if air have gained admission into the cavity of the abscess, and the pus have become putrid, and prostration of strength and dry brown tongue show its influence on the system, then the indications plainly are, to make free openings and counter-openings, so as to prevent all lodgment of the putrid pus; and to wash out the sac occasionally with injections of warm water, containing a very little of the solution of chloride of soda. At the same time the strength must be supported, and the evil influence on the blood neutralized by wine, soup, bark, and the nitro-muriatic or sulphuric acid, F. 1, 22, 25. [The drainage tubes of M. Chassaignac may be used with great advantage in the treatment of large and deep-seated collections of matter. They will be found described under the head of Empyema.] i William Fergusson's Practical Surgery, 4th Am. ed. p. 82; and Lancet, Nov. 6, 1841. 2 W. Adams, Subcutaneous Surgery, p. 48. Lond. 1857. 78 erysipelas. CHAPTER XI. erysipelas, diffuse inflammation of the cellular TISSUE, AND PYiEMIA. SECTION I.—PATHOLOGY OF ERYSIPELATOUS INFLAMMATION. Erysipelas is an unhealthy inflammation, which, wherever situated, ex- hibits the following characters:—It has a disposition to spread widely along the surface of skin or membranes, or in the areolar tissue. The lymph which is secreted is incapable of organization, and has no disposition to form a sac, within which the pus shall be confined ; on the contrary, it is liable to universal softening, and the exudations are. diffused widely, and thus extend the disease into sound parts. Erysipelatous inflammation is liable to attack different parts, sometimes simultaneously, sometimes by metastasis; that is, leaving one part and flying to another, thus giving evi- dence of its origin in a vitiated state of the blood. The different varieties of erysipelatous disease prevail epidemically together. Thus Dr. Ferguson tells us, that erysipelas and puerperal fever were generally co-existent in his lying-in hospital, the mothers perishing of one and the infants of the other. These diseases are capable of direct propagation by infection, i. e. through the medium of gaseous emanations, and by contagion. Instances are now common enough, showing that the contagion of erysipelas may cause puer- peral fever, just as inoculation with the fluids of a female who has died of puerperal fever is a most fatal source of diffuse cellular inflammation to the dissector.1 The diseases which are grouped together under the term erysipelatous, are the simple and phlegmonous erysipelas, the diffuse inflammation of the cellular tissue, puerperal fever, pysemia—which, from its often following injuries of the veins, was formerly confounded with phlebitis—and hospital gangrene. The causes are, 1st, some morbid state of blood generated in the system itself, through the combined influence of disordered secretions and atmo- spheric influences. This is probably the cause of the milder isolated non- contagious cases of erysipelas. 2d. The miasmata to which Dr. Gregory assigned the term ochletic (from 5*a.os, a crowd), and which are generated out of the effluvia of the skin and breath when many persons are crowded together, especially in hospitals. 3d. The blood and secretions of persons already affected with these diseases; or putrid matter of any sort introduced into the blood, especially through wounded veins. The modus operandi of these causes cannot be doubted ; they are zymotic; that is, they act like ferments on the blood, and communicate to it a dispo- sition to undergo the same changes in composition which they are themselves undergoing. The blood so poisoned deposits in the affected parts of the body an unhealthy plasma, which causes wide-spreading irritation and exu- dation. Since hospitals are frequently rather a curse than a blessing through the 1 See Robert Ferguson on Puerperal Fever, p. 29 ; Storrs, of Doncaster, who first clearly proved the common origin of these and other septic diseases, in the Prov. Med. Jour., 23d April, 1842; Nunnely on Erysipelas, Lond. Is41 ; Dr. G. Gregory on Ochlesis, Lancet for July 15, 1848; Routh on the Puerperal Fever of Vienna, Med.-Chir. Trans. vol. xxxii. ERYSIPELAS. 7 9 mortality arising from erysipelatous diseases, contracted within their walls, or carried into the lying-in chamber, no pains should be spared to obviate the causes, and to prevent the extension of these diseases. Hospitals should have rooms in which the convalescents should be during the day. The floors should be dry-rubbed and polished, not washed. The walls and ceilings should be whitewashed at regular short intervals. Ventilation should be constantly watched; a space of at least 1500 cubic feet be allowed for each patient in a ward. The feather beds and mattresses should be baked, and the bedsteads be taken to pieces and exposed to the air at least once a year. No patient should be put into a bed just quitted by another. The patients should be obliged, when practicable, to use the warm bath and soap, .and when not able to do so their feet should be washed often. On the outbreak of the disease, all the inmates who can be moved should be sent away, the infected ward be shut up, and the erysipelatous patients put into separate small rooms. Surgeons and pupils should not come to the bedside, especially to a midwifery case, immediately from the dead-house or dissecting-room, still less from a case of erysipelatous disease. The dressings and bandages used in any case should be destroyed, and tow, which may be destroyed when once used, should be substituted for sponge, which would be used again and again. Moreover, in the case of fetid and profusely-suppurating wounds, it would be far better for the patient so affected, and for the others likewise, that he should be put into a hut, or tent, or cottage, than be allowed to re- main in a crowded ward. Bags filled with charred saw-dust, or any other form of charcoal, should be placed so as to absorb all putrid vapors; and Condy's, or Burnett's or Macdougal's disinfectant, or the chloride of lime, should be used liberally. SECTION II.—THE CUTANEOUS AND CELLULO-CUTANEOUS ERYSIPELAS. Definition.—Diffused inflammation of the skin, or skin and cellular tissue, with a tendency to spread. Symptoms.—The cutaneous or simple erysipelas is known by redness of the skin, which disappears momentarily on pressure;—considerable puffy swelling from serous effusion into the cellular tissue ;—and severe stinging, burning, or smarting pain. The redness is generally of a vivid scarlet hue ; but it will be faint and yellowish if the disease is attended with much debility, or if it affect the eyelids, scrotum, or other loose cellular parts, where it always produces a good deal of serous effusion. In the cellulo-cutaneous or phlegmonous erysipelas the redness is deeper, and sometimes dusky or purple, and it is scarcely, if at all, dispelled by pressure;__the swelling is much greater, and is hard, brawny, and tense;— and the pain is not only burning, but throbbing. [A remarkable symptom, and one very often observed, is a painful swelling of the lymphatic glands that receive the lymphatic vessels of the part about to be attacked with erysipelas, although there is as yet no appreciable change in the color, thickness, temperature, and sensibility of the skin. This swell- ing, which is to be found in at least two-thirds of the cases, precedes the development of the erysipelas from twenty-four hours to one week. It is a phenomenon to be noticed, as its occurrence will place the surgeon on his guard.] . . Constitutional symptoms.—-Both varieties are ushered in with shivering, headache pain in the back, nausea, and bilious vomiting; and both are attended with fever, which will vary in its type according to circumstances. It may be of a sthenic inflammatory character, if the disease affect a young robust countryman ; but it soon assumes a low typhoid character if the patient is old and weak; or if the disease were contracted in some close, 80 ERYSIPELAS. foul, ill-ventilated hospital, or if a large portion of cellular tissue has begun to slough. Terminations.—The cutaneous erysipelas may terminate, 1, in resolu- tion, leaving nothing but desquamation of the cuticle with slight oedema; 2, but more frequently it produces large bullse or vesicles from effusion of serum under the cuticle ;—and these dry into scabs, which peel off, and leave the cutis either healed, or superficially ulcerated. 3. Sometimes, however, it is followed by small abscesses. The ordinary duration is from seven to fourteen days. Before its termination, however, this variety of erysipelas sometimes assumes a lingering erratic character, wandering progressively along the skin, and spreading in one direction as it fades in another. Sometimes it disappears entirely from one part, and flies by metastasis to a distant one ; and sometimes it quits the skin suddenly, and some internal organ is affected with an inflammation having the same constitutional characters. The phlegmonous or cellulo-cutaneous erysipelas may terminate as favor- ably as the simple variety ;—but it more generally leads to unhealthy sup- puration and sloughing of the cellular tissue ;—in which case the swelling becomes flaccid and quaggy;—patches of the skin become purple, and covered with livid vesications, and these patches slough, giving exit to a thin sanious pus, and to flakes of disorganized cellular tissue. And not only the subcu- taneous, but the intermuscular tissue and fasciae may slough, rendering the limb useless, even if the patient escape with his life. Moreover, after a very severe attack of erysipelas, the cellular tissue is apt to be left in a hardened, brawny state, through infiltration with lymph. Prognosis.—This must be guarded if the patient is old, enfeebled, and habitually intemperate ;—if the fever is of a low cast; if the malady is situ- ated on the head or throat, and there is coma or great dyspnoea;—or if the erysipelas is of the phlegmonous variety, and a large portion of the cellular tissue and skin is on the point of sloughing. The return of suppuration in ulcers, and the formation of abscesses, are most favorable signs. Local Varieties.—Erysipelas usually attacks any part of the body which is injured or wounded ; and in new-born children the vicinity of the navel; but where there is no external injury it usually manifests itself on the fore- head : whence it may spread to the scalp, throat, and trunk. Erysipelas of the scalp is apt to be complicated with headache and delirium in the early, and coma in the later stages; and erysipelas of the throat with great dyspnoea. Treatment.—The indications for the constitutional treatment are, to purify the blood and to support the strength ;—and for the local treatment, to allay irritation—to arrest the extension of the disease—and to give free exit to sloughs and discharge Emetics and Purgatives.—It is always necessary to begin with what Dr. Todd calls eliminative treatment; that is, to produce a full and copious discharge of all the excretions, by which the blood is naturally purified. On the first occurrence of the symptoms an emetic should be given (F. 98), and be followed by five grains of calomel, and by purgative draughts, every six or eight hours, as long as they bring away hardened lumps, or dark offen- sive liquid motions. (F. 33, 34.) Antiphlogistic Measures.—Bleeding is said to be required if the patient is young and vigorous, the pulse full and strong, the face flushed, and deli- rium violent; and if the inflamed part is full, tense, and vividly red, and especially if seated on the head or throat; but in most cases, a small dose of mercury at night, F. 63; with very gentle aperients and carbonate or citrate of ammonia, F. 58, will suffice, after a good preliminary purging by calomel. The practice of bleeding in zymotic disease belongs to a past generation. PYAEMIA. 81 Diet.—During the whole course of the disease, the patient should have a good quantity of nourishment; beef-tea, soda-water and milk ; barley-water with lemon-juice, and port wine or brandy ad libitum, in proportion to the failure of pulse. Tonics.—Bark should be given in all cases as soon as the tongue be- comes clean and the skin moist; but it should be resorted to without delay if the pulse is soft, tremulous, or very rapid, the heat moderate, and the delirium low and muttering, or if suppuration or sloughing has com- menced, F. 1. Opium may be given in full doses at bedtime in the later stages, to allay restlessness, provided there is no cerebral congestion nor coma. If there is great irritation of the stomach, with sickness or diarrhoea, small repeated doses of hydr. c. creta et pulv. ipec. c. should be given with effer- vescing draughts, F. 64, 58. [The tincture of the chloride of iron, given in frequently repeated doses, has a very marked effect upon erysipelatous inflammation; in that type, at least, in which it has appeared in this country for several years past.] Local Measures.—Leeches are useful when the pulse is good, and the redness vivid, and the part throbbing violently. Minute punctures about one-fifth of an inch deep, made with the point of a lancet, may be used as substitutes; and often permit the discharge of considerable quantities of blood and serum. Cold lotions may be used under similar circumstances. But warm or tepid poppy fomentations will generally be found more sooth- ing, and theoretically are safer than cold applications.—Flour, dusted on the inflamed part, or soft carded cotton wool, is often very soothing in simple erysipelas.—Pressure by bandages is serviceable in the latter stages of most cases ;—and from the very first, if the inflammation be atonic and oedema- tous.—Stimulants. Painting the surface with solution of nitrate of silver, or blisters, are of great use in creating a healthy exudation, and so putting a stop to tedious erratic cases of simple erysipelas, after proper constitu- tional remedies have been used. In similar cases, the extension of the disease may sometimes be arrested by applying the nitrate of silver so as completely to encircle the inflamed part. When there is a tendency to sinking, with diminution or disappearance of the external inflammation, warm cloths, moistened with turpentine or sp. camp, may be applied ex- ternally, whilst diffusive stimulants are administered internally. Incisions are, to use a French expression, the heroic remedy in phlegmo- nous erysipelas. When the swelling is great, and increases rapidly ;—when it is hard, tense, and resisting, not soft and cadematous as in simple erysipe- las ;—when the pain is severe and throbbing ;—when there is the least sen- sation of fluctuation or quagginess; or when the skin is becoming livid or dusky, or covered with livid vesicles, they are imperatively demanded. They are absolutely necessary for the discharge of pus and sloughs ;—for, as James observes, these matters are neither brought to the surface by pointing, nor walled in by adhesion. And they are not merely apertures for the discharge of matter, but a very effectual means of cutting short the inflammation, by relieving the tension, and by emptying the distended bloodvessels. They are also requisite in erysipelas of the throat, when great swelling threatens suffocation by pressure on the trachea. They should be made of sufficient length—in as many places as required;—they should be carried quite deeply through the diseased tissues, and should be repeated as often as neces- sary. Two, three, or four inches will be a sufficient length in most cases; but it can never be necessary to gash a limb from hip to ankle. They should not be permitted to bleed long ;—and hemorrhage, if profuse, is best stopped by continued pressure with the fingers on the bleeding points. The subse- 6 82 PYAEMIA. quent measures are poultices, followed by nitric acid lotion; and bandages to prevent lodgment of matter and sinuses.1 SECTION III.—PYiEMIA, AND THE CONSEQUENCES OF SEPTIC LIQUIDS INTRODUCED INTO THE VEINS. Definition.—Pyaemia is a diseased state of the blood, caused by the in- troduction of decomposing animal matter; often producing rapid effusions of fibrine or of puriform fluid into several internal organs. Symptoms.—The symptoms are those of puerperal fever, erysipelas, and dissection wounds. If a patient, after parturition, injury, or operation, is seized with severe shiverings, pulse rapid, countenance anxious, weight about the heart, spirits low, healthy suppuration (if any) arrested, tongue dry, tight headache, sleeplessness, sallow skin, and nausea, this disease may be predicated. But there is an almost infinite variety in the further progress and specific symptoms in various cases, depending on varieties in the kind or mode of action of the blood-poison ; and these we proceed to enumerate. 1. In some cases the patient sinks; life is extinguished by the poisoned state of the blood, without the development of any local disease. 2. In a second set the poison expends its chief force on the liver, which exudes an immense quantity of dark bile, discharged by vomiting and purg- ing. This seems to be a natural and beneficial effort at elimination. 3. The bowels may be the part to which the poison is determined ; then, there is great discharge of mucus, or serous, or bilious, or bloody liquids, of various colors and foetor, and after death the mucous membrane is found intensely congested. This too seems salutary in its intention. This second and third set of cases correspond to the bilious and dysenteric forms of puer- peral fever. 4. Inflammation of the serous membranes may ensue ; rapid pleurisy, cough, dulness on percussion from effusion of bloody or turbid serum; or pericarditis; or effusion into the head, with delirium and coma ; or peri- tonitis, tenderness and tightness of the abdomen, patient lying on his back, and not breathing with the diaphragm. 5. The skin may be, though less commonly, affected. There may be pro- fuse offensive perspirations, or in some cases an attack of erysipelas, or an eruption of carbuncles, or of pustules like those of smallpox. 6. Lastly, the most characteristic effect is that from which the name pyaemia is derived ; namely, the production of profuse suppuration. There can be no doubt that decomposing pus or fibrine, mixed with the blood, spoils a considerable portion of its ingredients, and that the blood elements so spoiled, are deposited in the form of unhealthy fibrine, which usually softens down into puriform fluid. Thus are formed the abscesses, which are sometimes called secondary, or metastatic, or purulent depots—names which are correct enough, in so far as they imply that the puriform fluid is deposited in and not elaborated by, the suffering part, which may be said to be, pathologically, more sinned against than sinning. The most usual situa- tion of these abscesses is, as might be expected, the lungs and liver, parts much traversed by blood ; but they may occur in the eye, the joints, or any other part, and may form with extreme rapidity. The patient, who may be lying in bed, with anxious, sallow countenance and rapid pulse, but no par- ticular local symptoms, may all of a sudden complain of excruciating pain in the shoulder or calf, or some other part. This may pass off by degrees, with no great or mischievous effusion; or, on the other hand, in a few hours 1 Vide James, op. cit.; Copland, Diet. ; Higginbottom on Nitrate of Silver; Copland Hutchinson's Surgical Observations ; [Gross, op. cit. vol. i. part 2d, chap. i. sect, i.] PYAEMIA. 83 the part so complained of may be found a bag of pus. Abscesses in the lungs or liver do not often give rise to much pain. We must add to the list of consequences, the possibility even of gangrene of the oesophagus, or of any other part, internal or external. Amongst the forms of suppuration, one that is common is that to which the name diffuse inflammation of the cellular tissue has been given. It ap- pears to be the cellulo-cutaneous erysipelas, without the affection of the skin. A rapidly-increasing swelling appears on one of the limbs, or on some part of the trunk. Its surface is tense, shining, and usually pale. When pressed upon, it feels in some cases hard and resisting, but more frequently it yields that peculiar, semi-elastic sensation described by the term boggy, or quaggy. There is always most excruciating pain—which in some cases is burning and throbbing, in others heavy and tensive. The disease is invariably attended with fever of an asthenic character. The pulse is always frequent; it may be sharp and jerking, but is without strength and steadiness. The counte- nance is anxious and haggard ; the mind irritable and desponding, and de- lirious at intervals ; respiration quick and laborious. In unfavorable cases, low muttering delirium, copious offensive perspiration, and jaundiced skin, usher in the fatal termination.1 This form of inflammation is produced by dissection wounds, glanders, and snake-bites. Prognosis.—This disease is always serious; often fatal. The patient's chances of recovery may be estimated by a knowledge of the characters of the prevailing epidemic; by considering the amount of local mischief; and the degree in which the constitution seems able to resist the disease, as indi- cated by strength of pulse, clearness of intellect, sleep, or the reverse. The disease may prove fatal rapidly ; or the patient may linger, and slowly sink from abscesses or visceral disease; or, he may recover, if the amount of local mischief is not great, and if the excretory organs are enabled to get rid of the poisonous material before the patient is quite exhausted. The author has been repeatedly struck with the immense quantities of lithate excreted with the urine of women recovering from slight attacks of puerperal fever. Causes.—1st. The predisposing causes are those that produce a low state of constitution, and render the blood incapable of forming a firm clot; such as profuse loss of blood ; deprivation of food ; anxiety of mind ; organic disease; impure states of the atmosphere; residence in the contaminated air of an hospital. 2dly. Disturbance of the coagulum in a wounded vein ; as by exercise of an arm after venesection, or imprudent movements soon after parturition ; local circumstances interfering with the closure of veins, such as the patulous condition of the veins of bone, of the liver, and of the sinuses in the dura-mater, which allows of the ready passage of diseased fluids into them. A very large proportion of cases of pyaemia are found to follow in- juries and operations on the bones. 3dly. Infection or contagion from puerperal fever or erysipelas; or inoculation with putrid fluids.2 Treatment—The leading indications are, 1, to purify the blood; 2, to keep up the strength. For the first purpose it is well to give one ten-grain dose of calomel, and to follow it by purgatives; saline purgatives, F. 33, 34, 35, 42, if the bowels are torpid—milder ones, as rhubarb and castor oil, if they are inclined to diarrhoea ; endeavoring to bring away black or yellow 1 See two papers in the Edinburgh Medical and Surgical Journal for 1825. vol. xxv..; Copland's Diet. Art. Cellular Tissue ; James on Inflammation ; Travers on Constitu- tional Irritation ; and Butler on Irritative Fever, Devonport, 1825, which gives an ac- count of an extraordinary visitation of this disease in Plymouth Dockyard m li-24. 2 See Robert Ferguson on Puerperal Fever, Lond. 1839 ; Arnott, M. C. T. xv.: Henry Lee, Med. Gaz., vol. xxxviii. ; London Journal of Medicine, March and July, ISoO ; also Med.-Chir. Trans, for 1852. 84 PHLEGMASIA DOLENS. fetid stools, not mere water or slime. An emetic may sometimes be of ser- vice. For the second purpose, good beef-tea and port wine are of most value ; but it will be very desirable to consult the patient's taste. Some patients crave for bottled beer; others for soda-water, with or without brandy ; or milk, or lemonade, or nitro-muriatic acid, F. 22, or simple effer- vescing draughts; and in almost all cases the dictates of nature may be safely yielded to. Pain and restlessness may be allayed by regular doses of opium, administered in sufficient quantity to produce sleep at night and to tranquillize the nerves; such as eight or ten grains of Dover's powder at bedtime, with a small dose of hyd. c. creta; and smaller d6ses of Dover's powder during the day. In other respects, the practitioner must treat symp- toms : local pain and tenderness by a few leeches and fomentations ; inflam- mation of pleura, or peritoneum, or joints, by leeches and bran or mustard- poultices, or blisters; diarrhoea, if exhausting, must be moderated by chalk or bismuth mixture, and by isinglass ; and in all respects the strength should be husbanded, and the constitution assisted in its struggles with this too fatal disease. Whenever suppuration or puriform deposit takes place, incisions are ne- cessary, on the same principle as in phlegmonous erysipelas. SECTION IV.--PHLEGMASIA ALBA DOLENS. This disease apparently depends on the reception of poisonous fluids into the veins, the coagulation of the blood in them, and the exudation of fibrin- ous matter into the tissues in which the affected veins and their branches are situated. The symptoms are peculiar, and well expressed by the threefold name. There is swelling, considerable, firm, and not cedematous; with the surface of the skin pale ; intense heat; very excruciating pain ; and loss of all power of using the muscles. The importance of this disease depends very much upon the circumstance whether it is purely local,, or accompanied by genera] blood-infection. If local, the consequences are obliteration of ven- ous trunks, obstinate swelling and oedema of the parts below; perhaps abscesses around the affected veins. If accompanied with pyaemia, there will be some one or more of the consequences of that disease which we have just described. This, like all other diseases of its class, is most common in women after parturition, especially if they have lost much blood; and< the open veins of the uterus, and the fetid discharges with which they are in Contact, furnish a ready explanation of the cause. The part affected is generally the thigh. But it is not confined to women, as the following cases from the author's note-book will show. A very stout gentleman had for two years a small fistulous orifice in the ham, resulting from a boil. This be- came the seat of fresh inflammation, and was freely laid open with great relief. On the fifth day he was rather feverish; there was an obscure doughy swelling, not cedematous nor fluctuating, over the inner part of the thigh ; there was no pain, but a sense of tightness. This increased during the next three days, and became painful, till the whole thigh was greatly swelled and doughy, the leg cedematous. A hospital-surgeon insisted that there must be deep-seated suppuration; and made a long and deep gash on the outside of the thigh. The parts cut seemed gelatinous, and exuded very little blood, no pus, and no serum. The pulse gradually rose ; headache, diarrhoea, and delirium came on. The thigh continuing in statu quo, the hospital-surgeon made deep punctures in the upper part of the limb with a grooved needle : neither serum nor pus exuded. Death on the twentieth day. The writer has also seen it in a gentleman, recovering from a sloughing sore produced by scarlet fever. ULCERATION. 85 Treatment.—For the local symptoms, nothing answers so well in the case of women, as warm poppy fomentations, or bran poultices sprinkled with laudanum ; and, later in the case, gently smearing with opiate liniments, F. 147, and wrapping up in flannel bandages. The bowels should be gently relieved. Opium should be given to allay the pain. All lowering and vio- lent remedies are hurtful.1 CHAPTER XII. ULCERATION. SECTION I.—THE PATHOLOGY OF ULCERATION. Pathology.—Ulceration consists in the progressive softening and disin- tegration of successive layers of the ulcerating tissue. Symptoms.—It generally begins as an excoriation, i. e., slight inflam- mation, with loss of cuticle. Then the skin beneath begins to melt away, its surface being covered with a tenacious slimy matter. If this is wiped off, or separates, the surface underneath is seen to be red, -and it easily bleeds. Supposing the case to proceed, there is formed a chasm, eaten into irregular hollows, with intervening red eminences, which easily bleed if touched; its edges are ragged or undermined; the surrounding skin red, hot, and swollen; there is a thin serous, or bloody discharge, and a severe gnawing pain. An ulcer having these characters may always be considered as extending itself. Ulcers spread with varying degrees of rapidity. An attack of violent inflammation may cause the death of a considerable portion of the affected tissue in a very short time; then there is said to be a sloughing ulcer. When an ulcer spreads very rapidly, but regularly and without sloughing of any great portion at one time, it is called phagedsenic. And when it spreads more rapidly still, not by one fit of sloughing, but by the constant reiterated mortification of considerable layers, the disease receives the name of slough- ing phagedaena. Pathology.—The ulcerative process generally consists in the inflamma- tion, and infiltration with unhealthy lymph, of a part whose vitality is already greatly impaired, and in the gradual disintegration and discharge both of the exudation and of the tissues in which it is situated. Secondly, it may consist in the destruction of the surface of a tissue, by some poison, as that of syphilis, which has the power of giving its own properties to the solids and fluids around, so as to propagate the means of increasing destruction. Or, thirdly, in the softening and discharge of some special morbid deposit, and of the parts in which it is found, as in the ulceration of Peyer's glands in typhoid fever, or of any part infiltrated with scrofulous deposit, as in lupus. Lastly, a primary ulceration, i. e., a softening and disintegration from mere debility, independent of inflammation or other anterior change, may occur, as in the cornea, during periods of intense debility.3 1 See Mackenzie on Phlegmasia Dolens, Lancet, March 19, 1853, 2 The former editions of this work contained a copious array of arguments, in favor of the disintegration theory of ulceration, as opposed to the absorption theory of Hunter; but it is not°necessary to repeat them now, since the question may be considered as settled For further information, consult Mr. Gaskell's MS. Jacksonian Prize Essay on Ulceration in the Library of the College of Surgeons in London, and the preparations accompanying it; also J. W. Earle, Med. Gaz. for 1835 ; C. Aston Key, Med. Chir. Trans vol. xviii. and xix. ; Copland, Diet. Pract. Med. Art. Inflammation ; Pearson's Principles of Surgery; and particularly Wallace on the Venereal Disease, Lond. 1838, p. 47. 86 VARIETIES OF ULCERATION. It will be noticed in its proper place, that bone, and cartilage, and teeth, sometimes ulcerate by disintegration, sometimes seem to be removed by a rapid cell-growth in the textures in contact with them. Predisposing Causes.—The Tissues most disposed to ulceration are the skin, and the mucous and synovial membranes. From these it may spread to other subjacent tissues, which yield to it with varying degrees of rapidity. The areolar tissue ulcerates very easily, but muscles, blood- vessels, and nerves, very slowly; so that they often appear to be as it were dissected out in spreading sores, by the destruction of the areolar tissue around them. Tendons and ligaments are also very slow to ulcerate owing to their physical qualities ; but cartilage, bone, and the cornea are in cer- tain constitutions extremely liable to it. The serous membranes very rarely ulcerate primarily.1 The Constitutions most liable to ulceration are those which are debilitated by intemperance or privations ; tainted with syphilis or scrofula;—or broken down by the excessive use of mercury;—or in which the blood is impure from inaction of liver, skin, and kidneys. The parts most disposed to it are those whose circulation is most weak and languid ; such as the lower extremities: and more especially if the return of their venous blood be in any way impeded by a varicose state of the veins. On this account, tall persons are much more frequently affected with ulcers of the legs than the short. Sir E. Home shows, on the authority of Dr. Young, that twenty-two out of one hundred and forty-five tall men, and only twenty-three out of two hundred and seventy-six short men, were discharged from a regiment in the West Indies in four years, on account of ulcers. Defect of nervous influence may cause parts to ulcerate or mortify. Ulcers of the cornea have followed injury to the fifth, and ulceration of the hand has followed injuries of the median nerve.2 But whether the tendency to ulcerate is produced directly, or whether it follows indirectly from loss of sensibility to injury, is a question. Exciting Causes.—In constitutions or parts predisposed to it, the slightest irritation may be sufficient to excite ulceration. In the healthy it may be produced by the continuous application of some irritant, such as continued pressure, or contact with poisonous secretions. SECTION II.--THE VARIETIES OF ULCERS. Definition.—It is not easy to give a rigorous definition of the term ulcer, nor is it necessary. For all useful purposes, it will suffice to say, that it signifies a chasm on the surface of any organ caused by the stripping off of its proper cuticle or epithelium, or by the destruction of a portion of its substance by disease, or by injury which has not been repaired. Ulcers present many varieties, which may be classed under three heads. 1. Healing.—They may be in a state tending to reparation; as the healthy ulcer. 2. Stationary.—Their surface may have an imperfect form of organ- ization, under which they may be incapable of healing, though they are not necessarily spreading; the weak and indolent ulcers are examples. 3. Spreading.—They may be under the influence of the destructive process which formed them originally, and which is still causing them to spread ; as the phagedsenic. I. The Healthy or Healing Ulcer is nothing more than a healthy, granulating, and cicatrizing surface. The granulations are small, numerous, 1 There is a specimen of ulceration of peritoneal coat of stomach. Organs of Di- gestion, 76, Musee Dupuytren, Paris. 2 ;5ee cases quoted by Paget from Swan and Hilton. Med. Gaz. N. S. vol. iv. p. 1023. inflamed ulcer. 87 florid, and pointed, and yield a moderate secretion of healthy pus. The edges are smoothed and covered with a white or bluish semi-transparent pellicle, which is gradually lost on the margin of the granulations. In favorable cases such an ulcer may cease to granulate and suppurate, and may fill up with moist lymph, which rapidly cicatrizes. Treatment.—The only treatment required will be a little dry lint, if there be much discharge, or the water-dressing, or simple ointment, if there be not. If there be not much discharge, the dressings should not be changed more frequently than every second or third day. If the granulations are too luxuriant, they may be touched with lunar caustic, and dressed with dry lint. If the granulating surface is very extensive, or if all applications disagree with it, as sometimes happens, it will be expedient to form a scab on its sur- face ; by sprinkling a little chalk on the surface, or by passing a stick of lunar caustic over the surface of the sore, as recommended by Mr. Higgin- bottom. This salt instantly coagulates the fluids on the sore, and forms a white pellicle, which soon becomes dry and black, and is much less irritating than an ordinary scab. If the scab act favorably, suppuration ceases, and cicatrization will be found complete when it is detached. II. The Inflamed Ulcer, with which we may conjoin the Irritable Ulcer, is hot, tender, and subject to gnawing pain. The surface is red and easily bleeds ; the discharge is thin and ichorous. The usual situation is the leg; the class affected, the laboring population; the predisposing cause, an unhealthy state of skin from degeneration of the veins; the ex- citing cause, any injury whatever occurring at a time when the health is deranged. A thin, foul, copious discharge is generally a true natural pro- cess of elimination, and requires purgatives. Treatment.—The patient should be kept in bed with the limb raised on a pillow. [Dr. Sargent, in the previous American edition, calls particular attention to this advice. He says : " Too much stress can scarcely be laid upon the importance of perfect rest of the part, in the treatment of ulcers. If the lower extremity be the seat of the disease, a fracture-box will be found to be the most convenient apparatus for the fulfilment of this indica- tion : a pillow, protected by a piece of oil-cloth, upon which bran or cotton is spread to imbibe the secretion from the ulcer, should be placed in the box, and the limb laid upon it and secured by closing the sides of the box, the foot being attached to the foot-board. If the arm be the part affected, it should be placed upon a splint, and confined by a bandage so applied as that no undue pressure shall fall upon the ulcer."] The first point is to amend the general health. For this purpose, if the tongue is white, and the patient feverish, active purgatives must be given (F. 33), with salines (F. 39). For the local treatment, in the first place soothing applications should be resorted to ; and the author, from very extensive experience, most strongly recom- mends the poppy lotion (F. 121) applied warm, by means of pieces of lint covered with oiled silk, and changed three times daily. Washing should be effected without touching the sore. Plain bread-and-water poultices (F. 153) and lead lotion sometimes answer well. If warm applications aggravate the pain, cold evaporating, or saturnine lotions (F. 115, &c.) should be used, the sore being protected by a piece of oiled silk or simple dressing. When feverishness has been relieved, and the bowels well opened, pain may be relieved by henbane, or hemlock, or F. 30; or, if very severe, and there is a great mental anxiety, the patient should have such a dose of solid opium at night as will insure sleep, and such smaller doses during the day as may be requisite. . Then if the soothing plan ceases to do good, very mild stimulants may be tried, in the form of lotions, applied by means of small pieces of lint thoroughly soaked, laid gently on the sore, and not beyond the edges, and 88 indolent ulcer. covered with oiled silk, or lint thickly spread with spermaceti ointment. The lotions of nitrate or acetate of lead, or of zinc (F. 116), and black wash, are the best. Should these not answer, and the pain of the ulcer de- pend evidently on irritable surface, and not on inflammation, the surface may be destroyed by lunar caustic, or by nitric acid. III. The Weak Ulcer has large, pale, flabby, and insensible granula- tions rising above the margin of the skin, and showing no disposition to cicatrize. IV. The Indolent Ulcer has its surface smooth and glassy, and of a pale ashy color, like a mucous membrane. Sometimes, however, it displays a crop of weak fungous granulations. The edges are raised, thick, white, and insensible ; the discharge scanty and thin. Such ulcers are often sta- tionary for a great length of time ; but from any slight cause of irritation, may enlarge rapidly by ulceration or sloughing ; and even when they have made considerable progress in healing, the granulations and cicatrices that have been months in forming may perish in a few hours from some constitu- tional disturbance or local injury. Treatment.—The general rules are, to promote constitutional vigor by good diet and tonics, to excite the local actions by various stimulants, and to support the venous circulation in the affected part. The following is perhaps the best plan of curing these ulcers. A number of pieces of lint, thoroughly soaked in the nitric acid lotion, should be laid on the sore, and be covered with a warm soft poultice. These applications should be changed twice a day, and be continued till the discharge becomes healthy, and granulations begin to arise. During this time the patient should be, confined to bed and be purged. Afterwards, when the surface is clean, the following mode of dressing may be adopted. First, some pieces of lint, saturated with the nitric acid lotion, or zinc lotion, or with some other stimulating substance, should be laid on the sore. Then strips of ad- hesive plaster, about 1^ inch wide, should be applied two-thirds round the limb, from an inch below the ulcer to an inch above it; and in applying each strip, the edges of the sore should be drawn together with a moderate degree of force. Next, a compress of soft linen should be placed over the plaster, and, finally, the limb should be well and evenly bandaged from the toes to the knee ; observing that the bandage is to be applied most tightly below, and more loosely by degrees as it ascends. Fig. 11. Application of the bandage to the leg. The frequency with which the dressings should be changed, must depend on the state of the discharge ; for if that be profuse they should be changed every day; otherwise from twice to four times a week will suffice. ^^fc One thing scarcely noticed by writers, but perhaps of more consequence M^Kthan most plasters, is the observance of perfect cleanliness. When it is indolent ulcer. 89 considered how filthy the habits of many persons are, who often leave their legs and feet unwashed for weeks and months together, it cannot be wondered that skin so neglected should, in the decline of life, possess a very imperfect vitality; and the author is convinced by experience, that daily washing the lower limbs with a piece of flannel and yellow soap and water, is one of the best means of reviving their decayed powers. During this plan of treatment, the patient may, after the first few days, walk about moderately ; but he should not stand about, nor sit with the leg hanging down. If the common strapping irritate the skin, the empl. plumbi, spread upon cheap thin split leather, or the isinglass plaster, will answer better. But although the plastering and bandaging are adapted for most cases, the immediate application to the ulcer will require to be frequently varied. Sometimes the strapping may be applied without anything else ; or dry lint may be placed under it; or lint imbued with lotions of sulphate of copper, or alum; or with lotions made by adding half an ounce of the tincture of myrrh, or of benzoin (comp.), or aloes (comp.), to four ounces of water; or the balsams of copaiba or Peru; but metallic preparations agree better in general than the vegetable. The author fancies that resinous lotions and ointments are best when the skin is irritable and eczematous, or covered with scales of cuticle which readily peel off. In such cases plasters cannot be borne. The ung. hyd. nitric, oxid. is very useful;—and the ung. hydrarg. nitrat. dilut. is praised for its efficacy in reducing thick callous edges. The green ointment is worth a trial. F. 171. Particular Plans of Treatment.—From the middle of the last century, when the surgeons of St. Thomas's Hospital were in treaty with an apothe- cary in Half Moon Street for the purchase of an infallible method of healing ulcers, or rather from time immemorial to the present, the multitude of plans recommended for the treatment of ulcers, shows but too truly that they all often fail. Pressure forms the basis of many plans; as Baynton's and Scott's, accord- ing to which the affected limb is inclosed in strips of plaster, regularly applied from the foot upwards.1 A well-applied calico bandage is always Fig. 12. Application of adhesive strips over the ulcer. of service. A laced stocking, or elastic stocking, is still better. Pressure may be combined with exclusion of the atmosphere; as in the plan of Mr. 1 Baynton, T.. Descriptive Account of a New Method of Treating Old Ulcers of the Le°-s, Bristol, 1797; Burnes, Lancet for 1847, vol. i. ; Critchett, James Arnott, Chap- man,' and others in Lancet for 1848 and 1849 ; Burgess's Cazenave, p. 288 ; Gay, Lancet, 1853', vol. i. p. 566. 90 FISTULOUS ULCER. Stafford, who recommends old, deep, indolent ulcers to be treated by filling up their cavity with a mixture of one part of Venice turpentine, and four of beeswax, melted, and poured in warm. Mr. Syme covers an indolent ulcer with a blister. M. Malgaigne is said to use in some cases a warm iron held at a little distance from the ulcer, so as to dry its surface. Heated air, or fumigation with vapor of sulphuret of mercury, or of iodine with sulphur, has been used by Mr. G. A. Walker and others. The affected limb is put into a tin case, or large jar, provided with a heated iron at the bottom, and with a grating above this, to prevent the patient from being burnt. On the heated iron there is to be sprinkled, just before the patient's limb is subjected to the treatment, a powder composed of thirty grains of sulphur, six of cin- nabar, and two of iodine; and the top of the apparatus should be covered with a thick cloth, to prevent the vapor from escaping. The limb may be thus fumigated for fifteen minutes every day, and the quantity of iodine gradually increased fourfold. Mr. Gay has called attention to the fact that cicatrization proceeds only from the cutis vera, and, consequently, from the edges of an ulcer; that there appears to be great difficulty in cicatrizing a wide surface ; and that nature causes the skin to contract, so as to cover the vacancy, in preference to form- ing a large cicatrix;—and that the healing of many ulcers is delayed because the surrounding skin cannot contract; either through adhesions which bind it down to the subjacent parts, or through extensive loss of skin, or from the fact that the sore is situated on a projecting part, as the ankle. Hence he proposes, in some cases, to liberate the edges of the sore by incisions parallel to, and at a little distance from them; or to excise the edges and surface of the ulcer, when firmly bound down by hardened tissue. Should old ulcers be healed ?—The propriety of healing old ulcers has often been made a question, inasmuch as certain diseases, and especially apoplexy, palsy, and mania have been said to come on afterwards. Sir E. Home specified the following cases in which a cure ought not to be attempted. 1. If the ulcer be "evidently affected with the gout, having regular attacks of pain, returning at stated periods ; and those attacks similar to what the patient has experienced from gout in other parts." 2. If an ulcer habitu- ally occur whenever the constitution is disordered. 3. If the patient be very infirm and old; for under these circumstances the removal of an habitual source of irritation, or the diversion of an habitual afflux of blood may prove fatal; more especially as very old ulcers have been known to heal spontaneously a short time before death. To these cases must be added that of ulcers on the legs of stout women, about the critical time of life, and displaying a tendency to discharge copiously as the periodic uterine flux diminishes. On this point we may observe, 1, that in the case of every habitual ulcer, purgatives should be freely used during the cure, and for some time after it. 2. That if, spite of this, there be symptoms of congestion in the head, an issue or a seton in a convenient situation may answer the purpose of an ulcer in an inconvenient one; and, therefore, that with these safeguards ulcers on the legs may always be healed—if possible. VI. The Fistulous Ulcer (Fistula or Sinus) is a variety of the indo- lent, and consists of a narrow channel lined by a pale pseudo-mucous mem- brane, which may or may not lead to a suppurating cavity. In old cases the parietes of the tube are often dense and semi-cartilaginous. Causes.—Fistulae are produced when abscesses are not thoroughly healed from the bottom ; when there has been a defect in the bandaging or in pro- viding proper outlets for the discharge; or when there is some standing cause of irritation, as a ligature, or a piece of dead bone, which keeps up a dis- charge of pus. PHAGEDENIC ULCER. 91 Treatment.—The first indication is to remove any source of irritation that may happen to exist, and diseased bone should always be looked for. The second, to prevent the lodgment of matter; for which purpose it may per- ' haps be necessary to make another opening. The third indication is to produce, by stimulating injections, especially the strong caustic lotion, the destruction of the pseudo-mucous lining, and to cause the exudation of plastic matter, so as to fill up the fistula. At the same time the sides of it should be kept constantly pressed together with compress and bandage. If these means fail, the fistula should be slit up with a bistoury ; and then a thin piece of lint be introduced in order to prevent premature union of the cut edges, and make it heal from the bottom. The fine-wire cautery, invented by Mr. Marshall, which can be passed into the track, and then heated to a white heat by means of a galvanic current, is a very efficient instrument, both for the vivification of the interior of a fistula, and for laying it open without hemorrhage,—the white-hot wire cutting its way out readily.1 If there have been a succession of small unhealthy abscesses in a part, or if ulceration have spread irregularly in the cellular tissue, so as to leave the skin ragged and extensively undermined with tortuous sinuses, it may be advisable to destroy the whole of the parts so diseased by the potassa fusa; and this will stimulate the neighboring sound parts, so that when the slough separates, a healthy surface will be left, which may be healed by the ordinary means.3 VII. The Varicose Ulcer occurs in consequence of a varicose state of the veins of the lower extremity. This greatly impedes the return of blood, and, by producing habitual venous congestion, weakens the parts, and ren- ders them prone to ulceration. The ulcers are usually three or four in number, situated above the ankle. They are oval in shape, indolent in their progress, and neither extensive nor deep; but they are attended with con- siderable pain, which is of a deep-seated, aching character. The treatment must be directed principally to the veins; and for this we must refer to the chapter on that subject. We will merely observe here, that the applications to the ulcers must be suited to their condition, whether irritable or indolent; and that great relief to the pain is sometimes obtained by opening one of the enlarged vessels, and abstracting a moderate quantity of blood. The advantages of proper support by bandages or laced stock- ings, or by encasing the limb in strapping from the foot upwards, need scarcely to be noticed. Sometimes there is a constant desquamation of the cuticle, with serous discharge, for which the best remedies are equal parts of lime-water and milk, or the ointment of chalk (F. 164), or oxide of. zinc, or F. 131, or 188. VIII. The Sloughing Ulcer is formed whenever either of the other varieties of ulcer is attacked with sloughing,—which is particularly liable to occur to the indolent, when subjected to undue irritation. Or, this name may be given to ulcers originally produced by a sloughing of the skin,—as on the legs of the dropsical. Treatment.—The best applications are warm fomentations of poppy de- coction, to which a little spirit has been added ; poultices of yeast or carrots ; or the nitric acid or chloride of lime lotion on lint; or the creasote oint- ment F. 163, which the author particularly recommends. IX. Phagedena is a peculiar variety of ulceration in which copious exudation, and infiltration of the affected part, go hand in hand with rapid decomposition. The surface of the sore is irregular, generally whitish or yellowish ; the discharge serous or bloody, and often extremely profuse; and the pain extreme. Some cases are attended with fever and acute inflam- » Med.-Chir. Trans, vol. xxxiv. 2 Liston, Elements of Surgery. 92 SLOUGHING PHAGEDENA. mation, the margin of the sore being highly painful, swelled, and red,—others with atony and debility, the margin being pale, dusky, or livid. Causes.—This disease may be induced either by extraordinary local irri- tation, or by some peculiar constitutional disorder. It may attack primary or secondary venereal sores, in consequence of filth, intemperance, the abuse of mercury, or of a weakened and vitiated, or scrofulous habit, or of some peculiarity in the venereal virus. Sometimes it appears in the throat after scarlatina; it may attack a blistered surface when the constitution has greatly suffered from an acute and exhausting disease, as measles, &c.; sometimes it affects the mouth or genitals of children, constituting cancrum oris, noma, &c. Treatment.—One of two courses may be taken. The soothing, consisting in the administration of opium with bark, wine, and good nourishment, and the local applications directed for irritable ulcers, especially a weak solution of tannin, F. 131. This will often be found successful; if not, recourse may be had to the destruction of the diseased surface by caustics, in the manner described on p. 93. X. Sloughing Phagedena, or Hospital Gangrene, seems, says Mr. Lawrence, to be a state of phagedasna carried to its fullest extent. Its causes are, (1) great local irritation, combined with a vitiated state of the constitution; (2) contagion; that is, the application of poisonous matter to a wound: and (3) infection; that is, the reception of poisonous mias- mata into the blood. We shall first treat of it as it occurs sporadically in civil practice, where it bears the name of sloughing phagedasna; and next, pf those more serious visitations that decimate the patients in crowded naval or military hospitals, whence it derives its other name, hospital gangrene.1 In the cases seen in civil practice, the disease is mostly seated in or near the genital organs; in the cleft of the nates, in the groin, or at the upper and inner part of the thigh. It often supervenes on syphilitic ulcers ; espe- cially in young prostitutes, who have been exposed to cold and wet and privation of solid food, and the abuse of ardent spirits. It is especially liable to be induced by the too free administration of mercury, or by intem- perance and exposure to wet during a mercurial course. The worst cases, however, appear to arise from neglected local irritation without any specific virus ; as from acrid discharges and defective cleanliness. Mr. Lawrence mentions the case of a young woman who had suffered from severe small- pox, and from diarrhoea after it. The continual moisture from the rectum, with a mucous discharge from the vagina, irritated and inflamed the skin of the nates, and caused a large sloughing phagedaenic excavation on both sides. Symptoms.—" It usually commences as a highly-irritable and painful boil, surrounded by a halo of dusky-red inflammation, and much elevated ; the patient also in general having mucous discharges from the vagina, and a diffused redness of integument in the vicinity of the pudenda." There are severe darting and stinging pains, which are at first intermittent, but gradu- ally establish themselves as a constant symptom, with occasional exacerba- tions. When the pustule is ruptured, the exposed surface of the ulcer dis- plays a stratum of adherent straw-colored flocculi, mottled with darker 1 In civil hospitals any serious attack of hospital gangrene is almost unheard of. Yet it appeared in 1844 in University College Hospital. Liston, Lancet, 1845, vol. i. p. 57. In the Middlesex Hospital in 1835, South's Chelius, vol. i. p. 67. The disease appeared in St. Bartholomew's Hospital and in St. George's in 1847 ; C. Hawkins, Med. Gaz. N. S. vol. iv. p. 1026. An account of its ravages in the British camp after the battle of Feroze- pore, by Mr. Taylor, surgeon to the 29th Begt., is quoted by Guthrie, Lancet, 1848, vol. ii. p. 714. S HOSPITAL GANGRENE. 93 points of reddish-brown and gray. The sore thus formed soon enlarges in breadth and depth; the edges become everted, and attended with a circum- scribed thickening which is surrounded by dusky inflammation and diffused puffy swelling. The surface is composed of gray or ash-colored sloughs, which may become brown, or resemble coagula of blood. The discharge is reddish-brown, and peculiarly fetid, and there is occasionally severe hemor- rhage. Meanwhile the agonizing pain, the hemorrhage, and the absorption of putrid matters, soon induce severe irritative fever—with loss of sleep, anxiety, restlessness, thirst, and exhausting diarrhoea;—which, if not relieved, may produce death in about three weeks; and, as delirium is rare, the patient retains a miserable consciousness of severe suffering to the end.1 Hospital Gangrene is the name given to this affection when occurring in military and naval practice. It is engendered by crowding together a number of sick and wounded men, and by inattention to cleanliness and ventilation. It frequently is a concomitant of dysentery or typhus, origin- ating in the same sources. It may affect any kind of wound, or even a mere bruise. Symptoms.—According to Mr. Blackadder, it begins in the form of a livid vesicle at the edge of a wound or sore, accompanied with an occasional painful sensation like the sting of a gnat. Sometimes it first appears as a small livid spot on the sore, and near its circumference. In either case the disease soon spreads, and converts the whole surface of the ulcer into an ash-colored or blackish slough. The discharge, if previously healthy, is at first diminished in quantity, and sanious ; but soon becomes profuse, dirty yellowish, or brown, and offensive. According to Mr. Blackadder, the hos- pital gangrene is at first a purely local affection, like the sloughing phage- dsena; and he says that the constitutional symptoms do not make their appearance before the third or fourth, sometimes not till the twentieth day.3 But the disease, as observed by Dr. Hennen, began with constitutional symptoms, headache, nausea, perhaps bilious vomiting, quick pulse, hot skin, and an inflamed, dry, glassy, and painful state of the wound ; to which suc- ceeded sloughing of the surface of the wound, great swelling of the edges, and the other local and constitutional symptoms of sloughing phagedaena.3 It thus appears that the hospital gangrene may be either a local disease, caused by the influence of poisonous matter on a wound, or that it may be constitutional from the first, and be caused by the absorption of a septic poison into the blood. Treatment.—The indications in the treatment of all the forms of slough- ing phagedaena are, 1, to destroy the diseased surface and its secretions; and 2, to correct the disorder of the system. The first indication is to be carried into effect by means of caustics. The French use the actual cautery; but the concentrated nitric acid used in the following mode, as directed by Mr. Welbank, seems to be the best. In the first place the sore must be 'thoroughly cleansed, and all its moisture be ab- sorbed by lint or tow. If the sloughs are very thick, they may be removed by means of forceps and scissors. The surrounding parts must next be de- fended with a thick layer of ointment: then a thick pledget of lint, which may be conveniently fastened to the end of a stick, is to be imbued with the acid, and to be pressed steadily on every part of the diseased surface till the latter is converted into a dry, firm, and insensible mass. This applica- ' Welbank, Med.-Chir. Trans, vol. xi. ; Lawrence, Med. Gaz. vol. v. 2 Observations on Phagedaena Gangrenosa, by H.' Home Blackadder, Edinburgh, 1818 ; Guthrie, Commentaries on Military Surgery, 6th ed. 3 Principles of Military Surgery, by John Hennen, M. D., F.R.S.E., 3d ed. London, 1829 pp. 217 et seq.; Sir G. Ballingall's Military Surgery; Dr. Boggie on Hospital Gangrene, Edinburgh, 1848 ; Velpeau, Lancet, 1848, vol. ii. p. 172. 94 malignant pustule. tion of course causes more or less pain for the moment; but, when that subsides, the patient expresses himself free from his previous severer suffer- ings. The part may then be covered with simple dressings and cloths wet with cold water. "It is always prudent, often necessary," says Mr. Wel- bank, "to remove the eschar at the end of sixteen or twenty hours, and then, if the patient be free from pain, and the ulcer healthy and florid, it is to be treated with common stimulating dressings, such as cerat. calaminae, or solu- tion of argenti nitras, or a cerate of turpentine, which may be melted and poured in warm." If, however, there be any recurrence of pain, or the least reappearance of the disease, the acid is again and again to be applied till a healthy action is restored. [The American surgeons in the Russian service at Simpheropol and other hospitals in the Crimea, at the time of the siege of Sebastopol, found creasote to be the most useful application to the gan- grenous surface. It is less painful than nitric acid, and in a very large number of cases in their hands it proved entirely successful.]1 As for the general treatment;—the patient should be narcotized by chlo- roform during the application of the acid. Opium should be given in suffi- cient doses to procure sleep at night, and to relieve pain during the day. If the disease, as observed by Hennen, begin with shivering and fever, the treatment may be begun with purgatives, as directed for erysipelas, p. 80, to which this disease is most nearly allied. The same rules are applicable also as regards diet, since it is on wine or brandy, beef-tea, and other forms of nourishment, and yellow bark with nitric acid, that the surgeon's chief dependence is to be placed. Change to a pure air, free ventilation, and destruction of all putrescent matters, need not be more than mentioned. XL Gangrenous Inflammation of Muscle, as described by Dr. Lyons,3 from his observations in the Crimea, generally affected soldiers who had re- ceived wounds, or suffered amputation in the thigh. With little or no swell- ing or pain, or change in the skin, the muscles gradually melted down into a soft, putrid, shreddy mass, and were discharged with immense quantities of fetid ichor. Indistinct febrile symptoms, with diarrhoea, accompanied the local disorder. The patients were generally exhausted by hemorrhage and discharge in the course of from two to six weeks. XII. Malignant Pustule (Charbon) is a contagious and very fatal disease, common in France, but almost unknown in England. It com- mences as a little dark-red spot, with a stinging or pricking pain, on which there soon appears a pustule or vesicle seated on a hard inflamed base. When this is opened, it is found to contain a slough, black as charcoal; and the sloughing rapidly spreads, involving skin and cellular tissue, and some- times the muscles beneath. The account given of this malady by the continental writers is exceed- ingly confused ; but it appears certain that it is caused by infection or contagion from horned cattle, which at certain seasons are affected with a precisely similar disease ; and it further appears that, like hospital gan- grene, it may commence in two ways:—By general infection of the system, from respiring air loaded with miasmata from diseased animals, or from eating their flesh ; or by inoculation of the diseased fluids. Mr. Lawrence gives an account of a man in Leadenhall Market, who accidentally smeared his face with some stinking hides from South America. The part touched by the putrid matter very soon became red, and swelled, and mortified, and the mortification spread over half the cheek. He has also met with two other cases affecting persons in a horse-hair manufactory. It is believed that flies which have alighted on the ulcers of the diseased animals convey the virus, and infect other animals and human beings. 1 Amer. Jour. Med. Sci., April, 1860, p. 570. 2 Report on the Pathology of the Army in the East, Lond. 1856. LUPUS EXEDENS. 95 The constitutional symptoms and morbid appearances are those of putrid typhus; the treatment, both constitutional and local, is the same that we have directed for hospital gangrene.1 XIII. The Ulcer of the Cellular Membrane, which burrows under the skin and destroys that tissue, must be treated as the fistulous or weak, according to circumstances. XIV. Menstrual Ulcer.—This name is given to ulcers occurring in chlorotic young women, and exuding a sanguineous fluid at the time of their monthly discharge, if that be absent. Wounds made in operating will fre- quently do the same. Treatment.—The chlorosis must be remedied by steel, aloes, &c, and the ulcer be treated on general principles. XV. Lupus non Exedens (Serpiginous Ulcer of the Face) is a most obstinate form of ulcer affecting the face, chiefly of young women of a deli- cate or scrofulous constitution. It begins either as a shining, soft, circum- scribed swelling of the skin, usually on one ala of the nose, which ulcerates ; or else as a mere crack or small excoriation, covered with a thin scab, under which it slowly spreads. When the scab is removed, the discharge, which is scanty and viscid, soon dries and forms another larger one. The ulcer is constantly spreading in one direction, and healing in another; it may last for years, and wander over the whole face, completely destroying perhaps the alae of the nose or the eyelids, but in other parts not penetrating the entire thickness of the true skin. The cicatrix is excessively irregular and shining, and of a dense whiteness, causing perhaps eversion of the eyelids and distortion of the features ; in some parts it feels soft and pulpy. The cause and pathology of this affection are unknown. The treatment con- sists in the use of soothing local applications, such as water-dressing, black wash, or very weak solution of nitrate of silver or of lead, and of a nutritious diet, cod-liver oil, sarsaparilla, bark, iodide of iron, and other tonics; in some cases of the chloride of arsenic in the dose of ten drops thrice daily at meal times, F. 97, from which the author has seen remarkable benefit in cases treated by Mr. Hunt. A mild purgative, F. 38, should be given just before the menstrual period. If the surface forms a scab, the writer finds it best to use no application at all. XVI. Lupus Exedens (Corroding ulcer of Clarke, Ulcere rongeante, Rodent ulcer of Paget, Cancroide of Lebert; Esthiomene of Huguier; chancrous, or cancerous ulcer, and Noli me tangere of older writers*) is an ulcer characterized by slow but constant increase, rebellious to all mild measures of treatment, and ultimately leading to fatal consequences, if not checked. Examples of it are found in the corroding ulcer of the uterus; in the perforating ulcer of the stomach and oesophagus, and in the lupus, or so-called cancroid ulcer of the skin of the face. The exact pathology and cause of the disease are unknown. It is not cancerous; there is no infiltra- tion of cancer cells nor yet of epithelium; the part affected ulcerates cleanly away, as if cut out with a punch, but up to the edge of the ulcer the tissues seem healthy, or at least contain such elements as are found in the base of all ulcers; and there is neither swelling nor hardness, nor adhesion of the ' Lawrence Med. Gaz. vol. v. p. 392 ; Diet, de M6d. Art. Charbon, Pustule maligne; Schwabe Brit, and For. Rev. vol. vii. p. 550 ; Lond. Med. Gaz. 21st Oct. 1842 ; South's Chelius, vol. i. p. 65 ; [Paper by S. Pennock, of Philad., Am. Jour. Med. Sci. vol. xix. 1836 ; Compendium de Cliirurgie Pratique, tome i. p. 257.] _ _ 2 Ure on Lupus and the Chloride of Zinc, Med. Gaz. vols. xvn. and xvm.; and Cyclop. Pract. Surg. Art. Cauterants ; Earle, Med.-Chir. Trans, vol. xii. ; Travers, ib. vol. xv.; Burgess's trans, of Cazenave, p. 250; Brodie, Surgical Lectures; Walshe on Cancer, r, 548 • Liston, Lectures in Lancet, 1844, vol. i. p. 775 ; Lebert, Traite Prat, des Mala- dies Ca'ncereuses, 1851, pp. 594 and 658; Paget's Lectures on Surgical Pathology, vol. ii. p. 452. 96 ULCERS. part, nor of the adjoining lymphatics. The perforating ulcer of the stomach is most common in young chlorotic women; the corroding ulcer of the uterus in women past childbearing; lupus Fig. 13. exedens of the face in persons above forty, especially women. The parts of the face most commonly affected are the nose and the cheek below the eye. The disease may begin as a small vascular wart, as a smooth red shining tubercular swelling of the cutis vera, as a little eleva- tion like a mole covered with dried cuticle, or as a small chap, or fissure. In this condition it may last for an almost indefinite time, till at length it spreads, forming a foul excavated irre- gular ulcer, with glassy non- granulating surface, and scanty ichorous discharge, eating away all before it in breadth and depth, till not merely the nose, or cheek, or eyelid may have perished, but the entire face is converted into Lupus exedens. one horrid chasm, with the eye- ball dropping into the mouth. Treatment.—Everything may be hoped from free and early cauterization; but recollecting the name noli me tangere, the surgeon must be careful to destroy thoroughly, and not irritate by inefficient measures. Of caustics, therefore, the most energetic should be chosen, such as the acid nitrate of mercury, F. 195 ; the Vienna paste (or compound of caustic potass with quicklime); the chloride of zinc, or arsenic. Of these, the arsenic is that which from long experience is believed to be the most efficacious. The most convenient mode of applying it is in the form of Manec's paste; which is composed of 15 grains of white arsenic, 75 of cinnabar, and 35 of burnt sponge, made into a thick paste, with a few drops of water. This should be thinly spread on the whole surface (pre- viously cleansed from discharge and scabs) of the ulcer, if small; or on a small portion of its surface if large, and be covered with a piece of soft lint. The pain which follows is very severe, and the redness and swelling even alarming; moreover there may be vomiting and purging, symptoms which must be met by the administration of repeated doses of solid opium. At the expiration of a fortnight, if the whole surface were not cauterized at once, a second portion may be attacked in the same way. The eschars are some weeks in separating, and if the surface which remains is unhealthy, it must be destroyed again and again. The chloride of zinc is generally mixed with three or four parts of flour (as used originally by Canquoin), or with two parts of freshly-burned plaster of Paris (as recommended by Mr. Ure, who introduced it to the notice of English surgeons). Then it is made into a paste with a few drops of water, spread over the ulcer, and allowed to remain four or five hours. It is nearly as painful as the arsenic. The general health must be improved by the remedies directed for the lupus non exedens, including the cautious and long-continued administra- tion of arsenic, F. 97. MORTIFICATION. 97 In cases in which cauterization cannot be performed effectually, the general and local palliative treatment are the same as of cancer. CHAPTER XII. MORTIFICATION. SECTION I.—PATHOLOGY OF MORTIFICATION. Definition.—Mortification signifies the death of any part of the body in consequence of disease or injury. Varieties.—Some persons use the terms mortification, gangrene, and- sphacelus, indiscriminately; but it is better to signify by sphacelus an utter and irrecoverable loss of life, and to restrict the term gangrene to the state which precedes, and commonly (but not inevitably) terminates in sphacelus ; and in which perhaps the part may be supposed to be still capable of recovery. Another distinction is made between humid and dry gangrene. The humid is a consequence of inflammation, or of obstacle to the return of the venous blood ; and the mortified part, being loaded with fluid effusions, soon undergoes decomposition; whilst the dry gangrene is generally a consequence of deficient supply of blood, or of constitutional causes, and is either pre- ceded by no inflammation at all, or by one so rapid that there is no time for interstitial effusions to occur, so that the mortified part becomes dry and hard. In the humid it is called a slough, in the dry gangrene an eschar. Another and a most important division is into constitutional and local. By constitutional mortification is meant that which primarily originates in constitutional disorder ; or that which, having begun from a local injury, is propagated and maintained by constitutional disorder. By local mortifica- tion is understood that which has originated in local injury, and by which the system is not implicated and with which it does not sympathize in a violent or dangerous degree.1 Causes.—The local predisposing causes are the same as those of ulcera- tion ; namely, congestion, deficient arterial circulation, and structural weakness. The constitutional causes of mortification are,—debility from old age, poverty, starvation, hemorrhage, scurvy, or long-continued disease of any kind ; disease of the heart with contraction of the aortic orifice, so as to impede the arterial circulation; a peculiar state of the blood causing it to coagulate, and the peculiar state induced by the use of diseased grain, especially by the ergot of rye. These causes are in general predisposing merely; but sometimes they are sufficient of themselves to induce mortifica- tion, which is then mostly seated in the lower extremities. The exciting causes may be divided into—First, mechanical and chemical injuries, especially gunshot wounds and compound fractures ; the injection of urine into the cellular tissue ; the application of irritants to constitutions weakened by previous disease, as the application of blisters to children after measles or scarlatina; long-continued pressure under the same circumstances; hence, the sloughing of the skin over the sacrum or trochanters of patients confined to bed with some exhausting disease,—or the application of heat after exposure to cold. 1 Thompson's Lectures on Inflammation; Guthrie, G. J., F.R.S., A Treatise on Gun- shot Wounds, p. 116, 3d ed. Lond. 1827 ; Case of Spontaneous Gangrene, by Dr. Fuller, Med. Gaz. N.S. vol. v. p. 244 ; [Gross, op. cit. vol. i. p. 195.] 7 98 SYMPTOMS OF MORTIFICATION. Secondly, an insufficient supply of arterial blood, whether from liga- ture of a main artery, from thickening of its parietes so as to contract its calibre, from coagulation of the blood within it, or from degeneration of the artery, and its obstruction by fibrine, which is the supposed cause of senile gangrene. Sloughing of the nose from great loss of blood after a wound in the throat—sloughing of the centre of one of the cerebral hemispheres after a wound of the corresponding common carotid—are further instances.1 Patches of skin often mortify in oedema and cellulo-cutaneous erysipelas, because its bloodvessels are obstructed by the distension of the subcutaneous tissue with fluid. Thirdly, impediments to the return of venous blood, whether from ligature of a venous trunk, from coagulation of the blood in it, from tumors (diseased liver, for instance) compressing it, or from disease of the heart, or from tight bandages, as sometimes happens after fracture. Fourthly, injury or division of nerves.—Thus, the cornea has been known to slough after division of the fifth nerve. Sir B. C. Brodie has seen mortification of the ankle begin within twenty-four hours after an injury to the spine. But, in general, deficient nervous influence operates merely as a predisposing cause. Besides diminishing the vital powers of the part, it takes away that sensibility which is necessary for its protection from injury. The tissue most disposed to mortification is the cellular, and next to it, tendinous and ligamentous structures, if the cellular tissue surrounding them have been destroyed; then bone, if deprived of its periosteum; next, the skin, especially if the subjacent cellular tissues have mortified or have be- come infiltrated with fluid ; and, lastly, parts of higher organization, as muscles, bloodvessels, and nerves, resist it most. Like ulceration, mortification may either be preceded by inflammation or not. On the one hand, a part which has been injured may mortify through excess or perversion of the inflammatory and reparative processes, or exu- dations, which ensue ; or, on the other hand, it may mortify slowly, and the mortification may spread slowly without there being energy enough in the system to set up inflammation. SECTION II.—VARIETIES, SYMPTOMS, AND TREATMENT. I. Inflammatory Mortification.—Symptoms.—When inflammation is about to terminate in mortification, its redness gradually assumes a darker tint, and becomes purple or "blue ; the heat, sensibility, and pain diminish ; but the swelling often increases in consequence of the continued effusion of bloody serum, which not unfrequently exudes through the skin, and ele- vates the cuticle into blisters. If the gangrene proceed to sphacelus, the color becomes dirty brown or black; the parts become soft, flaccid, and cold, and they crepitate when pressed, and emit a cadaverous odor from the gases that are evolved by incipient putrefaction. Whilst gangrene is spreading, the dark color is diffused, and insensibly lost in the surrounding skin ; but when its progress is arrested, a healthy circulation is re-established up to the very margin of the sphacelated portion, and a bright-red line of adhesive inflammation (called the line of demarcation) separates the living parts from the dead. And the appearance of this line is most important as a means of prognosis, because it shows that the mischief has ceased, and that there is a disposition to repair its ravages. Separation of the Mortified Part.—It is at this bright-red line of de- marcation that the dead part is separated by ulceration. A narrow white 1 Paget's Lectures, Med. Gaz. 1847, vol. iv. p. 1022. TREATMENT OF MORTIFICATION. 99 From a cast in the King's College Museum. The pa- tient was a destitute girl, and the gangrene arose from starvation. line, consisting of a narrow circular vesicle, and formed by a separation of the cuticle, first appears on it; and when this is broken, a chain of minute ulcers is seen under it. These gradually unite and form a chink, Fig- 14. which widens and deepens till it reaches the bone ; meanwhile the dead bone is cut off by a process to be hereafter described : thus the slough is entirely detached, and then a granulating and sup- purating surface remains. In this manner the whole of a mortified limb may be spontaneously ampu- tated ; the bone and tendons sepa- rating higher up, and being more slowly detached than the skin, muscles, and bloodvessels. When the adhesive inflammation has duly occurred, this process of separation is unattended with hemorrhage, the vessels being ob- literated by the effusion of lymph and coagulation of the blood within them. And this coagu- lation extends some distance from the mortified part, so that a limb has been amputated in the thigh for mortification of the leg without the loss of any blood from the femoral artery. Sometimes, however, as in hospital gangrene, these processes of adhesion are deficient, and the blood is found fluid in the vessels, so that the separation of the slough is attended with severe hemorrhage. Constitutional Symptoms.—The constitutional symptoms of mortification vary with its cause. If it arise in a healthy subject, from acute inflammation which is still progressing, there will be inflammatory fever; but, on the other hand, if the mortification be very extensive—if the inflammation of the adjacent parts be unhealthy, with no disposition to form the line of demarca- tion, but, on the contrary, with a greater tendency to serous effusion—or if the mortified part be of great importance, as intestine or lung, the constitu- tional symptoms will be of a low typhoid cast; there will be great anxiety, hiccough, a jaundiced skin, a soft, or rapid thready, and jerking pulse, and frequently profuse perspiration of a cadaverous odor. Diagnosis.—It is important not to mistake the lividity and vesications of bruises, especially when they accompany fractures, for gangrene. They may easily be distinguished by their sensibility and temperature, and by the fact that in gangrene the whole cuticle has lost its adhesion to the cutis, so that pressure will cause the vesicle to shift its place. Treatment.—The general indications are, to allay inflammation if exces- sive, to support the strength, and to cause the formation of a line of healthy adhesion, by which the mortification may be arrested. If gangrene occurs in a healthy, young, robust subject, with great pain, and a full, hard, strong pulse,—and if it appears likely to spread from the violence of inflammation (of which the best example is sloughing of the penis from inflamed chancre)—it will be necessary to use bleeding, purging, and the general antiphlogistic treatment; whilst fomentations may be ap- plied locally. But care must be taken never to reduce the strength, when a large part is so injured that its death is probable. But an opposite treatment must be pursued if the pulse is quick and feeble, 100 TREATMENT OF MORTIFICATION. and if there are the other signs of deficient vital power that have been before mentioned. The principal remedies for this state are wine and opium— whose united effect should be to render the pulse slower and firmer, and to induce a warm, gentle perspiration and sleep—whilst it will be a sign that they are injudiciously administered, if they induce or aggravate delirium and restlessness. Sir B. Brodie believes that brandy is by far the best stimu- lant, and that it is better to trust to it in urgent cases than to load the stomach with bark. Mr. Vincent agrees with him. Beef-tea, and other fluid nutriment, may be given with it. Opium is of prodigious utility from its power of allaying irritability ; so that it renders the constitution insen- sible as it were to the local mischief—or, in Hunter's language, " It does good by not letting the disease do harm to the constitution." It may either be given in small doses frequently repeated, or, if there be at any time very great restlessness, especially towards night, it will be better to give a full dose at once; such as forty or fifty minims of the tincture, or two grains of the solid opium. The remedy next in importance is bark, of which the most efficacious preparations are the decoction of yellow bark, and Battley's liquor cinchonae flavaa, the value of which the author learned many years since from Dr. Farre. It may be given every six hours, combined with nitric acid. Sir B. Brodie and Mr. Vincent believe that ammonia, if too long persevered in, depresses the vital energies. Their practical experience has confirmed the conclusions arrived at by those who have studied the properties of the blood, down to Dr. Richardson.— Vide F, 1, 2, 3, 4, &c. Local Measures.—If a part be gangrenous, but not quite dead, its tem- perature must be maintained by warm poultices and fomentations. If sphacelus has actually occurred, and the powers of the system are lan- guid, and there is little disposition to form the line of demarcation, or throw off the dead parts, stimulating applications are necessary, especially the nitric-acid lotion, F. 119, on lint under the poultice;—the ung. resinae, thinned with turpentine ; ointment of creasote, or of Peruvian balsam, F. 163; tincture of benzoin; solution of the chlorides (F. 127);—or poultices of yeast (F. 155), or of stale beer-grounds. Any loose portions of slough may be cut away by scissors, taking care not to tear them away violently. Incisions are of great service in spreading inflammatory mortification, attended with extensive effusion of serous or purulent fluids ; which not only contaminate the blood, and depress the nervous system by being ab- sorbed, but also propagate the disease by diffusing themselves along the cellular tissue, into parts that are still sound. Question of Amputation.—The rule formerly given on this subject was, that we ought to wait till the gangrene is arrested, and a line of demarca- tion is formed, otherwise the stump may become gangrenous. And this rule still holds good in mortifications arising from constitutional causes ; in that caused, for instance, by loss of blood or fever. But even after the line of demarcation has formed, it is necessary to take care that the patient has vigor enough to bear the loss of blood which must in some degree necessarily ensue. Sir A. Cooper mentions a case in which a mortified leg was sepa- rating favorably by itself through the calf, when the projecting bones were sawn off, with a view of expediting the process. A few granulations were accidentally wounded, and the trivial hemorrhage that ensued was fatal.1 But it will be proper to amputate without waiting for the line of separa- tion, if the mortification be local as to its cause ; as, for instance, in morti- fication of a limb from severe compound fracture or from injury or aneurism of the large arterial trunks. This practice is sanctioned by Larrey, Guthrie, Brodie, S. Cooper, Lawrence, Velpeau, James, and Porter of Dublin. We 1 Lectures by Tyrrell, vol. i. p. 237. TREATMENT OF MORTIFICATION 101 may add, that amputation seems to be justifiable as a last resource whenever there appears little or no disposition to limit gangrene, and whenever it spreads rapidly. "Where gangrene," says Mr. Guthrie, "is rapidly extend- ing towards the trunk of the body, without any hope of its cessation, the operation is to be tried ; for it has certainly succeeded, where death would in a few hours have ensued."1 II. Mortification from Obstacle to the return of Venous Blood.— This form of mortification mostly affects the lower extremities of persons who labor under dropsy from diseased heart, and it is always preceded by great oedema. It may occur without inflammation, or may be a consequence of inflammation, which if it attack cedematous parts is always liable to termi- nate in gangrene. In the former case, the skin of the oedematous limb, having become pale, smooth, glossy, and tense, assumes a mottled aspect of a dull red or purple color, from distension of the subcutaneous veins. " Then at some part where the congestion is greatest, or where the skin is less yielding, as over the tibia, or above the malleoli, phlyctenae or large bullae, are formed by the effusion of serosity, either alone or mixed with blood, under the cuticle. When these burst, the cutis beneath presents a dark-red or brown color, and very soon is converted into a dirty-yellow or ash-gray slough.3 After the spread of the mortification to a given extent, inflamma- tion occurs; and the slough, which is mostly an oval patch of skin and cellular tissue, separates. Treatment.—The part should be placed in an elevated position, and numerous punctures should be made with a needle, to let the serum exude. The mortified part, and the ulcer that results, are to be treated by warm poultices of yeast, carrots, or stale beer-grounds, and stimulating dressings, of which the nitric acid lotion is the best. III. Mortification from Pressure, Bed Sores, &c.—When a patient is confined to bed with some very tedious and debilitating malady, as a fever —and especially if he has not strength to shift his posture occasionally— the skin covering various pro ecting bony parts (as the sacrum, brim of the ilium, or great trochanter) is apt to inflame and rapidly ulcerate or slough; and more particularly if irritated by neglect of cleanliness or by the contact of urine. The first thing often complained of by the patient is a sense of pricking, as though there were crumbs of salt in the bed. The part, if exa- mined at first, looks red and rough; then becomes excoriated and ulcerates, or turns black and mortifies. This accident is particularly liable to happen if the spinal cord has been injured. Treatment.—When long confinement to bed is expected, it is a good plan to apply some stimulant to the skin of the back and hips, to cause it to secrete a thicker cuticle, and enable it to bear pressure better. Nothing can be better for this purpose than brandy or eau de Cologne. If the part seems likely to suffer, it may be covered with a broad piece of calico spread with soap plaster; and small pillows, or macintosh cushions, or ox-bladders half filled with water, or water-cushions of vulcanized India-rubber, should be arranged so as to take off the weight from the part affected; and the patient should be made to shift his position often, or occasionally lie on his face. The soft poultice (F. 153) will be found of great service. After sloughing has commenced, the ung. resinas or F. 163 is the best application. IV. Senile Gangrene.—A form of dry gangrene affecting the fingers or toes.__Symptoms.—In one instance which came under the writer's observa- tion, the patient, set. 70, with diseased heart, complained for some time of numbness and pricking at the tips of nis finger. Next they looked bluish, 1 Op. cit. p. 132; Velpeau, Lecture, in Lancet, 1848, vol. ii. p 32. 2 Carswell, Illustrations of Elementary Forms of Disease, Lond. 1837. 102 white gangrene of the skin. and the cuticle peeled ; then the surface of the skin black. But far more frequently it commences by a purple or a black spot on one of the smaller toes ; from which spot "the cuticle," says Pott, "is always found to be de- tached, and the skin under it to be of a dark-red color." "In some few instances, there is little or no pain ; but, in by far the majority, the patients feel great uneasiness through the whole foot or joint of the ankle, particu- larly in the night, even before these parts show any mark of distemper, or before there is any other than a small discolored spot at the end of one of the little toes."1 Its progress in some cases is slow, in others rapid and horribly painful. After its first appearance, the actual gangrene will gen- erally be preceded by a dark-red congestive inflammation. The dead parts become shrunk, dry, and hard ; and when the disease makes a temporary pause, which it frequently does, they slowly slough away,—and the wound may heal; but a fresh accession of gangrene mostly supervenes before any progress has been made towards cicatrization. In this way the patient may live several winters, but often sinks exhausted with the nocturnal pain before the whole of the foot is destroyed. Pathology.—This disease is supposed to be caused by degeneration and obstruction of the arteries. Hence the foot is imperfectly nourished ; it is weak and liable to pain and numbness if heated after being cold ; and a chilblain, or any other trivial source of inflammation, is sure to terminate in gangrene. A similar kind of gangrene sometimes attacks the skin of the leg. This affection mostly happens to old persons of the better class, especially if they have been great eaters. They are generally found to have lost their hair and teeth, and their face and hands betray a languid circulation. It mostly attacks men. Mr. James,3 however, has seen it in a woman of forty- two, who had disease of the heart; and Brodie in a man of thirty-six. Treatment.—It seems agreed now, that this disease should not be treated on a stimulating plan. If there should be any vivid inflammation and a good pulse the patient should be kept in bed; the bowels should be opened; the diet be restricted to fish and broth ; and Dover's powder be given at bedtime, to allay pain. But should the health be feeble the diet must be more generous. The foot may be wrapped in lint, and covered with oiled silk. Brodie recommends a piece of calamine dressing to be laid on the part, and the whole limb to be loosely wrapped in repeated folds of cotton wool, and afterwards sewed up in a silk handkerchief. If there is much dis- charge this may be changed every second day ; if not, it may remain for a week. Amputation is inadmissible.3 V. White Gangrene of,the Skin.—In this curious affection, a circular portion of the skin, generally of the arm, becomes painful, and suddenly mortifies; becoming hard, white, and dry, and showing the red streak of the vessels with the blood dried up in them. It sometimes spreads by the gan- grene of a circle of the surrounding skin. The cause is quite unknown, and the treatment must depend upon the circumstances of the case. The pos- sibility that the disease may be caused by the application of some strong acid, for purposes of imposture, should be borne in mind. 1 Pott's Chirurgical Works, 8vo. Lond. 1771. 2 James on Inflammation, pp. 445 and 552. 3 Vide Sir B. Brodie's Lectures on Mortification, Med. Gaz. vol. xxvii., and Mayo's Pathology, p. 231; Syme's Contributions to the Pathology and Practice of Surgery, Edin. 1848, p. 5. SCROFULA AND TUBERCULOSIS. 103 CHAPTER XIII. SECTION I.—SCROFULA AND TUBERCULOSIS IN GENERAL. Definition.—Scrofula, or Struma, is a state of constitutional debility, with a tendency to indolent inflammatory and ulcerative diseases. Tuberculosis signifies that state of constitution in which there is a ten- dency to the deposit of a substance called tubercle, in various tissues and organs. Some pathologists, as Rokitansky, look upon it as identical with scrofula, or as the climax of it. Others, as Lebert, believe it to be an en- tirely distinct disease, which may affect the scrofulous by preference, but may attack others also. According to this school, all scrofulous persons are not tuberculous, and all tuberculous are not scrofulous. Description.—There are two varieties of scrofulous habits, which, al- though they agree in the main essential of constitutional debility, are yet totally opposite in many respects. In the first (or sanguine variety), the skin is remarkably fair and thin, showing the blue veins through it, and pre- senting the most brilliant contrast of red and white ; the eyes are light blue ; the hair light or reddish, the forehead ample, and the intellect lively and precocious. Sometimes, however, as Mayo observes, the skin is dark and transparent, and the eyes dark, although there is the same general charac- teristic of delicacy and vivacity.1 In the second (or phlegmatic) variety, the whole aspect is dull and un- promising ; the skin thick and muddy ; the hair dark and coarse ; the eyes greenish or hazel, with dilated pupils ; the belly tumid, and the disposition dull, heavy, and listless to outward appearance ; although persons of this conformation will often be found to possess a clear, vigorous intellect, and powers of application far above the average. The great Dr. Johnson is an example. In both varieties the natural functions are liable to be performed irregu- larly. Digestion is weak, the tongue often furred, and red on its tip and edges ; the upper lip swelled, from a kind of turgescence of mucous mem- brane, whenever the health is worse than usual; the appetite sometimes deficient, but more usually excessive, and attended with a craving for indi- gestible substances ; the mucous membrane of the throat and tonsils flabby; the bowels torpid; the blood thin and watery;—its coagulum soft and small; the muscles pale and flabby; and the heart and arteries, as well as the in- testines, thin and weak. In the sanguine variety, the growth is generally rapid, and the bodily conformation good, as far as outward form is concerned—the limbs well made, the stature tall, and the chest broad. In the phlegmatic variety, on the other hand, the growth is often stunted, the chest narrow, and the limbs deformed with rickets, and puberty retarded, especially in the females, who are liable to prolonged chlorosis. Causes.—Scrofula being thus defined to be a peculiar state of the con- stitution, it may be shown, first, that it may be congenital and hereditary; that is to say, that scrofulous parents may transmit their peculiar organiza- 1 Vide Mayo's Philosophy of Living, 2d ed. 1838; Carmichael's Essay on Scrofula, Lond. 1810 ; B. Phillips on Scrofula, Lond. 1846 ; Ancell on Tuberculosis, Lond. 1852; Latham's Lectures on Clin. Med. ; Carswell, op. cit. ; the works of Addison of Malvern ; Wedl, op. cit. : Rokitansky, op. cit. ; Hughes Bennett on Scrofula and Tuberculosis, ed. 1856; Lebert, Anatomie Pathologique, vol. i. 1857; [Lebert, Traite Pratique des Maladies Scrofuleuses et Tuberculeuses, Paris, 1849.] 104 SCROFULA AND TUBERCULOSIS. tion, and predisposition to disease, to their children. It is believed that syphilis of parents occasions scrofula in children, and that gin-drinking has a still more decided effect. Secondly. The scrofulous habit, if not congenital, may probably be created by any circumstance capable, directly or indirectly, of lowering the vital energies ; by poverty and wretchedness ; meagre, watery, and insuffi- cient food ; neglect of exercise ; insufficient clothing ; neglect of cleanli- ness ; habitual exposure to damp and cold, but most especially by want of fresh air and sunlight. Thirdly. The scrofulous habit may be so intense, that the patient is at- tacked with some of the diseases that we shall presently describe, in spite of all care. Or, on the other hand, actual scrofulous disease may not appear unless the health is first depressed by some other disease, such as scarlatina, measles, the smallpox, or any other acute malady. Moreover, everything that disorders the digestive organs may bring it into action. It rarely breaks out before two or after thirty years of age ; although it may be called into active operation at any age by circumstances which lower the health. The time of the second dentition and puberty are dangerous periods. It is doubtful whether the English climate has more influence in causing it than any other. It is true that the natives of warm climates, who are brought here, are apt to suffer; and so are the birds and animals imported, and shut up in close dark cages ; but these are special cases. One fact, how- ever, is certain, that persons whose occupations cause them to be exposed to the weather at all hours and in all seasons, are not nearly so liable to scro- fulous disease as others, whose occupations are sedentary, and carried on in close, hot, dark, ill-ventilated workshops. Pure air and sunlight often make amends for defects of food and clothing. Scrofulous Disease.—When the scrofulous constitution has been created, and circumstances have occurred to elicit an outbreak of actual disease, a vast number of morbid processes may be set on foot, all of which are included under the term of scrofulous disease. Their general characteristics are, that they are excessively insidious in their approaches ; seldom attended with acute pain, or with symptoms of sthenic inflammation; excessively obsti- nate ; difficult to control by medicine ; tending to the destruction of tissues by slow ulceration ; and defective in the processes of repair. Such are the diseases spoken of in the next Section ; besides scrofulous otorrhcea ; ophthalmia; ophthalmia tarsi; ozsena; disease of bones, joints, testicle, and mammary gland; and convulsions and acute hydrocephalus during infancy. Tubercle.—This is a peculiar substance, which is found usually in the form of roundish masses (whence the name tubercle), Fig. 15. or else is infiltrated throughout the substance of vari- & y^ * 0US orSans- S° far as its naked-eye appearances are ^§£^'1! concerned it may be met with in the form—1st, of ,<^©@°P miliary tubercle; grayish, semitransparent, granular- «£, V;c©Q- looking bodies, varying in size from that of a pin's head • ^J® || 2 to that of a small pea, and tolerably firm. 2d, of yel- <$W ef ®> low tubercle 5 of a dull yellow color, and cheesy con- ° ° °° %>. ^ sistence. * Microscopically considered, tubercle consists of. i represents the micro- molecular granules ; of certain bodies called tubercle scopic elements of miliary corpuscles ; and of a structureless solid matter (cor- tubercie from the lungs; responding to a solidified blastema) in which the other Lrrftelr^; S Parts are P.0?*ained- , The so-called tubercle corpuscles consisting of imperfectly- a.re roundish, or oval, or irregular bodies, varying in developed cells. size, but generally about half the size of pus-globules • SCROFULA AND TUBERCULOSIS. 105 containing granules, and not exhibiting the reaction of pus with acetic acid. The nature of the deposit is fibrinous exudation ; and it seems that the early solidification of the blastema prevents the cells from attaining any degree of development; although the circumference of a tubercular deposit may display elongated fibro-plastic cells. If the lungs or any glandular organ be the part affected, there may be likewise a collection of ill-formed epithelium. Tubercle may involve old bloodvessels, but no new ones are developed within it. Tubercle is thus incapable of development into tissue, but one of two other courses is open to it. 1. In favorable cases it may remain quiescent, and wither, and be partly absorbed, partly degenerate into a harmless mass of granular, oily, and earthy matter, which may remain till the end of life (cretification). It may be remarked that there is scarcely any form of morbid growth which may not decay, and be converted into a yellow tubercular-looking, or putty-like mass, in which the atrophied elements of the tumor are combined with oil-globules and cholesterine. (See Reticular Cancer.) 2. In unfavorable cases it softens, beginning at its centre; the amor- phous basis liquefies, so as to set free the granules and corpuscles ; inflam- matory infiltration takes place at the circumference, and pus is formed which is discharged by ulceration along with the softened tubercle. This process is too often attended with an increase of the tubercular deposit around, which rapidly undergoes the same destructive changes, until the organ affected be destroyed, and with it the life of the individual. This is phthisis. Tubercle is usually deposited slowly, painlessly, and unsuspectedly during some period of defective health, and may remain in this condition for an indefinite time, till it wastes, if the health improves, and softens and causes abscess if the health is made worse. In some cases after this, by proper treatment, the deposit may be checked ; in others it goes on with fatal rapidity. The favorite seats of tubercle are the upper lobes of the lungs and the mucous membrane of the intestines in middle life, and the cervical glands in childhood, and the meninges. General Treatment.—The general indications are to procure and maintain a healthy condition of the blood, and to protect the patient from depressing influences. To describe at length the general treatment of scrofulous persons would be to write a treatise on general hygiene : we must content ourselves with hinting at the most important points. (1.) The diet should be nutritious, digestible, and abundant, consisting, as a general rule, of meat twice a day, good bread, green vegetables, such as peas and the various kinds of cabbage, mealy potatoes, preparations of eggs and milk, and a sufficient quantity of beer or wine to promote digestion, without creating drowsiness or feverishness.1 (2.) The clothing should be warm, especially for the extremities, so as to keep up the cutaneous circulation, and prevent congestion in the chest or abdomen. Flannel should be worn next the skin, both in winter and sum- mer : in the former for direct warmth ; in the latter to neutralize any acci- dental changes of temperature. 1 The author begs to warn his junior readers against the old-womanish doctrine, that children ou^ht not to have animal food until they have cut a certain number of teeth. On the contrary he would state it as a positive rule, that if the teeth are unusually slow in appearing, broth and meat ought on that very account to be given, in order to compensate for the want of nutritive force on which the delay in teething depends. 106 SCROFULA AND TUBERCULOSIS. (3.) Free exercise of the muscles and lungs in pure open air is indispen- sable. All over-exertion of the brain should be avoided. The moral facul- ties may be trained ; self-control inculcated, a thing very necessary to patients who are as passionate and excitable as they are weak; the faculty of observing the objects and operations of Nature should be cultivated ; the garden, the farm, and the hill-side should have as much attention as the schoolroom. (4.) The best residence for the scrofulous is one that is warm, without being damp in the winter, cool and bracing in the summer, and in the autumn, the sea-side. That climate, caderis paribus, will be the best, which admits of the greatest amount of exposure to the air. Hence, for the winter, Ma- deira, or the Cape, in the earlier stages; but it is far better not to send patients away from home and friends (as is too often the case) merely to die. (5.) Abundance of sunlight should be sought, as well as purity of air, since it is indispensable for the production of healthy color and composition of flesh and blood. (6.) Daily washing and friction of the skin are as beneficial to the scro- fulous as they are to every one else; and if the patient be precluded from taking exercise, friction is indispensable. Cold sea-bathing is in general so advantageous, that it has been deemed a specific. The best season is from the middle of August to the middle of November. The object in using the cold bath is to produce a vigorous reaction; consequently, before taking it, the nervous and circulating systems should be in some degree of excitement, and the skin should be warm, although not perspiring. At all events the person who bathes should not be exhausted by fatigue, nor in a cooling condition from perspiration. If the bather be strong, he may plunge into the open sea early in the morning on an empty stomach, not only with im- punity, but with advantage ; but the forenoon is the best time for a weakly child, when the air is become warm, and the system is invigorated with a breakfast. Bathing will be injurious if a short immersion renders the surface cold, numb, and pinched. Warm salt baths are very useful. (7.) Tonics.—It follows from our definition of scrofula that the medicines most likely to be of service are those which tend to give a firmer, healthier composition to the flesh and blood. The first of these which deserves notice is the cod-liver oil, whose wonderful properties of checking emaciation are now happily well known. It may be given in any scrofulous disease, and in any case in which the patient is losing flesh, in as large quantities as the stomach can tolerate. The author recommends it to be given just as the patient is lying down in bed, as by this means all chance of nausea is pre- vented. The best is a pale or light yellow sweet oil, prepared at home or imported from Newfoundland. Any other fish-oil that is not too rank; good chocolate, calf's-foot jelly, blancmange, isinglass, good pea or lentil soup, the essence of meat, F. 196 ; or a little rum and milk taken quite early, may occasionally be tried as extra nutritives. Bark is of immense service when there is a great exhaustion from suppu- ration, or when ulcers spread rapidly. The decoction, or liq. cinchonas flavae (F. 1, 4), are the best forms. Iron is sure to agree with pale, flabby children, provided their liver and bowels are kept in proper action. Bark should be given in large doses for a short time when the system seems exhausted; iron in small doses for a very long time, with occasional intervals of a week. Every preparation of it has its value, from the mild citrate, or potassio-tartrate, or acetate, the old-fashioned vinum ferri, and the aromatic mixture of the Dublin Phar- macopoeia—to the more astringent and stimulating sulphate or sesqui- chloride, F. 10, 20. The sulphate of zinc, the nitro-muriatic and sulphuric acids, and various bitter substances, are also useful. SCROFULA AND TUBERCULOSIS. 107. (8.) Anti-strumous remedies.—There are some medicines which have obtained repute from their supposed power of improving the condition of the blood : and possibly from their solvent power over morbid deposits. Such are iodine and its compounds with potassium or with iron; the liquor potassae ; lime-water; the combination of corrosive sublimate with tincture of bark; the chlorides of barium and of lime ; the extract or decoction of walnut leaves. Of these remedies, the preparations of iodine have the greatest repute, F. 88-95. Alkalies are often of great service in scrofula, by neutralizing acrid secre- tions in the stomach and bowels. They are especially indicated if the patient complains of heartburn or great thirst, or if the tongue is very red, or if there is a sinking and craving for food soon after meals, F. ft. Sarsaparilla, F. 84, 85, seems to improve the powers of nutrition gene- rally, and may always be given in cachectic diseases for which there is no palpable cause. (9.) Purgatives are often necessary to sweep away the refuse left by an imperfect digestion; and besides it is fair to believe that the tendency to local disease will be greatly increased by an impure state of the blood. In some cases the gentlest alteratives, F. 65, in others, mere aperients are re- quired ; whilst in the case of active strumous disease of skin or mucous membrane, of a congestive or ulcerative sort, with foul tongue, the greatest possible benefit is sometimes derivable from efficient doses of calomel with scammony ; or of rhubarb and polychrest salt, F. 37, 38, 41. Of course we exclude cases in which a red tongue and relaxed state of bowels indicate a tendency to ulceration of the intestines, and in which soothing absorbent remedies, F. 79, are indicated. (10.) Anodynes.—Pain, when violent, must be relieved by opium or other anodynes ; and the extract of conium, in regular doses thrice a day, may be of service when there are intractable ulcers. [The following remarks, which were inserted in preceding American editions, though not at the present day so earnestly called for as they were some years ago, may still be read with benefit in many parts of the United States:— " Genuine tuberculous scrofula is less common in the Valley of the Mis- sissippi than on the Eastern coast of the Union. But a very large portion of what is regarded and treated as scrofulous disease in this part of the country appears to me to be merely the result of indiscreet mercurialization. Under the prevalent idea that biliary derangements either constitute, or co- exist with, every departure from health, some form of mercury is adminis- tered, in almost every prescription, and the whole capillary system of persons who happen to be occasionally unwell, soon becomes impregnated and poi- soned by this subtile mineral. " So, too, if an alterative impression be desired, under any morbid condi- tion whatever, instead of employing regimen, diet, and more harmless medi- caments, it is common to resort indiscriminately to mercurial agents. The consequences of such reckless medication present themselves to the physician in dyspeptic affections, chronic headaches, pains in the limbs called rheumatic, &c.; and to the surgeon, in the more striking forms of alveolar absorption and adhesions, inveterate ulcerations of the fauces and nostrils, where no specific taint has been suspected, and in various degenerations, malignant and semi-malignant, of glandular organs. " Moreover, the evil does not stop with the individual,—for where im- portant elementary tissues are so deteriorated in the parents, a constitutional infirmity will be impressed on the offspring, which, if it may not properly be called scrofulous from birth, is the most favorable condition possible for the 108 PARTICULAR SCROFULOUS DISEASES. development of the phenomena of that diathesis, whenever co-operating in- fluences shall assail the unfortunate subject. " The interests of humanity, no less than the honor of medicine, demand that those who observe and understand these things should utter, on all proper occasions, the most unqualified protestations against such abuses of a medicinal agent whose timely and judicious use is so important to the healing art, and thus prevent it from becoming so detestable, that its em- ployment will not be tolerated at all."] SECTION II.—PARTICULAR SCROFULOUS DISEASES. I. The Skin is particularly liable to suffer from pustular and suppurative maladies; especially behind the ears, on the scalp, and about the mouth, nose, and eyelids. There eruptions are generally contagious. Treatment.—The general health must be attended to, according to the foregoing rules, and the local disease be treated by the frequent use of soap and water, and the application of the ointment of oxide of zinc, or of white precipitate or nitrate of mercury, or the black wash. Lupus, a scrofulous ulceration of the skin of the face, is described in the chapter on ulcers. II. Scrofulous Abscesses (besides those which are caused by diseased glands or bone) may occur under three forms. 1st. They may commence imperceptibly in the cellular tissue, either under the skin, or between the skin and bone, or in the deep intermuscular tissue, or in the neighborhood of a joint, beginning with painless deposit of lymph, which after a time softens down. 2dly. A circular piece of skin, of the size of a shilling or half-crown, with the tissue immediately beneath, may slowly inflame and swell, forming a hard, red tumor like a carbuncle, but painless. After a time it suppurates imperfectly, and it does not get well till the whole of the diseased part is destroyed by ulceration. 3dly. A small hard tumor of un- healthy lymph may form in the cellular tissue, which after a time inflames, causes abscess, and then sloughs out. III. Disease of the Lymphatic Glands, especially in the neck, is the commonest of scrofulous or tubercular maladies. It may begin with an acute attack of inflammation, or with an indolent and painless deposit. The enlarged glands may remain for years stationary or slowly enlarging, till at length, from local irritation or disorder of the health, they inflame, and chronic abscesses form between them and the skin. In some few cases, after the abscess is opened, it contracts and heals, the glands remaining nearly as before. But more generally all the skin covering the abscess becomes red and thin, and ulcerates, and the ulcer heals with an ugly puckered cicatrix, but not till the whole gland has wasted with suppuration. These swellings have been known to destroy life by compressing the tracheal or cervical vessels, or by bursting into them. IV. Scrofulous Ulcers may be a result of the pustules and excoriations of the skin that have been spoken of; or they may be formed by the ulcera- tion of glandular and other chronic abscesses; in which case they sometimes destroy extensive tracts of skin and cellular tissue, and may kill the patient by exhaustion, or render a limb rigid and useless if he recover. Or they may be attended with a hardened base, thick everted edges, a copious forma- tion of pale granulations, and deposit of unhealthy lymph into the adjoining cellular tissue, which, with the granulations, is liable to fits of sloughing, preceded by severe pain. Treatment.—The first and main point is to procure a radical improvement of the general health by the means already spoken of. The second is the consideration of how far these outward and superficial diseases may serve as outlets for tubercular exudations that otherwise might be deposited in the particular scrofulous diseases. 109 lungs. Hence the various means for repressing and exciting absorption of local deposits might be of doubtful benefit if employed to the neglect of other measures. But if proper constitutional remedies are adopted, it is quite justifiable to preserve the integrity of each individual part; and lotions of zinc or iodine, or chloride of ammonium, F. 118, poultices of the ficus vesiculosus, or mercurial plaster on leather, may be used. The objection to these remedies is, not that they are mischievous, but powerless. 3dly. When suppuration occurs, the matter should be evacuated by a sufficiently large puncture or incision before the skin has become red and thin. ^ 4thly. Indolent abscesses, some time after opening, may be treated with injections of iodine lotion, or of zinc or copper lotion. Ulcers may be treated locally on the principles laid down in the sections on weak and irritable ulcers. Poultices and emollients are seldom of service. The thin red skin over- lapping the edges of an ulcer or abscess, which is inclined to heal, may be removed by a clean incision, or by a touch with iodine paint. Such are the chief points worthy of notice in the local treatment of scrofulous abscesses and ulcers. In some few cases an enlarged gland may be extirpated. V. Tabes Mesenterica, or Marasmus, consists in a tubercular disease of the mesenteric glands, and of the follicles of the intestines, precisely similar in its course and pheno- mena to the same disease in the FiS-16- cervical glands. The diseased intestines inflame, adhere to- gether, and ulcerate, so that openings form between different convolutions ; and on examina- tion the peritoneum is found as thick as leather, and the intes- tines resembling a collection of cells rather than a simple tube. Symptoms.—Emaciation and voracity, owing to the obstructed course of the chyle ; the belly swelled and hard; the skin dry and harsh; the eyes red; the tongue strawberry-colored; the breath foul; the stools clay- colored and offensive, sometimes costive, sometimes extremely relaxed. The patient of course dies hectic, although he often lasts wonderfully long. Treatment.— Animal food and other nutriment given in small quantities at short intervals; mild mercurials to amend the intestinal secretions espe- cially the combination of corrosive sublimate with tincture of bark, X. 87 ; tepid salt bathing; stimulating liniments to the abdomen; change of air; and the cautious administration of the anti-scrofulous remedies before men- tioned, especially the cod-liver oil. Represents enlargement of the mesenteric glands from a scrofulous patient. 110 TUMORS. CHAPTER XIV. MORBID growths and tumors. SECTION I.—OF TUMORS GENERALLY. Definition.—By morbid growths are understood certain masses of living tissue, growing independently, excessively, and abnormally. The word tu- mor is used in pathological language to signify, not any kind of swelling or enlargement, but only such enlargements as are caused by morbid growths. Thus the enlargements caused by inflammatory swelling and exudation—by cedema, abscess, ecchymosis, and emphysema; by tubercular deposits; by the intrusion of hydatids or other foreign bodies; by the dilatation of organs, as in aneurism, or by their displacement, as in hernia—are not properly called tumors. Thus in the definition of tumors are included the ideas: 1st. That they are composed of a living tissue, either natural or unnatural, and if of natural tissue, yet developed in unnatural quantity or situation." 2dly. That they grow independently, or, in Mr. Paget's words, "they grow with appearance of inherent power, irrespective of the growing or maintenance of the rest of the body, discordant from its normal type, and with no seeming purpose." Again—"while forming part of the body, and borrowing from it the appa- ratus and materials necessary to its life, the tumor grows, or maintains itself, or degenerates, according to peculiar laws."1 Tumors seem to originate in morbid states of the blood, which either cause exudation and new growth, as in cancer; or which cause preternatural growth of already existing structures, as in epithelioma. Each sort re- spectively depends, no doubt, on some specific constitutional vice. But the nature of that vice is quite unknown. The remedies are equally unknown; for there is scarcely any morbid growth that is influenced by any medicine yet discovered. Classification.—The true basis of the classification of morbid growths is their structure; and the structure being known, both in its naked-eye and microscopical characters, the origin, development, symptoms, and subsequent history of each kind of growth must be attentively studied A large group of tumors are composed of fibrinous, or fibro-plastic matter, in some stage of development between indistinct fibrillation, or rudimentary cell-growth, and perfect fibrous or areolar tissue. This group includes the fibro-plastic, fibro-nucleated, and fibrinous and gelatinous tumors; which are composed of masses of cell-growth (see p. 51), which increase in bulk, without being developed into perfect tissue; and in which a great variety of abortive cell-forms is displayed. Many pathologists think that cancer and tubercle belong to this group. Besides these it includes the fibrous and fibro-cellular, in which the structure of areolar tissue is fully developed. A second group consists of bony and cartilaginous tumors. 1 Vide Carswell's Pathology; Miiller on Cancer and Morbid Growths, by C. West, Lond. 1840 ; Walshe on Cancer, Lond. 1846 ; also on Adventitious Formations, in Todd's Cyclopaedia, parts 30 and 31; Hughes Bennett, on Cancerous and Cancroid Growths, Edinburgh, 1849 ; Paget's Lectures, Lond. 1853 ; Lebert, Physiologie Pathologique, 1845 ; Traite Pratique des Maladies Cancereuses, Paris, 1851 ; and Anatomie Pathologique, Paris, 1857 ; Wedl, Pathological Histology ; Rokitansky, op. cit. TUMORS. Ill A third group is composed of new and independent development of gland tissue, more or less perfect. A fourth of bloodvessels. A fifth is distinguished by the presence of cysts, although this is an acci- dental circumstance in several instances. A sixth consists in the local overgrowth of fat tissue. A seventh consists in enormous production of epithelium An eighth, of black pigment. A ninth is distinguished by certain peculiarities in its cell elements; and no less by its fatality. This is the group of cancer. Formerly all tumors which had the fatality of cancer were considered to belong to a group apart, and called malignant; whilst the remainder were called benign or innocent. 1. Of the benign, it is assumed that they originate in a sort of local error of formation. That they are homologous, or homceomorphous, or in other words, identical with, some of the normal tissues of the body. That they may be continuous with normal tissues of the same sort, but circumscribed, discontinuous, and not infiltrated amongst a variety of other tissues. That there may be many in one individual, but usually in the same tissue. That they are perfectly compatible with a high state of health. That they have an uncertain period of increase, after which they may remain stationary for an indefinite time, or may undergo a process of fatty or earthy degeneration. That they may, by their bulk and situation, cause oedema or paralysis, or obstruction to various canals; or may inflame and suppurate; or may undergo ulceration or sloughing, and so may seriously impair the health; but that all these ill consequences are local and accidental, and cease if the tumor be removed; and that if effectually removed, there is no return, either in the same, or in any other place. 2. Of the malignant, on the contrary, it is said that they possess the following marks : 1. They are of constitutional origin. 2. Their progress is generally rapid. 3. They progress constantly; 4, are attended with pain ; 5, return if cut out; 6, are liable to be diffused over the body from increase of the materies morbi; or 7, are liable to secondary deposits, from being absorbed from one part and deposited in another; 8, they are attended with cachexia; 9, they resist all treatment; 10, they infiltrate every tissue in their vicinity; 11, soften inwardly; 12, ulcerate outwardly; 13, invade the lymphatic glands; 14, are heterologous in structure, that is, resemble no tissue naturally found in the body; and lastly, after a time prove fatal. The only tumor possessing all these marks is cancer.1 3. There is a third intermediate class, of semi-malignant or cancroid growths, including those which have some, but not all of the vital charac- teristics of cancerous growths ; as well as those which (like the fibro-plastic) resemble cancer in their coarse appearances, though not in their real struc- ture. But in truth, there is no absolute line of demarcation between malignant and non-malignant growths. All tumors are constitutional. All are liable to return after extirpation. Some varieties of fibrous and fibro-plastic and cartilaginous tumors may not only return, if removed, but may invade many internal organs. There is no tumor which in some individuals, or under some circumstances, may not display at least ten out of the fifteen signs of malignancy. But for all this, it is absurd to erect the malignant into a separate class, from the innocent tumors of the same structure. It is like putting all the fatal cases of a disease into one class and the unfatal into another. 1 See a paper on Cancer, by R. Druitt, Association Journal, Jan. 1854. 112 FIBROUS TUMORS. SECTION II.—THE FATTY TUMOR. The Fatty Tumor (Lipoma) is composed of genuine fat-tissue ; that is, of oil-cells, rounded or polygonal, packed in the meshes of a natural areolar tissue. Such tumors are contained in a fibrous capsule, in which their blood- vessels ramify, and which sends partitions throughout their substance, dividing them, more or less completely, into lobules. In outward characters they are soft, painless, and lobulated ; feeling just like fat. Their most usual situation is the subcutaneous cellular tissue of the trunk, especially about the back of the neck and shoulders; but they may extend between and under fasciae, deep amongst the muscles of the neck, trunk, or limbs. They may even be found in parts where no- fat exists naturally, as the scrotum or eyelid; but, in such cases, probably began to grow higher up, and moved downwards afterwards. In number this tumor is generally single ; its growth is slow; it may attain enormous bulk, even 7.0 lbs.; but causes no inconvenience save what arises from its weight and situation ; and is liable to no process of de- generation, except that it may possibly become inflamed and adherent, or hardened by the development of fibrous tissue, or even may ulcerate or slough out. It may by its softness be mistaken for chronic abscess or encysted tumor; but the tactus eruditus, or puncture with a grooved needle, will distinguish the difference. Treatment.—The liquor potassaa has considerable influence in causing the absorption of fat, when there is a universal tendency to obesity, or even when there is a partial overgrowth of fat in some part of the body ; where it is an exaggeration of the whole fatty tissue of some region, and not a true circumscribed tumor. Sir B. Brodie has seen such local hyper- trophies of fat in the neck more commonly than elsewhere, and gives a case of a servant, in whom such an overgrowth was aggravated by iodine, and cured by liquor potassse. The dose is a fluid-drachm, thrice daily in table beer. But neither this nor any other medicine has any effect on the true fatty tumor. Sometimes a fatty tumor on the cheek has been caused to waste in sup- puration by means of a seton passed through it; but, for most cases, extir- pation by the knife, after the manner described in the last Part, Chap. II., is the only remedy, and an effectual one; for this of all tumors is the least likely to return, although in rare instances it does so.1 SECTION III.—THE FIBROUS, PAINFUL SUBCUTANEOUS, FIBRO-CELLULAR, FI- BRO-PLASTIC, FIBRINOUS, FIBRO-NUCLEATED, AND COLLOID TUMORS. I. The Fibrous Tumor (desmoid tumor) is composed of fibrous tissue, identical with that which forms the normal tendinous structures of the body, and which it perfectly resembles in naked-eye appearances. In many tu- mors the fibres are arranged in bands or loops, or perhaps in concentric circles round numerous centres; in others they are inextricably matted together. Some are vascular and pinkish, but the majority almost destitute of bloodvessels. Microscopically they are seen to consist of fibrous tissue, which when rendered transparent by acetic acid, usually reveals numerous nuclei scattered amongst the fibres The most frequent habitat of these tumors is usually said to be the womb. [' See Gross, op. cit. vol. i. p. 285.] FIBROUS tumors. 113 Section of fibrous tumor from the uterus. But the so-called fibrous tumors of this part consist in reality of unstriped muscular fibre. Fibrous tumors are common in connection with the peri- osteum, especially about the jaws, or may grow in the interior of bones; in the subcutaneous cellular tissue ; in the breast, and particularly in the nerves, where they receive the name neuroma. On examination these tumors are usually firm, free from tenderness, smooth, oval or pyriform ; slightly lobulated ; of slow growth ; lasting any number of years, and attaining almost any size; gene- rally single as to number, or, if multiple, affecting but one and the same organ. Their origin is usually quite spontaneous, and cause unknown : sometimes they follow an injury; but even then the reason why is quite unknown. Of the degenerations this tumor is subject to, the commonest is calcification, that is, infiltration with earthy salts, by which parts of it are converted into a stony mass. Cysts also, filled with serous fluid, may form in the interstices. Such a tumor may inflame, soften, suppurate, and slough out entirely or by de- grees ; or may adhere to the skin over it, and cause it to ulcerate by distension and slough, or may throw out livik bleeding fungous pro- trusions. Extirpation is the only treatment; after which the patient may be com- forted with the probability that there will be no return of the disease in the same place or elsewhere. Yet, as we before said, cases occasionally happen in which a fibrous tumor has returned again and again, after apparently thorough extir- pation, and has been excised five or more times, till at last a permanent cure has been obtained. In any such case of recurrence, early and free extirpation should be resorted to ; and the iodide of potassium be ad- ministered. In other rare cases a fibrous tumor, after repeated extir- pation, has been succeeded by a cancerous growth; whilst in other still rarer cases, not only does the fibrous tumor return in situ, after excision. but the tendency becomes diffused, and the lungs or other internal organs are attacked. II. The Painful Subcutaneous Tumor, of Wood, is a small body, rarely larger than a pea or coffee berry, composed of fibrous tissue, situated under the skin, generally single, generally affecting women, subject to fits of most excruciating neuralgic pain, and often the cause of hysteric and other spas- modic affections. Hitherto, anatomists have failed to detect, on dissection, any connection between these tumors and the nerves ; so that a distinction must be drawn between them and the neuromatous tumors, which are generally multiple, affect men rather than women, and consist of small fibrous tumors embedded in the sheaths of nerves. Extirpation is the remedy.1 III. The Fibro-cellular Tumor is composed of the common areolar tissue of the body. On a section it displays bands of firm white fibrous tissue, intersecting a softer, yellow, gelatinous-looking substance, infiltrated with serum. Microscopically, the characters are those of fibrous and fila- mentous tissue, in a more or less complete state of development. The most 1 See the paper by Mr. Wood, who first accurately described and named this tumor. in Edinburgh Med.-Chir. Trans, vol. iii. ; Lond. Med. Gaz. vol. vi. p. 59 ; Paget's Lec- tures ; Wedl, op. cit. p. 400. 114 fibro-plastic tumors. frequent seats of this tumor are those in which the fatty tissue is not found : as "the scrotum, or labium, or the tissues by the side of the vagina, the deep-seated intermuscular spaces in the thigh, and the scalp." But the same tissue likewise constitutes, says Mr. Paget: " 1st. Nearly all the softer kinds of polypi, such as the mucous or gelatinous polypi of the nose ; and the polypi of the external auditory meatus. 2d. The various cutaneous out- growths, such as occur in the scrotum, labia, nymphae, clitoris, and more rarely in other parts; and, as hardly to be defined away from these, the warty and condylomatous growths of skin ; and 3dly, the outgrowths of scars, the cheloid tumors as they are named." When occurring as distinct tumors, they are felt as soft, elastic, painless masses. Their growth is usually quick, though a sudden increase of size may be due to serous infiltration, rather than to increase of tissue. They may attain a very large size ; may accidentally slough or ulcerate, but can be radically cured by excision. IV. The Fibro-plastic Tumor, of Lebert (sarcoma), is composed ap- parently of plastic lymph permanently arrested in its development into areolar tissue. There are two varieties of naked-eye appearances which are often combined in the same specimen. 1.* The soft variety has a great resemblance to encephaloma, being quite as soft, though more elastic, and not so readily torn ; yielding, when cut, a clear serous, and not milky juice; and having altogether the character of flabby granulations, such as are found surrounding carious bones. 2. The harder variety, or real sarcoma, is of firm consistence, like that of muscle, or of carnified lung, or rather of kidney; but not so firm as the fibrous tumor; on a section it appears homogeneous, and finely grained ; its color varies from reddish yellow to a deep fleshy red : these tints alternate in patches, and are mixed with spots of ecchymosis; it is often intermixed with fibrous bands, and contains many bloodvessels. The microscopic elements of the fibro-plastic tumor are—1. Fibro-plastic cells, spherical or ovoid : with pale cell-wall, well-marked nucleus, and nu- cleolus in the form of a small dot 2. Cells elongated into oat-shaped or pyriform bodies; pointed, or branched, and losing their nuclei. 3. Free nuclei, some elongated; and small globules. These elements are depicted at page 50. 4. Mother-cells; large oval bodies from .001 to .003 inch, inclosing from two to ten or twelve fibro-plastic nuclei. These cells are Fig. 18. Fig. 19. Fig. 18. Myeloid cells from a fibro-plastic tumor of the upper jaw, removed by Mr. W. Fergusson, 24th Nov. 1855. In color and consistence it exactly resembles human kidney. Fig. 19. Imperfect areolar tissue, and large cells containing fat-globules from a fibro-gelatinous tumor of the calf of the leg, drawn from nature. See a description of the same tumor, Pathological Trans, vol, v. plate xvii. called myeloid by Paget, from their resemblance to cells found in the mar- row of fcetal bones ; and the tumors in which they are formed he also calls myeloid 5. Fibrillary matter, more or less perfectly developed into tissue, inclosing the cellular elements ; sometimes very scanty, sometimes abundant, cartilaginous tumor. 115 soft, and gelatinous (fibro-gelatinous, or fibro-colloid tumor). 6. Well- developed areolar tissue enveloping the tumor, and forming boundaries to its various lobules. In external characters, fibro-plastic tumors are usually smooth, lobulated, and globular. They may be situated in the skin; in the subcutaneous, or submucous, areolar tissue ; deep amongst the muscles (especially of the thigh), in or upon bone, especially the maxillae ; or on the dura mater; or in the mamma, or other secreting glands, or in the lymphatic glands. They generally, but not always, grow slowly ; they may attain enormous size ; may undergo calcification ; or may inflame and ulcerate, or slough, and so prove fatal. They usually are single ; may occur at any age ; they some- times seem to arise from a syphilitic taint. As regards origin, some seem to follow an obscure inflammation, which has produced exudation into a lymphatic gland, or the testis. Others are of independent spontaneous or unknown origin. If extirpated they are exceedingly apt (much more so than the fibrous tumor) to return in the cicatrix, but very rarely in any other part; yet they may do so, or may be diffused over the system in the same manner that cancer is. The tumors most likely to become thus malignant are those of spontaneous origin, which yield most varieties of embryonic cell-forms. Fibro-plastic elements are also found in abundance in glandular, and most other rapidly-growing tumors. The treatment consists in extirpation, repeated if the disease returns ; and the prolonged use of iodide of potas- sium. In rare instances these tumors have been known to disappear spon- taneously. V. The Fibro-nucleated Tumor, of Hughes Bennett, Fig. 20. is a tumor composed of filaments infiltrated with abund- ance of naked nuclei. In outward appearance it may resemble the fibrous, or fibro-plastic tumor, or cancer; but microscopically examined the presence of nuclei, instead Fibro-nucieated tu-- of cells or fibres, distinguishes it from the former two mor. From an ass. growths, and the absence of cancer cells from the last. Its clinical history is, so far as is known at present, almost identical with that of the former tumors. VI. The Fibrinous Tumor is composed of almost structureless decolor- ized blood-clot, and is the result of extravasation of blood. It forms a soft tumor, and may generally be distinguished by its history and by its sudden origin. VII. Colloid, or Gelatiniform Matter is a substance closely resem- bling glue, or jelly, of various degrees of firmness and transparency; and is often found in cysts in the thyroid gland, and in the ovaries and prostate. The writer has several times found it in the substance of fibro-cellular tumors ; and it may be found amidst the products of chronic inflammation of the pleura and peritoneum. Moreover, a glue-like matter is a charac- teristic of one form of cancer. (See Colloid Cancer.) [A colloid or gelatiniform appearance is found also in many hypertrophic glandular tumors; such as those met with in the mammary gland.] SECTION IV.--CARTILAGINOUS AND OSSEOUS TUMORS. I The Enchondroma, or cartilaginous tumor, consists of round masses of cartilage, embedded in fibrous membrane. It may be of various degrees of firmness ;' almost as soft as the vitreous humor, so soft as to be mistaken and punctured for ganglion, or as firm as ordinary cartilage. It consists microscopically of cartilage cells embedded in an intercellular hyaline sub- stance • but there are very many varieties, not only in the quantity, consist- ence and transparency of the intercellular substance, but also in the number 116 CARTILAGINOUS TUMOR. and arrangement and size of the cells, and of the nuclei. Generally speak- ing, the cells are numerous, and loosely connected to the hyaline substance. They are round or oval; from 7T^ to y^ incn in breadth ; and the cell-wall may be completely distinct from, or inseparably blended with, the intercel- lular substance. The nuclei are single, sometimes double ; round, or oval; rendered paler by acetic acid ; with one or two nucleoli; some shrivelled or full of oil-granules; some throwing out projections, like those of cartilage in process of ossification. Fig. 21. Fig. 22. Fig. 21. Microscopic characters of enchondroma. Nuclei granular. Fig. 22. Enchondroma of the hand. Chemically it consists for the most part of phosphate of lime, and of a peculiar variety of gelatine, called chondrine, which is extracted by boiling in water from the temporary cartilage of the foetus, and from the permanent cartilage of the adult, but not from the adult bone or tendon. It differs from common gelatine, in containing less oxygen, and in being precipitable by alum, acetate of lead, and sulphate of iron. In external character, cartilaginous tumors are firm and smooth, usually somewhat nodulated, sometimes hard, sometimes so soft as to be mistaken for cysts. Their usual situation is on or within the bones, particularly those of the hands; [of the thirty-four cases collected by Miiller, by whom the name enchondroma was first given to these tumors, twenty-three were on the phalanges and the metacarpal bones ;] and they may be developed either within the bones, which they then cause to expand into a thin shell, or else from their surface.beneath the periosteum ; in which case they usually have, like other tumors in the same situation, a skeleton of light papery plates, and spicula of bone shooting throughout their substance, as represented in the next cut. Or they may become ossified, from internal independent centres of ossification. But besides the bones, enchondroma may form in the glands, as the testi- cle, mammary, and particularly the parotid. It may form isolated movable tumors in the subcutaneous tissue, and may be found in the lungs. It may likewise be combined with the fibrous, fibro-plastic, colloid, or cystic growths, or with cancer. The growth of cartilaginous tumors is usually slow; but this is subject to great variety. Thus in one case, related by Mr. Frogley, a tumor of this sort, growing upon the femur, attained the circumference of three feet in five years; another, twenty inches in eleven years; another, mentioned by Mr. Paget, acquired the circumference of a man's chest in three months from the time when it was first noticed. The articular surfaces in the neighborhood are not affected, GLANDULAR AND VASCULAR TUMOR. 117 23. nor is there any adhesion, or infiltration of other tissues. But, after an uncertain time, the cartilaginous tumor may undergo fatty or earthy degene- ration, as in the case of a small nodule the size of a walnut, removed by Mr. Walton from the subcutaneous tissue of the forehead, in which the writer found half the tumor degenerated into a yellow, cheesy mass. Moreover, the hyaline substance may soften down into a stuff like pease soup, as in another specimen from the vicinity of the parotid which Mr. Walton sent to the author, and which was converted into a mass of cysts, with fresh lobules of cartilage growing into them. Such cysts may ulcerate and discharge their contents, giving rise to great constitutional irritation and exhaustion. Cartilaginous tumors are more frequent in early life. They are often multiple and hereditary; and although, as a general rule, they do not return when thoroughly excised, yet to this rule there are many exceptions. A case is narrated by Mr. Paget, in which a cartilaginous growth ex- tended along the lymphatics from the testicle, to the vena cava inferior, and into the cavity of that vein; masses of cartilage were also found in the lungs.1 II. Osseous Tumors are so constantly found in connection with the bones, that it will save repetition if we refer our readers for an account of them to the Chapter on Bones. But we must say here, 1, that a distinction is to be drawn between tumors containing true bone- tissue, and others which are merely calcified or impregnated with amorphous earthy salts. 2. That some osseous tumors are formed by the hypertrophy of existing bones; and 3, others by the ossification of pre-existing fibrous, fibro- plastic, or cartilaginous tumors. When these are attached to the bones, they constitute exos- toses ; but true bony tumors, formed by the os- sification of the other kinds, may exist isolated in the soft parts. The term osteosarcoma was formerly used to signify any tumor in which bone was mingled with softer tissue; as, for example, the enchon- droma, or fibrous tumor, when ossifying, and cancerous growths springing from the surface of bone. Bony skeleton of enchondroma. SECTION V.—GLANDULAR AND VASCULAR TUMORS. I. Glandular Tumors are formed by the development of a tissue re- sembling that of secreting glands. Such tumors are most common in the female breast, where they are known by the terms chronic mammary tumor, and imperfect glandular hypertrophy; but they may also be found in the lip, and in the prostate, parotid, and thyroid glands. Such tumors are generally painless, not tender, moderately soft, elastic, and lobulated. On examination they are usually found to consist of three elements : 1, common fibrous tissue, hypertrophied, forming septa and loculi. 2. Abundance of 1 Miiller on Cancer, &c, translated by West, Lond. 1840; Lebert, Phys. Path. vol. ii. ; Paget, Lectures, Med. Gaz. 1851; Frogley, Med.-Chir. Trans, vol. xxvi. ; Paget, ib. vol. xxxix. 118 CYSTIC TUMORS. fibro-plastic cells and nuclei. 3. Imbedded in the former two is found the essential constituent, gland-tissue. This consists of sacs, or pouches of clear pellucid membrane, arranged in lobules or acini, and Fig. 24. filled with glandular epithelium. If the containing membrane be ruptured, the epithelium may be seen to pour out. Both the fibro-plastic and epithelial ele- ments in these tumors are liable to softening from in- flammatory disturbance, or from fatty degeneration. ef'&i ^f^<-^ This disease may disappear spontaneously; or it may remain stationary; or it may enlarge, distend the skin, Three acini, from a gland- ulcerate, protrude as a bleeding fungous mass, and niar tumor of the breast; destroy life by irritation and exhaustion. It is some- one ruptured, with epithe- traCeable to local injury, or disorder of the health, hum coming out. Sketched """^ k*™^.^ * j j, . . ' from nature. but more frequently not. The iodides of potassium and of iron sometimes seem to delay the growth of this tumor; but in general if*requires extirpation. Even then it is exceedingly liable to return t and cases are on record of five or six successive operations on the same patient, followed by renewed growth of the tumor.1 II. Vascular Tumors are composed of bloodvessels or of spaces con- taining blood, and will be more conveniently described in the Chapter on the Arteries. SECTION VI.--CYSTIC TUMORS. These are tumors consisting of a sac, containing solid or liquid substances. They may arise in three ways : 1. By the formation of definite cavities in the meshes of the common areolar tissue. 2. By the dilatation and growth of obstructed gland ducts or follicles. 3. By the independent and erratic development of nucleated cells, which become exaggerated into cysts; or of isolated particles of gland-tissue, which fill with secretion, but are unpro- vided with ducts. 4. By the extravasation of blood, and the disappearance of the red particles, and separation of the serum from the fibrine. 1. Serous Cysts.—Of the simple cysts, the most common are those con- taining serum. They may occur in almost any structure, natural or morbid: in the intermuscular areolar tissue ; in bone ; in tumors of almost every kind; in the secreting glands, as the kidney and breast; but most frequently in the neck in connection with, or in the neighborhood of, the thyroid gland; also in the vicinity of the jaws. The cyst itself is composed of fibrous tissue, and is often lined with epithelium. The contained fluid may be serum, pale or yellow, or tinged with bile or blood, or perhaps ropy or honey-like, and containing abundance of crystals of cholesterine. Or, lastly, it may be colloid matter, yellow stuff of the consistence of the vitreous humor, or of half-melted calf's-foot jelly. II. Sanguineous Cysts, containing fluid blood, are most common in the neck. They probably arise from the partial obliteration of naevi, of which these cysts, formed of distended veins, are the remains. Treatment.—This, and the preceding kind, sometimes heal and collapse after simple puncture, sometimes they require to be dissected out. III. Synovial Cysts or Ganglia. See Part IV., Chap. III. IV. Gland Cysts are formed by the obstruction of excretory ducts, or follicles of glands, or by the abnormal development of portions of glands without ducts. Under this extensive division we may include cutaneous cysts, or wens; which are formed by the obstruction, or by the misplaced 1 See M. Charles Robin on Heteradenic Tumors in the Nasal Fossae, &c. ; Lebert, Anat. Path., Paris, 1857, vol. i. EPITHELIOMA. 119 development of follicles, whose inner surface secretes cuticle and sebaceous matter, with, perhaps, hair; and such cysts are found, not only under the skin, and in the ovaries, but in the skull, the chest, and many other parts. Teeth (which, it will be remembered, are parts of the dermal, or exo- skeleton) are also found in these cysts in the ovaries, as well as in cysts attached to the jaws. Cysts in the vicinity of the testicle, containing sper- matic filaments, or in the breast, containing milk; the cysts formed in mucous membranes, and ranula, may be classed under this head. The contents of these cysts, which at first may be presumed to be identical with the natural secretions of the parts in which they are formed, become greatly altered by time. Solid curdy masses ; viscid honey-like fluid; or colorless pellucid mucus, are found in different instances. V. Compound Cystic Tumors ; such as occur in the ovaries, and in the villi of the chorion ; formed, by the exaggerated development into cysts, of the cells of which these structures mainly consist. VI. Proliferous Cystic Tumors (Sero-cystic Sarcoma) are composed of cysts, having solid fibro-plastic or glandular growths projecting into them. (See the Chapter on the Female Breast.) They may originate in two modes—either as tumors, in which cysts are afterwards developed ; or as cysts, to which the solid growth is superadded afterwards. In either case, the history may be divided into three stages: First, there is the formation of cysts, possibly single ; usually very numerous. Secondly, there is the growth into the cysts, from some part of their walls, of vascular tumors, composed of fibro-plastic cells, or else of rudimentary gland structure. The intracystic growths in either case enlarge and fill the cavities; and then the third stage arrives, in which the growths, having filled the cysts, burst through, enlarge, distend the skin, cause it to ulcerate, and then protrude through it in the form of bleeding fungous granulations. The most frequent seats of this disease are the mammary and thyroid glands ; but it has been found in the lip, the prostate gland, and in the in- termuscular tissue. The diagnosis and treatment will be more fully spoken of in the Chapter on Diseases of the Breast. Suffice it to say here, that the disease, although generally incurable, save by extirpation, and although liable to return in situ after extirpation, yet has no tendency to contaminate the lymphatic glands, or to be diffused over various distant organs, like cancer. VII. Fibro-Cystic Tumors are fibrous, fibroid, or fibrinous tumors con- taining cysts, probably from extravasation of blood. section vii.—epithelioma. Definition.__A disease consisting first in abnormal development of the epithelium, and probably of the villi or papillae of skin or mucous membrane; then in ulceration; and then in infiltration of the deeper tissues and lym- phatic glands with epithelium. Symptoms.—It may begin in the form of hypertrophy of the epidermis or epithelium; there being a softish itching vascular spot, from which cuticle is frequently desquamating; or a patch covered with a dry crust or scab. 2. There may be combined with this, a hypertrophy of the papillae in some one of the multiform shapes of warts or excrescences; either sprouting, prominent, and cauliflower-like, with narrow elongated neck, or broad, flat, and low. ' 3. The cutis vera may be the part first affected; being thickened and forming a broad, oblong hard swelling, with a slight scab, or perhaps a crack on its surface ; but whether affected or not at first, it is sure to be involved as the disease extends. 4. The subcutaneous tissue, or even the lymphatic glands or bones, may be, in rare instances, the parts first affected. 120 EPITHELIOMA. Anatomical Characters.—On examining a section of the diseased tissue, there is distinguished first, on the surface, a layer of thickened epidermis; mixed, perhaps, with pus and scabs; it is Fig. 25. generally opaque yellow, cheesy and brittle, _^<^ and easily scraped off. 2. Next to this are noticed the papilla?, hypertrophied in va- rious degrees, and imbedded in the exube- rant epidermis around them. 3. Under this is the true skin, thickened into a tough brawny mass, composed of a fibrous basis interspersed with numerous spots and streaks Fig. 26. yzz. ,zyz%yy - _y;:y.:-m A representation of a papilla, or the apex of a granu- lation, found in the urine, in the case of epithelioma of the Section of three papillae ; the middle bladder. Internally it contained a loop of vessels ; out- one split. Sketched from nature. About wardly it was clothed with scales of exuberant epithelium. 100 diameters. About 200 diameters. of-opaque yellow, or brown. 4. If the subcutaneous tissues are involved, they present the same character. Microscopical examination shows, 1, the epidermic layer to be composed of epithelium, arranged in concentric layers around and between the papilla?. 2. The papilla? and dermis are composed of white, intermingled with yellow fibrous tissue, everywhere abundantly infiltrated with epithelium cells, and with their nuclei and fibro-plastic matter. In the papilla? the epithelium is seen to be arranged symmetrically in concentric layers amongst the scanty fibrous elements ; and this arrangement may penetrate to some depth within the cutis, from which elongated and imbricated rolls of epithelium, somewhat resembling the heads of young asparagus, can be extricated. 3. Within the cutis and subjacent tissue, the epithelium is found sometimes in concentric pellets, like the comedones or grubs, or inspissated contents of sebaceous follicles; sometimes in rings formed within ob- structed ducts or follicles, but usually in large irregular quantities infiltrated amongst the fibres of the cutis and of the subcutaneous areolar tissue. The epithelial cells vary much in size, although their nuclei do not; they may be round, elon- gated or spurred, wrinkled, split into fibres ; they may be infiltrated with oil-globules ; dried up ; or softened into an almost amorphous granular mass mixed with oil and cholesterine, which to the naked eye resembles tubercle. Generally speaking, the larger the cell the less perfect the nucleus. Some cells have double nuclei, or some nuclei double nucleoli, but not often. Epithelial tumors usually exude from a cut surface a copious, clear, serous juice, in which may be observed floating masses of epithelium cells, nuclei, m> Epithelial cells infiltrating the deep tissues of the lip, near a so- called cuncer of the lip. EPITHELIOMA. 121 and, perhaps, oil-globules and cholesterine. The diagnosis of this disease from cancer is spoken of in the last section. The Clinical history of this disease is this: First, there may be a period of quiescence ; the tumor remaining as an innocent wart for week's or years. But if it once begins to ulcerate, its course is one of constant progress. The skin and subcutaneous tissues become more deeply and widely infiltrated, and consequently hardened and adherent; the nearest lymphatic ganglia enlarge and become the seats of similar deposit; and muscle, bone, and every other adjacent tissue, is attacked. But whilst the deeper parts are enlarging, the surface becomes the seat of foul and extensive ulceration. It cracks and oozes a purulent or sanious fluid, which, mixing with the epidermis, dries into a scab. When this is detached, a wide ulcer is brought into view; and at last there is formed a deep irregular excavation in the centre, exuding a thin ichor, surrounded by fungous warty growths, and resting on a base of hard adherent and infiltrated skin. Thus the entire lower lip may be destroyed ; or the bladder, rectum, and vagina of the female may be con- verted into one huge cloaca. If excision be performed, the nearest lym- phatic ganglia enlarge, and form a foul ulcer like the original. The consti- tution may be apparently sound at first, and may continue so, till it begins to be worn by the incessant discharge, the pain and irritation of the ulcerated surfaces, the absorption of fetid matter, and the interruption to various functions which ensues, especially if the disease be situated near the mouth, the anus, or the genito-urinary apparatus. In singularly rare instances, secondary epithelial deposits have been found in the liver, lungs, and heart. Causes.—Men are more subject to this disease than women, and it is rare before 40 ;—but of its predisposing and exciting causes little more is known than may be summed up in three statements ; viz.—1st, in some few instances, hereditary predisposition may fairly be assumed; inasmuch as, in Tf s£SI> 0- Fig. 37. <5J>s Fig. 35. Nodule of black cancer in the true skin. Fig. 36. Soft cancer impregnated with pigment. From a bay mare. 4. Colloid, or Gelatiniform, or Alveolar Cancer, is a peculiar growth, composed of a stroma of thin membranous or fibrous material, so arranged as to form circular loculi, resembling in this respect the pulmonary tissue, and filled with globular masses, composed of concentric layers of that structureless material which we have described as colloid matter. The loculi, or rounded cells, are visible to the naked eye on a section, and may vary from the size of a pin's point to that of an egg. The colloid matter seems to differ much from other animal products, and to resemble the jelly of the umbilical cord, or mucus, or the substance of the intervertebral cartilages, or the tissue of the acalepha? and medusa?. Its animal basis is said to contain only 7 per cent, of nitrogen. The rounded masses of gelatinous matter contain granules and nuclei; and the larger masses contain abundance of smaller ones, into which their substance appears to have divided and developed itself after the manner of the growth of cartilage. The gelatinous matter is arranged around these granules and nuclei after the manner of cell-growths. i Windsor Prov. Med. Journ. 1850, p. 225; Fawdington on Melanosis, Lond. 1826. It must be admitted that we know not how many of reputed cases of melanosis are cancerous, and how many consist of pigmentary deposit without cancer. This cut represents the outward ap- pearance of a colloid growth on the me- sentery, from King's College Museum. See also Ballard, Med.-Chir. Trans, vol. xxxi.; Sibley, ib. vol. xxxix., and a clas- sical case in Lebert, Anatomie Physiolo- gique, vol. i. 126 CANCER. The question now arises, what is this growth ? is it cancer ? Most patho- logists consider it as cancer, and Lebert describes some, though not all, of the nuclei, as having the characters of cancer-nuclei. The peculiar chemical composition of the mass, however, seems to claim for it a place by itself. Its most frequent seat by far is the peritoneum and abdominal viscera, yet it is found in the female breast and elsewhere. It has all the characteristics of cancer except that its progress is slow, and that it is slow in relapsing. It is an infiltrating growth, destroying the tissue it invades, spreading to adjoining parts, affecting the lymphatic glands, and appearing in remote organs; as in a case recorded by Lebert, in which a colloid tumor of the left breast of twelve years' duration destroyed the breast, appeared in the axillary glands, destroyed the intercostal muscles by infiltration; and invaded both lungs, the mediastinum and bronchial glands. 5. Haematoid Cancer (Fungus hsematoides) is a variety of soft cancer, distinguished by its excessive vascularity, which is sometimes sufficient to cause a sensible throbbing like that of a vascular tumor. Hence arise ex- travasations of blood into its substance, giving it the appearance of blood- clot mixed with brain. If ulcerated, there are frequent hemorrhages from the surface. This, however, is common, to every form of rapid ulcer, can- cerous or not. 6. Cystic Cancer.—Cysts may be produced in cancerous growths by the extravasation of blood, and the absorption of the coagulum, leaving in its place a clear or coffee-colored serum. Or, cancer may be superadded to a previously-existing cystic growth, and may grow from the walls of the cyst as a portion of hypertrophied gland may. Or, lastly (as in the case of can- cer of the ovary), it may, from the first, assume the cystic form which cha- racterizes the morbid growths of that organ. 7. Osteoid Cancer (Malignant osseous tumor) is characterized, not merely by the partial ossification of the fibrous or periosteal tissue, intersecting a cancer when developed in or upon bone (which is common), but by the con- version of the newly-developed cancer stroma, first into fibrous tissue of extreme density, then into a peculiar bone. This bone when macerated and dried is exceedingly dense and compact, like ivory ; yet dull in color, rough and porous on its surface, extremely brittle and capable of being reduced to a chalky powder; and may be seen, under the microscope, to be imperfectly constituted as to its bone structures, and to contain an admixture of amor- phous earthy matter. In the recent state its surface is covered and its in- terstices filled with the dense fibrous matter, and with a few cancer-cells. 8. Villous Cancer.—This name has been assigned to a growth composed of the most delicate papilla?, containing each a vascular loop, growing from the surface of mucous membrane, and associated with cancer, or more pro- bably with epithelioma. The bladder is the usual seat of this growth. Causes.—Under this head we have chiefly to confess our ignorance. Neither temperament, mode of life, civilization, previous disease, nor moral causes have been proved to have any special predisposing influence. Do- mestic animals and cattle are quite as subject to the disease as man is. The dark and bilious are not more subject to cancer than the light and florid. The rich are rather more liable than the poor; but it is because they are not so often cut off beforehand by other diseases. The healthy, well-fed, the happy and prosperous, are as liable as their less-fortunate brethren. The disease is alleged, however, to be more rare in tropical than in temperate climates; and, although there is no such incompatibility as is sometimes supposed be- tween cancer and phthisis (because cancerous patients often display the signs of pre-existing tubercular disease, and many become affected with phthisis), yet it happens most rarely that any person actually phthisical is attacked by CANCER. 127 cancer.1 External violence cannot be a cause of cancer, although it may perhaps occasion or hasten its development in the injured spot. In fact, the only known predisposing causes are—1. Descent from a cancerous parent, which seems to have some slight influence, and was found by Lebert to exist in about f of a certain number of cases. 2. Sex: for cancer is at least from ^ to ^ more prevalent in the female. 3. Age: because nearly half of the entire number of cases occur between 40 and 60. Lastly—although cancer is not contagious in the ordinary sense of the term, there seems reason for believing that, if fresh cancer-cells are introduced into the blood, they may be deposited and propagate themselves. The experiment has been tried on dogs by Langenbeck and by Lebert; and cancerous tumors were found in various parts, when the animals were killed some time afterwards ; yet it must be remembered that some of the tumors found in these cases may have existed before the inoculation. General Pathology.—Our knowledge of the essential nature of cancer is best expressed by the phrase, that it is the consequence of some specific, but quite unknown, condition of the solids and fluids of the body, to which is assigned the name of the cancerous diathesis. The type, and the most frequent variety, is the encephaloma; for although most of the cancers of the female breast are of the scirrhous variety, and although this is common in the periosteum, dura mater, and pylorus, yet in every other tissue and organ the encephaloid largely prevails. Cancer may occur at any age ; Lebert has seen it in the brain of a child of seven months ; and believes it may be developed in the foetus in utero. Cancer of the eye is most frequent under 15 ; that of the female breast and of the uterus (which form more than a fourth of the entire cases of cancer) between 40 and 60 ; of the testicle between 20 and 50 ; of the intestinal tube in advanced life ; whilst cancer of the bones is equally frequent at all ages. The Progress of Cancer may be divided into three stages :— 1. In the first, it is deposited in the form of liquid blastema ; out of which cancer-cells develop themselves. They are contained in the meshes of some natural tissue, or in a new fibrous tissue developed with them. The tissue so formed gradually increases and attracts capillaries to supply it with blood; and may remain for a greater or less time almost without symptoms and unnoticed, if in an organ (such as the skin or breast) whose functions are not active ; though in any more important part the functions are sure to suffer. In this stage the constitutional symptoms may be slight, if any. 2. The second is a stage of active local progress. The tumor grows faster; begins to adhere to and to infiltrate neighboring tissues and the nearest lymphatics. And now, not only the functions of the organ affected, and of the others implicated by contiguity, become more decidedly deranged, but other symptoms manifest themselves peculiar to the morbid growth. Pain of a most severe, intermitting, neuralgic sort; gradually increasing in severity; felt in the tumor itself as a sharp, stabbing, or burning sensation; in the muscles and bones as a wearing rheumatic pain, often disturbing the sleep at night; sometimes preceding all local disease ; sometimes not felt till it is far advanced, is one of the most marked symptoms of cancer. This is quite independent of other pain arising from pressure, distension, or stag- nation of blood. So valuable a sign is pain, that if after extirpation of a doubtful tumor, the patient complains of neuralgia, secondary cancer may be almost certainly predicted. This practical rule was communicated to the writer by his friend and preceptor, Dr. Robert Ferguson. In this stage, also, may occur several changes in the nutrition of the morbid growth. A i See case by Mr Sibley, of concurrent development of cancer and pulmonary tuber- cle ; and two other cases in J. Z. Lawrence on Surgical Cancer, 1855, p. 30. 128 CANCER. portion of the cells may undergo disintegration into a granular mass ; pre- ceded by fatty infiltration and formation of round granular corpuscles; or by a drying up and condensation ; and the portions thus altered form a yellow tubercular-looking mass mingled with the rest of the tumor, which Miiller described under the name reticular cancer, and Lebert as the phxj- matoid. Ecchymosis, inflammation, and abscess may occur, or ulceration; but be it observed that ulceration is by no means so common a phenomenon in cancer as is generally taught, unless it be in hard cancer of the skin, breast, or stomach. After ulceration, or before it, portions of the tumor may soften, or may slough away; but none of these changes are curative ; for whilst one part is perishing, others are germinating and spreading the faster. Respecting ulcers which form in scirrhous growths, we must observe, that neither the excavated surface, nor the fungous granulations, nor the raised and everted, or excavated edges, nor the fetid sanious discharge, varied by hemorrhage, are so characteristic as the hard and fixed base. In some few cases the ulcer may heal; but the cancerous mass beneath remains. The constitutional symptoms of this stage are those of an increasing ca- chexia, added to the detrimental consequences of pain, discharge and inter- ruption of function. The complexion becomes sallow, the lips pale, the mind despondent (though delirium in any case of cancer is rare), digestion feeble ; the flesh and strength waste ; and the bones become light and fragile. In the third period, whether because (as the author believes) the blood has become saturated with cancerous plasma, or because a cancerous infec- tion has taken place through the molecules or nuclei absorbed from the seat of primary deposit, diffused and secondary cancerous growths are formed in the liver, uterus, bones, pleura, and other parts ; and the increasing func- tional disturbance, added to the increasing decay of the vital qualities of the blood, ultimately prove fatal. Prognosis.—The final destiny of a cancerous patient is pretty certain; the time in which the disease may prove fatal is uncertain; it is shorter in the soft than in the hard cancer ; in, young patients than in the aged ; and in cancer of internal organs, especially if of vital importance, than of ex- ternal. Some patients succumb in a few months ; others survive, if carefully treated, several years; but two years, or three, may be considered as more than the usual limits. Treatment.—In the first place, it must be confessed that we know of no radically curative measures, such as are capable of removing the cancerous taint from the blood, and of arresting the growth of the local disease. All that we can do is to check the disease so far as we can, and make the patient's life as long and as comfortable as our means permit. The first thing to be spoken of is extirpation; against which must be alleged the facts—that the removal of one affected part cannot remove the diathesis, and that the disease is almost sure to return in the original situa- tion, or in some other. That in some instances outward cancer is accom- panied by the disease inwardly, and that to remove the former would be taking away only part of the disease already existing ; for instance, in cancer of the eye, or of the testis, some part within the head or abdomen is com- monly affected likewise, and operations in such cases are most rarely success- ful. That some patients are killed by the operation itself; and that some have died from being operated on for what afterwards proved to be no cancer at all. On the other hand, in favor of extirpation it must be said that life may undoubtedly often be prolonged by it. That if the disease does return, an operation, thanks to chloroform, may be painless, and the interval one of health and comfort; and that it is possible the disease may not be cancer, but some other growth which excision might cure. CANCER. 129 The first point the surgeon should consider is, whether an operation can be performed without danger to life ; for it would be both useless and un- justifiable to perform it, if the health were so completely broken down, or visceral disease so advanced, that the patient was liable to sink after it, or if the diseased mass were so adherent or extensive that it could not be re- moved effectually, so that the wound made by the operation would not heal. The methods of extirpation are two—the knife, and caustics. The knife is undoubtedly to be preferred in all cases as the more merciful; and de- cidedly so if the tumor is circumscribed, and can be removed entire, leaving a wound capable of healing by the first intention, so as to give the patient the chance of the most rapid recovery possible. Caustics, or astringent substances used assiduously, and in sufficient strength to shrivel up and kill the diseased tissue, are of the greatest service in cases for which the knife is not available.' In the case, for instance, of an open fetid sore, or of a protruding mass giving issue to blood or to fetid sanious discharge, the chloride of zinc, in the form of BurneWs solution, is an admirable thing. The writer has long been in the habit of using it in cancer of the womb; and its powers of checking fetid discharge and bleed- ing, of allaying burning pain, and of causing soft masses to shrink, are great. It may be applied in varying strength according to circumstances ; so dilute as to be a mild astringent and deodorizer, or so concentrated as to be a powerful caustic. The point seems to be to deaden the surface, then to get it to absorb as much of the chloride as possible, so as to tan a considerable depth, and to continue the process till the whole of a diseased mass comes out as a slough. One part of the solution to 64 of water is a good proportion to begin with, but it may be increased. F. 117. There are other caustics in great variety from which the surgeon may make his choice,1 such as Manec's arsenical paste, or Canquoin's chloride of zinc paste, described at p. 96. Dr. Simpson recommends the sulphate of zinc dried and powdered, and sprinkled on the sore, or made into a paste with glycerine or lard, in the proportion of an ounce of the sulphate to a drachm of glycerine, or two drachms of lard. It is not deliquescent, and like the chloride does not attack sound surfaces. The concentrated sul- phuric or nitric acid, made into a paste with tow, saffron, sawdust, or asbestos, is an efficient though less manageable caustic; the concentrated solution of chloride of iron, the acid nitrate of mercury, the permanganate of potassa, and various other caustics may be mentioned, but the sulphate or chloride of zinc appears the best. If it be desired to penetrate deeply into a large mass of cancerous tissue it may be done in three ways—by deadening the surface with chloride of zinc, and then cutting through the slough nearly down to the living part, and inserting more of the caustic into the incisions—or by puncturing and injecting a few drops of solution of chloride of iron, as is done for na?vus— or by inserting into the diseased mass small lozenges or stylets composed of chloride of zinc, flour and water, baked till they are hard enough.2 In the case of cancerous masses which are so adherent and extensive that they cannot be removed by the knife, and in which the skin is not yet ulce- rated, we believe that puncture and the injection, or insertion just described, so as,' if possible, to eradicate the tumor with as little destruction of skin as possible, is the best plan, if any plan of extirpation be determined on. Since the preceding edition of this work was published, an American plan 1 An interesting account of them all is given by Mr. Spencer Wells, Med. Times, July 11, 1857. See also Simpson, Med. Times, Jan. 17, 1857. 2 Med. Times, Feb. 7, 1857, p. 144. [Also Simpson, Clin. Lect. Diseases of Women, page 88. (Phila. I860.)] 9 130 CANCER. of treating cancer has risen, flourished, and decayed in London, by which the public were promised, not merely that local deposits should be removed, [Fig. 38. Fig. 39. Fig. 40. Fig. 38. Diagram illustrative of the introduction of conical arrows into the base of a tumor for its circular or radiated cauterization or destruction. (Maisonneuve.) Fig. 39 shows the mode in which flat arrows are introduced for parallel or fascicular cauterization or destruction of cancerous tumors. (Maisonneuve.) Fig. 40 shows a fusiform arrow such as is used for the central cauterization or destruction of cancerous tumors. (Maisonneuve.)] but that the disease should be eradicated from the blood. [To style the treatment practised by a charlatan born in America, an American plan of treating cancer, is not a correct mode of expression. The plan was not an American plan, but the plan of a quack, and it was practised as such. Here we do not say, East Indian plan of treating consumption, Polish plan of treating cataract, Army and Navy plan of treating stricture, or English plan of treating deafness.] The means employed were, destruction of the skin by nitric acid, and of the cancer by chloride of zinc, introduced into incisions made in the first slough. The chloride was mixed with a red root—the sanguinaria—which has some stimulating properties, but, so far as cancer is concerned, is inert. What the nature and results of this treatment were, so far as the writer has had the opportunity of learning, may be gathered from the following memorandum of one case :—* On May 15th, 1857, he saw a lady, a?t. 46, wife of a clergyman ; child- less ; fifteen years ago she struck the left breast; a lump ensued, slowly increased, and became of late very painful; a gland in the axilla was also enlarged and painful; she suffered severe pain in the tumors, and above the clavicle in the neck; she had been seen by several surgeons during the last five years, all of whom said that the case was not fit for an operation. In March, 1857, she put herself under the care of a gentleman who professed to cure cancer. On the 25th, a large portion of the skin of the bosom (including the nipple), and over the gland was destroyed by nitric acid; after this, the slough was gently cut through, and various substances inserted into the cuts ; the pain was most agonizing, and brought on violent flooding; she sat in bed hour after hour, rocking herself in agony; the discharge was very profuse ; but an essential part of the treatment was that she was not allowed to keep her bed, but was taken daily into the open air in an easy chair; she lived well, and drank plenty of wine. In December the writer saw her again; she said that the first slough had been six weeks in separat- ing, and that it was obliged to be removed by scissors; that the wound was six months in healing, if healed it could be said to be ; for it had left a large, tense, red, thin cicatrix adherent to the ribs, which cracked and bled every time she coughed. Her breathing was difficult, her cough severe, there were swellings above the clavicle, and evidently cancerous deposit in the ELEPHANTIASIS ARABUM. 131 chest. She was greatly emaciated ; strength and appetite gone ; pain con- stant. At the first interview she was hopeful, and said she had been relieved of the neuralgic pains above the clavicle ; at this second interview she con- demned the whole treatment as a delusion. She assured the writer that three ladies who had begun the treatment in March, when she did, were already dead; and she followed them in February, 1858. So this poor creature had passed the last year of her life in unutterable torture. So much for extirpation. But the very hopelessness of the disease ought to stimulate the surgeon to use every effort to delay its course and soothe the patient's sufferings. The growth of the tumor may in some cases be checked by the incessant application of cold, by means of bladders filled with ice, or with a freezing mixture, on Dr. James Arnott's plan—or, by pressure, with Dr. N. Arnott's slack air cushion. Powerful astringents, as the tannic and gallic acids, may delay the growth of, and check oozing from a rapidly- growing soft cancer. F. 186. 2. Antiphlogistic measures are quite powerless against cancer; but when it is mixed with some degree of common inflammatory effusion, which is apt to give a great impetus to the cancerous growth, a few leeches, cold applica- tions, and alterative doses of Plummer's pill may be of great service. 3. Tonics, and especially the iodide and other preparations of iron, and qui- nine, are desirable in order to assist in forming healthy blood, and enabling the system to withstand the ravages of the disease. 4. Specific remedies—such as iodine and its preparations, bromine, arse- nic, and ergot of rye—are not known to be of service. 5. Narcotics may be given most unreservedly, for the purpose of sub- duing the gnawing pain and irritation which tend rapidly to exhaust the nervous system. Opium in the solid form, given regularly and boldly, is the sheet-anchor. Conium and other remedies of its class may be tried. 6. As local applications, during the earlier stages, fine cotton wool dusted with iodide of lead, and an occasional painting with tincture of aconite, or application of a bladder of ice, or of a lukewarm lead and opium lotion, to relieve the neuralgic pain. For the ulcerated stage the local remedies may be arranged under the following heads :—1. The soothing, including the opiate and conium lotions, F. 120, on lint covered with oiled silk; poultices, F. 157, medicated with the same remedies; chalk, lead, and bismuth ointments. 2. The gently stimulating; as the black-wash, carrot poultice, yeast poultice, weak zinc or nitrate of silver lotions. 3. The astringent; as the lotions of iron and tannin, F. 128, 131; or poultice of bread and powdered matico. 4. The antiseptic; as lotions of the chloride of lime or of zinc, or of creasote ; of acetate or nitrate of lead; or Condy's disinfecting fluid. We may add that poultices should not be applied too warm; and that care should be taken not to let the skin around become pimpled or excoriated. If it should, the tannin lotion, or bismuth ointment, are the best applications. A flat bag of peat charcoal, dry, and wrapped in flannel, may be laid over the wound, to absorb effluvia. 7. The general health and strength must be carefully looked to, since whatever disorders these will hasten the progress of the disease. Good diet, cod-liver oil, change of air, tranquillity of mind, and means for securing a proper action of the eliminative organs, will greatly aid in prolonging life, and in lessening the sufferings which our art cannot prevent. SECTION X.—ELEPHANTIASIS ARABUM. Under the term Elephantiasis, two dissimilar diseases have been con- founded. One, the Elephantiasis, so vividly described by Areta?us, the 132 GENERAL DIAGNOSIS OF TUMORS FROM CANCER. Elephantiasis Graecorum, which begins by tubercular swellings of the face; the other, the Elephantiasis Arabum, which we propose to describe here. It consists in a slow hypertrophy of the skin, areolar tissue, and bones, and in their infiltration with a peculiar cacoplastic deposit. The epi- dermis is thickened and the papilla? enlarged, but not much: the true skin is immensely thickened : its fibrous structure dense and almost rigid : the areolar tissue thickened, its areolae expanded, and filled with oily or gelatinous-looking stuff. In cases which the writer has examined, the microscopical appearances were those of hypertrophy of the tissues in- volved. The bones also of the affected limb became enlarged and heavy. This is peculiarly a disease of warm climates. The dark races are more liable to it than the fair. In India, it is particularly liable to attack the scrotum, which it converts into a huge tumor. (See Scrotal Tumor.) In the West Indies the leg is its favorite seat, hence the term Barbadoes leg. The best description of it is that given by Mr. Dalton, an able prac- titioner of Guiana; * and from this it plainly appears, that it is from the first a constitutional malady. It begins insidiously with feverish or aguish symptoms, pain in the leg about to be attacked, firm doughy swelling re- sembling that of phlegmasia alba dolens, and some tenderness of the lym- phatic glands. In the course of months, or perhaps of years, the patient suffers a frequent repetition of these attacks; the limb becomes permanently swelled, and in confirmed cases presents a huge, misshapen, useless mass, like the leg of an elephant; hard, and almost insensible to the touch, yet painful. A fetid serous discharge is liable to ooze from the skin ; or ulcers may form, and if not very extensive, may diminish the pain, and seem to eliminate a something noxious. Treatment.—The usual thing proposed is the knife; but Mr. Dalton has shown that in the earlier stages the disease may be at least controlled, if not checked. The remedies he proposes, are, first, a course of thorough eliminatives, purgatives, and emetics ; followed by tonics. Afterwards, the limb should- be thoroughly and tightly bandaged. Fomentations with as- tringent decoctions and lotions ; the preparations of iodine, diuretics, and a small issue on the outside of the thigh are the remedies for the later stages. SECTION XI.—GENERAL DIAGNOSIS OF TUMORS FROM CANCER. The Diagnosis of cancer implies—1, its distinction from other tumors in the living body, which is chiefly based upon its uncircumscribed and adhe- rent nature, and the severe and increasing pain and cachexia, which are sure to be present, if it has existed any time, or if it exists in many separate organs ; 2, its distinction anatomically after removal; and here it must be remembered that the one absolute, physical sign, is the cancer-cell, or nu- cleus, detected by the microscope. The student, who wishes to ascertain the microscopic nature of a tumor, should first carefully note its consistence, color, and general appearance. Then he should divide it by a clean incision, and note carefully whether any liquid exudes from the cut surface, with or without the aid of slight pressure. If the liquid is mere serum, tinged with blood, the tumor probably belongs to the fibrous or fibro-plastic species, in which the cell-structures are suffi- ciently developed to be coherent (see p. 114). If, on the contrary, a milky or gruelly juice exudes, easily mixable with water, this must be carefully searched to determine the nature of the solid substances which give the milky appearances. They may be pus, or granular corpuscles, or epithelium; but if, on repeated examination, they present the characters of cancer-cells, 1 Lancet, 1846, vol. ii. p. 453. GENERAL DIAGNOSIS OF TUMORS FROM CANCER. 133 or nuclei, the diagnosis is complete. If no juice is yielded, the tumor may be examined in sections. [It happens sometimes that no juice can be ob- tained from cancer, when examined immediately after removal, but can be had in abundance in the course of a day or two, when the amorphous matter in the cancerous tissue has undergone a certain softening.] 1. Inflammatory induration is infiltrating and adherent, but never causes so hard, lumpy, and distinct a tumor as cancer. It contains fibro-plastic, or pus-cells. 2. Soft cancer may present such apparent fluctuation as to be mistaken for abscess; but its greater elasticity and inequality of surface may serve as distinctions. 3. Ulcerated cancer is distinguished from any simple ulcer, and from lupus, by the pre-existence of cancerous tumor, and by its hard and im- movable, and extending base. From the ulcer of epithelioma, it is differ- enced by the warty origin, and the hypertrophy of the cutaneous papilla? of the latter. But as the two affections may coexist, and as extirpation is the remedy for each, it is important to attend to the microscopic differences of structure, in order that it may be known whether it is the almost surely fatal cancer, or the possibly curable epithelioma, that the surgeon has to deal with. If cancer, there will be found the cancer-cells, or if not, an abundance of cancer nuclei, with one to three nucleoli; and in most cases of cutaneous cancer, melanotic infiltration. On the contrary, in epithelioma there will be found the epithelial cell, in every variety, with their large, flattened, and often folded walls, with nuclei, smaller proportionably than those of cancer (for the nuclei of epithelial cells are mostly of the same size, nearly in every cell; they do not grow with the cell, as cancer nuclei do), and there are the concentric pellets or asparagus-like rolls of epithelium. But as Lebert well observes, it is very possible that some epithelial cells may be found so like some cancer-cells that it is hardly possible to distinguish between them. In any case, however, it is the character of the great mass, and not of individual, possibly exceptional, specimens that should be regarded. Moreover, epi- thelial tumors yield no juice; or if a liquid be squeezed out, or scraped up, it does not mix uniformly with water, as pus and cancer juice do, but runs into clotty or leafy masses, composed of large numbers of adherent cells, with clear water in the interstices of the masses. It is sometimes stated that cancer may be diagnosed by the microscopical appearances of the discharge. But this is fallacious. The cancer-cell would perish on an ulcerating surface, and could scarcely be distinguished amidst the pus and ichor present. Ulcerated epithelioma may be more easily distinguished, because epithelium is less destructible and more likely to come off in coherent masses. The cut at p. 120 represents a papilla from epithe- lioma of the bladder, found in the urine, and diagnosed during the patient's life. 4. Soft cancer of the fungus hsematodes variety, when abundantly vascular and pulsating, may be mistaken for an erectile tumor, or aneurism by anas- tomosis. But the long, perhaps congenital, duration of the erectile tumor, with the fact that the pulsating cancer must be of very rapid growth, and that the erectile tumor can generally be emptied by steady and continued pressure, are leading diagnostic marks. 5. Glandular hypertrophy (chronic mammary tumor of the breast) may be distinguished by its finely-grained surface, like that of the fully developed gland during lactation; by its mobility; and by the absence of adherence to the skin, of retraction of the nipple, of swelling of the lymphatics, and of serious derangement of the health. 6. Enlargement of the lymphatic glands may be distinguished from can- cer by the circumstance, that if one only is affected, it presents a smooth, 134 GENERAL DIAGNOSIS OF TUMORS FROM CANCER. uniform, or lobulated surface ; that it is not adherent; and that it is neither so hard as the hard, nor so soft as the soft cancer. If several glands are enlarged, they are not adherent to each other; they do not increase at the same rate as cancer does, nor affect the general health. 7. Tuberculosis differs from cancer in affecting by preference the lungs and lymphatic ganglia in young subjects ; whereas the eye and bones in the young, and the breast, womb, and stomach, in the old, are the favorite seats of cancer. Tubercular deposit may continue for any indefinite time, and may be perfectly eliminated by suppuration, or may undergo earthy transfor- mation ; and the general health may improve in time ; not so with cancer. Tubercular deposit has no vascularity of its own ; and its small cells, desti- tute of nuclei and nucleoli, mixed with solid amorphous matter, not floating free in a special juice like those of cancer, and not readily and equally dif- fusible through water, ought not to be confounded with cancer-cells. 8. Fibrous Tumors present a rounded, smooth, firm, elastic surface; non- adherent, and not softer at some parts than at others; the neighboring lymphatic glands are unaffected, and they may acquire large dimensions without serious cachexia. After extirpation, the naked eye will recognize the white fibrous tissue, with few vessels, and no infiltrating juice containing cancer-cells. 9. Enchondroma differs from cancer in the circumscribed nature of the tumors, which leave the articulations and other neighboring parts intact; in their .smooth rounded surface ; and in their not producing cachexia, even though multiple and of long duration. Microscopic analysis shows cartilage- cells imbedded in a hyaline substance. But supposing that some of these cells are set free by the softening down of the intercellular substance, in which case they may have some resemblance to cancer-cells, or even that a portion of enchondroma is contained in a cancerous growth, a little atten- tion will prevent error. 10. Lastly, the Fibro-plastic Tumor seems more nearly allied to cancer in development and clinical history than any other except epithelioma, and often closely resembles it in rapidity of growth. Yet it usually differs from it in having its surface regularly and uniformly lobulated, and of uniform consistence ; it is usually circumscribed and non-adherent, unless it has been subject to inflammation; it does not usually infiltrate other textures, nor affect the general health. In its microscopic elements, whether, as Lebert observes, it be of the soft, gelatinous, or of the red, fleshy variety, there is an entire absence of cancer-cells, and the constant existence of fibro-plastic cells, depicted at p. 50, and every series of forms between mere nuclei and fibres elongated and fusiform. Yet it must be remembered that these tumors are exceedingly apt to return after extirpation; that possibly they may be- come multiple ; or even after extirpation be replaced by cancer. The Myeloid Tumor, which probably ought to be treated of as a special affection of bone, may be distinguished by the large mother-cells, depicted at p. 114. PART III. DIFFERENT KINDS OF INJURIES. CHAPTER I. BRUISES AND SUBCUTANEOUS INJURIES. SECTION I.--INTRODUCTION. Definition.—Injuries, consisting in the division of various tissues, with- out wound of the skin; or if with a wound of the skin, one which is very slight and quickly healed. This definition includes bruises or contusions, that is, injuries inflicted by blows with blunt weapons, as well as strains or sprains, which consist in the rupture of tendinous or ligamentous fibres, by over-stretching; besides simple fractures and dislocations, and those subcutaneous wounds which are made by surgeons in tenotomy and other operations. Pathology.—There is a great distinction between injuries without and with wound of skin; for, as Hunter said, wounds "in which the parts do not communicate externally seldom inflame, while those of the second order commonly both inflame and suppurate." The general progress of subcutaneous injuries is this. At first there is a certain amount of pain from the injury, consisting in a perpetuation of the original sensation of injury. There is some amount of extravasation from the bloodvessels, which are torn ; and there will be probably in twenty-four hours some amount of throbbing or inflammatory pain, with an increase of swelling, from inflammatory exudation. But if the case does well, all in- flammation soon ceases; inflammatory exudation and effused blood are absorbed ; and there is an exudation of pure, plastic material, which fills the gap of the severed muscle, tendon, or bone, as the case may be, and which infiltrates slightly the adjoining portions of tissue. This soon begins to organize itself, after the manner of nucleated blastema, described in the Chapter on Repair, and becomes a fibrous tissue, by which any severed parts are united. . . If the blood be in a diseased state, and charged with material for inflam- matory exudation, or if the reparative material be injured or disturbed, a subcutaneous injury may lead to abscess. The reason why a subcutaneous injury should be so much less dangerous than one in which the skin is divided—why, for example, a simple fracture or dislocation should be comparatively safe, whilst a compound fracture or dislocation is a highly dangerous accident, appears to be this; that the wound in the skin may be easily hindered from uniting by a variety of disturbing causes ; and that the exudation, in contact with the air and ex- ternal bodies, is liable to undergo decomposition; and that the state of decomposition may spread throughout the wound, and give rise to various local and constitutional disturbances, varying from slight inflammation, or suppuration, to pyaemia. Treatment.__The general indications are, to put the injured part into an easv posture and keep it at perfect rest; to apply moderate pressure, so as J l ( 135) 136 BRUISES AND ECCHYMOSIS. to check exudation ; to soothe pain, purify the blood, and so prevent inflam- mation and induce speedy repair. SECTION II.—BRUISES AND ECCHYMOSIS. Definition.—A bruise or contusion signifies an injury inflicted by some blunt object, without perforation of the skin. Bruises may be divided into three degrees. 1. Those which produce some laceration of small vessels in the areolar tissue, and perhaps some division of muscular fibre, accompanied with ordinary ecchymosis. 2. A large vessel may be ruptured, so that blood is effused in considerable quantity, and tears up the cellular tissue, in which it coagulates; or if an artery is ruptured, a false or diffused aneurism may be the result. 3. The tissue may be irretrievably pulpified and disorganized; as happens from the contact of a spent cannon-ball, for instance. Ecchymosis.—When ecchymosis has been produced in the skin or imme- diately beneath it, there appears a swelling of a reddish color, which speedily becomes black. On the third day it is violet, and the margin, which was at first well defined, is found to be faint and diffused. About the fifth or sixth day the color becomes green; on the seventh or eighth, yellow; and it gradu- ally disappears about the tenth or twelfth—sooner or later, according to the vigor of the individual, and the quantity of blood effused. If an ecchymosis be formed in the cellular tissue without injury of the skin, no discoloration may appear for twenty-four hours ; and if it be more deeply seated among the muscles it will not affect the skin for some days, and may then appear at a part quite remote from the seat of injury ; and, in this last case, will usually be in the form of irregular yellow spots, marbled with green and blue.1 Causes.—Ecchymosis may be produced by many other causes besides contusions. It is a symptom of certain diseases, as scurvy, purpura, and the last stage of fevers. It may be a consequence of oblique wounds, which do not permit the blood to flow freely out; of spasms, and other violent contractions of the muscles; it may also be caused by suction (as after leech bites), especially in a part where the skin is thin. It may further be simu- lated by the application of coloring matters to the skin. Lastly, ecchymosis produced during life may require to be distinguished from various appear- ances arising after death. Diagnosis.—Ecchymosis produced by suction may be distinguished from that which is the result of injury, by being generally in the form of small round spots, and situated on the inside of the arms or female breasts; and the surgeon required to decide on the cause of such marks should consider whether they correspond in their appearance to the date which is assigned to them. Artificial discoloration of the skin may be distinguished from ecchymosis by its being generally in round or irregular spots, fringed at the edges.2 Ecchymosis produced during life may be distinguished from the livid dis- coloration of incipient putrefaction, or that which is caused by the gravita- tion of blood in a dead body, by noticing that, in the first case, blood is effused into the cellular tissue, and is incorporated with the cutis, which is thickened ; whereas in the two latter cases, the blackness will be confined to the surface of the cutis, and if blood is effused into the cellular tissue, it will be only at some depending part, and will be fluid, and not coagulated.3 1 Devergie, M6decine Legale, Paris, 1836, tome ii. p. 57. [Briand et Chande, Mede- cine Legale, Paris, 1852, p. 309.] 2 Fallot, de la Simulation et de la Dissimulation des Maladies, Bruxelles, 1836, p. 67. 3 Beck's Medical Jurisprudence. [Briand et Chande, op. cit. p. 385.] WOUNDS. 137 Treatment.—The indications are (1) to check extravasation of blood ; (2) to prevent inflammation; (3) and afterwards to produce absorption of the effused fluids and restore the use of the parts. The bruised part should, if possible, be placed in a raised position ; and cold or iced water, or a bladder containing ice, F. 114, should be applied at once ; and a sufficient number of leeches, if there are signs of inflammatory pain and swelling, but not otherwise. These measures, together with rest, moderate purgatives, and not too full a diet, will suffice for the first two indi- cations ; whilst the third will be fulfilled by friction with stimulating liniments, and a bandage after tenderness has subsided. If the effusion of blood is great—if the skin is so tense that it will inevit- ably either burst or slough—an incision may be made into the swelling, but it is better avoided. Then the clot will be gradually extruded by the con- traction of the cavity, and a simple granulating wound will be left. But it is very bad practice to squeeze out the coagulum, as the bleeding might be brought on afresh, and severe inflammation be excited.1 If an artery of considerable size is lacerated, which will be known by the situation of the contusion, and the great and rapid swelling, the case must be treated as a diffused aneurism. Fingers or toes, however severely bruised, should not be hastily amputated. CHAPTER II. WOUNDS. Definition.—Wounds are commonly defined to be solutions of continuity, or separations by external violence of parts which ought to be united. "Varieties.—The incised wounds, or those made with clean-cutting instru- ments ; the punctured, or those made by instruments whose length greatly exceeds their breadth, including stabs, and pricks of all sorts ; the lacerated, in which parts are torn; and the contused, or those effected by bruising, are the chief varieties. The incised are produced with the least violence, and generally admit most easily of repair. The punctured are dangerous from their depth, and from the possibility that deep bloodvessels or viscera may be injured, or that deep-seated extravasation of blood, or abscess, may follow. The lacerated and contused wounds are produced with greater violence, less likely to heal, and more prone to slough or suppurate. They do not, however, in general, bleed so much as incised wounds, because arteries, when torn, contract more than when cut. Treatment.__The treatment of all wounds comprises four indications :— 1, to check bleeding; 2, to remove foreign bodies ; 3, to bring the divided parts into their natural position and keep them in union; 4, to promote adhesion. . -, -^ j ^ (1) To check bleeding, moderate pressure, a raised position, and the application of cold, will be sufficient in most cases; but if an artery have been wounded, or the bleeding prove obstinate, the measures must be adopted which will be pointed out in the Chapters ^on Wounds of Arteries and of Yeins. (2) The removal of foreign bodies, if any are in the wound, should be effected as soon as possible, by the fingers or by forceps, or sponge and ! Hunter on the Blood, part ii. chap. ii. sect. i. 138 WOUNDS. water. Dirt, gravel, &c, are best got rid of by affusion with water. All clots of blood must likewise be removed. (3) In order to bring the sides of the wound into contact, the part must be placed in such a position as will relax any muscular fibres that have been divided, or that lie.under the divided parts. Then the edges must be made to meet as nicely as possible. On this point the surgeon should use the utmost diligence, because the more that the parts are adapted, the less chance will there be of suppuration, and the more speedy and free from deformity will the cure be. The edges of the wound may then be kept in their place by cross strips of adhesive plaster, one end of the plaster being first applied to that side of the wound which is loosest, and the other being brought across. Then a compress and bandage may be applied to keep on the dressings, and protect the parts from injury, and should be applied with such a degree of firmness as feels comfortable, and will have the effect of preventing bleeding or other exudation. This point requires particular attention in subcutaneous surgery. If the wound is so situated that the plaster cannot be applied smoothly, a compress of lint may be laid on it first. Collodion.—A very useful substitute for adhesive plaster in many cases is the solution of gun cotton in ether, commonly known by the name collodion. This when applied to any surface dries instantly, forming a semi-transparent film of considerable tenacity, adhering firmly, and forming an artificial scab under which wounds often heal without any suppuration. In applying it, the edges of the wound should be held together as exactly as possible by an assistant, whilst a thick layer of the collodion is smeared across with a brush or small spatula. It is useful to apply it in the intervals of stitches or plasters, in order to exclude the air. This substance contracts so strongly that it should be put on in one layer, once for all; not in repeated layers, else those which are put on afterwards will drag off those applied first. Thick mucilage sometimes is used for the same purpose; so is Friar's balsam. Fig. 41. Fig. 42. Fig. 43. Fig. 44. SJ Needles for sutures. <3 Sutures.—In all extensive wounds, and most especially in wounds of the eyebrows, eyelids, ears, and other parts which it is most important to make WOUNDS. 139 to unite neatly, and in which plasters would be insufficient, sutures, or, in plain English, stitches, should be employed. Yet the surgeon must never employ them in order forcibly to drag the lips of a gaping wound into con- tact, or they will give great pain, and his intentions will be frustrated by their speedily ulcerating. They may be removed in from three to six days; sooner if violent irritation comes on. The requisite needles are shown in the foregoing cut: the straight glovers' needle at the top is very convenient, and may be procured at any cutler's. Five species of suture are enumerated in the older authors. 1. The Interrupted Suture is thus made. A needle armed with a single ligature is passed through the skin on one side of the wound from without, inwards; then at a corresponding part through the other lip from within, outwards. Then the ends of the ligature (which may be made of silk, or hempen thread, well waxed) are to be drawn together, without, however, any great straining, and are to be tied tightly in a double-reef knot. Silver or leaden wire is sometimes used for sutures, and has this advantage, that it does not absorb fluids, and so cannot be converted into a seton. As many of these stitches are to be made as are necessary; half or three- quarters of an inch is a proper interval. Fig. 45. Fig. 46. [Fig. 47. Interrupted suture. Twisted or hare-lip suture. India-rubber suture.] 2. The Twisted Suture is made thus : The edges of the wound having , been placed accurately in contact, a sufficient number of pins are to be passed through both of them at convenient distances. The first pin should be placed at any loose angle which there may happen to be. When all the pins have been introduced, and the parts are accurately adjusted, the middle of a long piece of silk is to be twisted around the uppermost in the form of a figure of 8. Then the two ends are to be brought down and twisted round each of the other pins successively in like manner; and, lastly, are to be secured by a knot. [A very elegant suture has recently been introduced into practice by Dr. Washington L. Atlee, in which small rings of India-rubber are used in place of the thread formerly employed in the twisted suture. These rings can be made of any size by cutting off smooth sections from gum-elastic tubes of different calibres.__See the American Journal of the Medical Sciences for January, 1860, page 81.] # The pins were formerly made of silver, with steel points which were re- moved after they were inserted; but fine steel needles with lancet points are 140 WOUNDS. now used instead. After they are inserted their points must be cut off with pliers.1 3. The Glovers1, or Continuous Suture, is nothing more than the ordinary way of sewing things together practised by seamstresses and housewives. It is employed in wounds of the intestines and abdomen. Fig. 48. Needle for passing the thread in quilled suture. 4. The Quill Suture is performed by passing a sufficient number of liga- tures with the needle here represented; but instead of being tied to their opposite neighbors, all the Fig. 49. threads on each side of the _________________ wound are fastened to a bougie, i i .....„.t.mmiimm,mu„ I, „ , > ^ or metallic rod, perforated with ___________________W*/A/'' J holes. It is very advantageous VVvw„~ / in pressing the deep parts of a ,■^.■.■0."- *w^.....*"!■—v ^y wound together, and is used in ' ~~i^ ' ~ ---i^^^^yT===:^ lacerations of the female peri- ^JC^^^^ neum. Quiii suture. 5- The Dry Suture was made by sticking a strip of adhesive plaster, or (before that was invented) a strip of linen smeared with white of egg and flour, to the skin on each side of the wound. The adjacent margins of the plaster or linen were then sewed together. [The bandages to be used in the treatment of wounds are thus described by Dr. Sargent:— The bandages used to promote union of incised wounds are the common roller, the bandage of Scultetus, and the invaginated bandage. The first two are employed to give support merely to adhesive strips and sutures. The invaginated bandage acts directly by approximating the edges of the incision; its composition and mode of application vary, as the wound is longitudinal or transverse. These bandages are applied to the extremities generally. The invaginated bandage for longitudinal wounds is thus prepared :—A linen roller is taken, of a width corresponding with the length of the wound, and sufficiently long to make several turns around the limb : at the free ex- tremity of this roller several slits are made, each about an inch broad and six or eight inches long ; and beyond these, at the distance of a few inches, fenestra? are cut, in number corresponding with the slits (Fig. 50). Thus prepared, the centre of the undivided portion of the bandage is placed directly opposite the wound, by the margins of which graduated compresses (a, a, Fig. 51) have been arranged, one on each side: the slits, .6, 6, b, are passed through the corresponding fenestra?, c, c, c, and these two portions of the roller drawn in opposite directions until the edges of the wound are in apposition (Fig. 51). Then the slits are laid flatly upon the surface, and 1 The old hare-lip pin is the second of the needles at p. 138, and the new needle the last. 31 WOUNDS. 141 the bandage is completed by circular turns of the roller. The efficacy of this uniting bandage is much increased by the employment of the compresses, Fig. 50. Fig. 51. Invaginated bandage for longitudinal wounds. which act very much as the quilled suture, by pressing together the entire depth of the sides of the wound. It will be found an advantageous mode of approximating the surface of deep incisions of the thighs, particularly. The invaginated bandage for transverse wounds, Composition.__A piece of linen from two to three feet long, correspond- ing in breadth with the length of the wound, and divided at one extremity into two or more slits, each about an inch wide and six inches or more in length, to correspond with the same number of fenestra? made in a second piece of linen of the same dimensions as the first; two rollers, each six yards long and two and a half inches wide; together with two graduated compresses. . ,. Application.—The limb having been placed in a position most favorable for relaxing the divided muscles, the surgeon makes a few turns of one roller, b, around the limb below the wound, and upon these lays the fenestrated bandage, so that the divided por- tion stretches upon and across the incision, while the other part rests upon the limb below the wound. The extremity of this portion is reflected upwards over the turns of the roller, which is now resumed and made to secure the bandage in position. The other band is now confined upon the limb above the wound, in the same manner, by Fig. 52. Invaginated bandage for transverse wounds. means of the second roller, the slits corresponding in position with the wound ; next the compresses, c, c, are placed parallel with the edges of the incision, one above and the other below : then the slits of one band are passed through the fenestra? of the other (Fig. 52). The two bands are drawn in opposite directions, so as to approximate the lips of the wound, and are firmly fixed by turns of the rollers passing respectively above and below the seat of the injury.—See Cutler's Treatise on Bandaging, or Sar- gent's Minor Surgery.] . (4) The fourth indication is to promote the process of adhesion. Jb or this purpose every circumstance that will disturb the lymph exuded, or that will cause it to decompose, must be scrupulously avoided. The wounded part should be kept absolutely at rest, and if the wound be at all severe the 142 WOUNDS. patient should be sent to bed. Pain and mental disturbance should be allayed, and sleep procured by opium ; the importance of which in prevent- ing fever and pyaemia cannot be over-estimated. The bowels should be re- lieved, in order to combat any tendency to inflammatory exudation, and the diet be regulated. In most cases just as much light food as will replace the waste of a man at rest is sufficient; in some it may be necessary to give meat and wine, in order to make up for loss of blood, and supply material for healthy exudation. No bandages should be tight enough to cause irri- tation or constriction. If much pain and swelling supervene, all tight applications and sutures must be removed, and fomentations or poultices be applied, till the inflammation has subsided, or till suppuration is established. Then the parts may be again gently approximated, that they may heal by the second intention; that is, by the inosculation of their granulations. In wounds, as in other inflammatory cases, cloths dipped into cold water, or a bladder filled with ice, is sometimes more comfortable than warm applications. Cases of Complete Disunion.—If any small portion of the body (a finger or part of the nose, for instance) has been completely cut off, and if it be reapplied as soon as possible, and retained by plasters or sutures, and wrapped up so as to preserve its temperature, it will very probably unite again. And even if such a part have been separated for a considerable time, the attempt should not be given up; but it should be well washed with warm water to free it from dirt, and the stump should also be bathed, so as to remove any dry coagulated blood, before they are reapplied to each other. One case is related in which the last phalanx of the middle finger was cut off, and after an hour and a half was replaced, and united firmly.1 Cure of Open Wounds.—If a part has been abstracted which cannot be restored, or if any kind of wound cannot be covered by skin, as is the case with lacerated and irregular wounds, the first plan on which it may be treated, is by endeavoring to form a scab, by covering the wound with pledgets of soft lint soaked in blood, which are to be allowed to dry and adhere. This is the natural and simple way in which most slight accidents heal when not interfered with by art; and Mr. Wardrop has seen the large surface exposed by the removal of a diseased breast heal completely under a crust of blood in thirty days. The old-fashioned remedy, the Friar's Balsam, or Tinct. Benzoes comp., is an excellent application for wounds attended with some degree of contusion. It causes the blood to coagulate, and seals up the wound from the contact of the air, and from infectious miasmata. If there is no pain or bad smell, the wound should be allowed to remain unopened till the scabs drop off, and show a cicatrix underneath. But if it becomes painful, and a fetid matter oozes out, warm poultices or water- dressing should be applied, and the wound be treated like a common granu- lating sore. Or, instead of attempting to form a scab, the surgeon may apply water- dressing or poultices from the first, when, if the case proceeds favorably, the wound will become filled with a pink lymph, which forms a pliant cicatrix, without granulation, and without suppuration. Abscess after Wounds.—After punctured wounds, or after any extensive surgical operation, or other wound, it is possible that part of the exudation, or that some portion of coagulum may decompose and cause suppuration, even after the wound in the skin has healed ; and that the sanious fluid which results may find its way into the veins and cause serious consequences. Pain and tenderness, restlessness and shivering, will cause the surgeon to examine the track of the wound carefully, and to make an incision if there is any mischief underneath. 1 Baily, H. W. of Thetford, Ed. Med. and Surg. Journ., July, 1815. • GUNSHOT WOUNDS. 143 Punctured Wounds.—The first point usually mooted in discussing the treatment of these wounds is the propriety of dilating them, and converting them into simple incisions, in order to avert deep-seated suppuration and confinement of matter. But as those evils by no means follow of necessity, an endeavor should be made first to prevent them. To this end, the part should be kept at perfect rest, and should be bandaged with an agreeable degree of firmness, so as to prevent subcutaneous oozing of blood^hich is the most likely cause of inflammation. If necessary, low diet, puTgatives, cold lotions, and leeches, must be employed. But if, notwithstanding, there should be severe pain, and swelling, and fever, a free incision must be made for the relief of tension and the discharge of matter; and the case must be treated in the same manner as a deep-seated abscess. CHAPTER III. GUNSHOT WOUNDS. SECTION I.—GENERAL DESCRIPTION. Definition.—Under the term gunshot wounds are included all the in- juries caused by shot and other substances discharged from fire-arms, by fragments of stone or splinters of wood struck thereby, and by the bursting of fire-arms, and of shells. "The cannon shot," says Mr. Cole, "for the first five or six hundred yards grinds to powder and destroys everything that opposes its hissing course."1 If it strikes a limb it either carries it away or completely smashes it, pulpifying all the tissues with which it comes into contact. The shock in such cases is always very severe, and often fatal of itself. The hemorrhage is usually slight; a gush of blood escapes at the moment the injury is in- flicted, but the torn vessels soon retract, and bleeding for a time is stopped. There were, however, a few instances, during the Crimean campaign, in which fatal hemorrhage from the femoral artery was caused by cannon-shot injuries. When the shot has travelled some distance, so as to have lost a portion of its impetus, the injury which it inflicts is often even greater. Instead of going right through the part struck, it will allow itself to be guided, or its course to be changed, by objects which it may meet in its way, and will thus give rise to wider and more serious injuries. This happened in the case of a private in the First Royals who was work- ing in the trenches before Sevastopol. He was in the act of shovelling up some earth, with his body bent, and his right hand, in which he held the handle of the shovel, low down in front of the space between his legs. In this position he was struck by a round shot. It shattered his arm, leaving it hanging only by the integuments, and passing between the thighs at their upper part, it tore away from each of them a large mass of the integuments and muscles, and laid bare the femoral artery on one side. It carried in front of it the penis, and scrotum, and anus, and, guided by the curve of the buttocks, it swept away a large portion of the glutaei of one side. Cannon shot when nearly spent may produce severe injury without break- 1 Cole. J. J., Military Surgery, or Experience of Field Practice in India during the years 1S48 and 1849, Lond. 1852. • 144 gunshot wounds. ing the skin. Bones may be broken, or the deep tissues so contused as to lead to severe sloughing and loss of the parts. However near the end of its career a round shot may be, it still carries destruction with it; and many a soldier's foot has been knocked off, when put out to stop a shot, slowly ricochetting along like a cricket ball. It is rare for round shot to lodge themselves, yet a case occurred in the Balaklam action in which a six-pound shot was found lodged in a man's ham, witn comparatively little distortion of the limb. Much has been said of" the effects of the windage of balls, that is, of injuries supposed to be produced by balls going near without touching, and ascribed to a current of air accompanying the ball. But later experience has shown the fallacy of all the views once entertained on this subject. Men's clothes have been torn, and even their caps carried off their heads by round shot, without producing any injury worth mentioning.1 Shells.—If a shell strikes anything before its explosion, it produces effects similar to those of round shot. After it has burst, the wounds in- flicted by its fragments are not so severe as those of cannon shot, although they certainly rank next in the amount of damage they produce. The large, irregular masses of iron often cause the most fearful contusions and lacera- tions of the tissues, and comminution of the bones. The extent of mischief produced by them may be estimated by the fact that during the late war the bursting of one howitzer shell caused ten admissions into the hospital of the 18th regiment, and that of the men so admitted seven lost an arm or leg. Musket Shot.—The largest number of wounds in any engagement is from musket balls. Until the late war, the old round leaden ball, fired from a plain or rifled barrel, was the only one in common use. Now, however, its place has been supplied by the conical ball, in our own and most of the continental armies, including that of our late enemies the Russians. As our men were wounded by both kind of balls, there were ample means of testing their de- structive capacities. The conical balls being projected with much greater rapidity, are capable of passing through one or two men, and lodging them- selves in the body of a third. They did not appear to deviate from their course to the extent that the old balls sometimes did. What they struck they usually perforated, in some cases drilling through bones, in others pro- ducing severe comminuted fractures. They lodge much less frequently than the round ones, and are far more destructive as instruments of warfare. Again, the ball may, if the force is nearly expended, lodge in the cancellous tissue of a bone, and form for itself a kind of chamber, in which it may be easily moved, but from which it is with great difficulty extracted. Sometimes a ball will strike a bone longitudinally, and channel a long groove without fracturing the bone. Grape Shot produce wounds like those from round shot, only, as they are much smaller, so the injuries they inflict are less severe. Canister, Shot likewise cause wounds similar, though not so severe as those from musket balls of the same size. Small Shot, discharged from a fowling-piece or pistol, produce different effects, according to the distance at which they strike. If the distance is great, they will in all probability be scattered, and fall singly; peppering the victim smajtly, but not penetrating beyond the subcutaneous tissue, nor doing much harm unless one of them strike the eye. But if the distance is 1 "A shot ricochetted with great force over one of the parapets, carrying away the cap from a seaman's head. The man was a little stunned, but no further mischief ensued. When his cap was picked up, it contained a handful of hair, which had been shaved from the scalp by the shot. This would have been a 'poser' for the old wind-contusion- ists." Account of the wounded in the recent bombardments of Sevastopol, by D. J. Dui- gan, Esq., Surgeon R. N., attached to the Naval Brigade.—Medical Times, Sept. 8, lb55. gunshot wounds. 145 small, so that they strike en masse, their effects are far more destructive than those of a bullet, for they spread in the flesh, and so cause greater laceration, besides the mischief arising from their lodgment in the tissues. Although there may be no ball in a gun or pistol, yet the wadding may act as a ball, if the piece is discharged close to the body. The surgeon in civil practice who examines a gunshot wound inflicted with intent to murder, should always save the wadding if he finds any, as it may afford a clue to the detection of the murderer. All gunshot injuries, too, may be complicated with severe burns from the explosion of gunpowder. Course of Balls.—In the passage of the ball everything is as a rule carried in front of it, and thus it is that we meet with fragments of the patients' clothing or pieces of wadding in the wound. If the ball in its course has already wounded one man, it may carry before it portions of his dress, or even spicula of bone, and lodge them in the body of the next. Yet it is remarkable how easily balls may sometimes be diverted from their course by the slightest obstacle. An officer in the engineers returning one evening from the trenches before Sevastopol, was struck in the abdomen by a musket ball. It first impinged against a button of his trousers, which it bent double. This served to change its direction, and instead of passing into the cavity of the abdomen, it travelled downwards between the abdominal muscles, and lodged deeply in the upper part of the thigh. Any trifling obliquity of sur- face, or difference of density in the parts which it traverses, may cause it to take a most circuitous route. Thus a ball may enter on one side of the head, chest, or abdomen, and may pass out at a point exactly opposite, just as if it had gone entirely through the cavity. In such instances the ball has generally been guided by a ridge of bone; thus, in the chest it travels round the ribs, or in the abdomen around the crest of the ilium. Sometimes it will make a complete circuit, as in the case of a friend of Dr. Hennen, who was struck about the pomum Adami by a bullet, which passed completely round the neck, and was found lying in the very orifice at which it entered. In a similar manner balls will run along concave surfaces; thus a soldier may be struck in the wrist, when the arm is bent in the act of firing, and the ball may graze along the arm, and fly off at'the shoulder: or a ball may enter the thorax or abdo- men, glide along the inner surface of the peritoneum or pleura, and pass out or be lodged near the spine. If a ball has passed through a part, an orifice of entrance and one of exit is usually found. The orifice of entrance is generally smaller than the ball, with its edge livid, and inverted. That of exit is a larger and more ragged opening, with its edge somewhat everted. The difference in appearance between the entrance and exit of the ball is, however, much modified by the speed at which the ball is travelling when it strikes the patient. The in- creased velocity with which the new rifles propel the balls, causes them to enter and leave a body without its offering sufficient resistance to produce a difference in the appearance of the two wounds. If, however, the speed of the ball's course be diminished, and a limb be then perforated by it, we have the characteristic appearances of its ingress and egress well marked. The ball in its passage through a part leaves a track which is often indi- cated by a bluish or dusky-red line or wheal on the skin, or sometimes by a peculiar emphysematous crackling. Along this track the tissues are bruised and broken down, and their vitality greatly destroyed, and lying in different parts of it are the fragments of foreign bodies which the bullet may have carried before it. 10 146 GUNSHOT wounds. section ii.—lodgment and extraction of balls. Lodgment of Balls.—It is always important to ascertain whether the shot has passed out of the body, or whether it has lodged ; and supposing that there are two holes, it must be considered whether they are produced by the entrance and exit of one, or by the entrance of two distinct balls. If there are two holes, and they are distant from each other, some light may be thrown on the question by ascertaining the position of the patient at the time he was wounded, and the posture of his assailant. Thus, a soldier has presented himself with two shot-holes, one on the outside of the ankle, the other near the trochanter; but they were both caused by the same ball, which entered at the ankle when the foot was raised in the act of running.1 In another instance, a soldier, who was ascending a scaling-ladder, was wounded in the right arm, and the ball was found under the skin of the opposite thigh.2 But even though there may be but one opening, it by no means follows that the ball has lodged ; for it may have escaped by the very hole at which it entered, after having made the circuit of the body. Or it may have impinged against some part, such as the cartilage of a rib, which has caused it to recoil; and a ball has been known to drive a piece of bone into the brain, and fall out of the wound afterwards. In some instances a ball has been unable to perforate a fold of linen, but has carried it for the distance of one, or even three or four inches into the wound; and on draw- ing this out, the ball of course comes out with it.3 Again, it is very possible that two balls may enter by the same aperture, one of which may pass out, and the other diverge and wound some impor- tant organ. Sometimes it will happen that a ball splits, either from a defect in the casting, or from its striking against some sharp bony ridge, as the vomer, or shin, or edge of a fractured bone of the skull; and although one portion may have been extracted, another may have injured important ves- sels or nerves. But it frequently happens, that large masses of metal are impacted in the substance of a part without much external sign of their presence, as in a case related at p. 144. Extraction of Balls and Foreign Bodies.—It is of the greatest importance for the future well-doing of the patient, that any ball or foreign particles which may have lodged should be removed by the surgeon. A most careful examination of the parts is always necessary. This should be made as soon after the injury as possible, before swelling and oedema of the tissues have come on. If the ball has traversed some distance, and it cannot be detected near the surface, a silver probe of about twelve inches in length is most useful, and will allow an exploration to be made along the track of the bullet. As a rule, however, the best examination is made with the finger, passed into the wound, which may be enlarged if required. When the ball is deeply lodged, a pair of Coxeter's bullet-forceps will be found of great service, their narrowness allowing them to pass down almost any bullet's track. When it is near the surface, a pair of straight incisor-tooth forceps will seize fast hold of a leaden ball and remove it with facility. If, however, the ball is lodged in bone, much difficulty is frequently experienced, and great tact is often required to get hold of it. A small channel may in some 1 Guthrie, op. cit. p. 17. 2 Hennen, op. cit. p. 35. 3 A silk handkerchief sometimes saves life in the same way; and Mr. Home, in his Report on Gunshot Wounds in Canada, in 1838, speaks of the great power which the canvas lining of soldiers' stocks has in resisting the passage of musket balls.—Edin- burgh Med. and Surg. Journ., July, 1840. collapse from gunshot wounds. 147 cases be made with a gouge in the bone, and with one of Bell's sharp-pointed tooth elevators the ball may generally then with tolerable ease be removed.1 SECTION III.--COLLAPSE FROM GUNSHOT WOUNDS. Collapse or shock is the first constitutional effect of a gunshot injury. It follows immediately or soon after the infliction of the wound, and is present to a greater or less extent in nearly every case. It is more intense in pro- portion to the severity of the injury, and according to the part of the body which has suffered ; but even comparatively slight wounds are often followed by a very great amount of collapse. Gunshot injuries of the thorax and abdomen are always followed by severe collapse. The severity of wounds in these localities, when the cavity is opened, or the viscera wounded, is sufficient to account for this ; but in instances where the ball has not penetrated the abdomen or thorax, but merely traversed their walls, there is still usually some shock, and often very much. The cause is probably partly the fear which men have of the result of wounds of either of the large cavities, believing that if a ball strikes the thorax or abdomen the case is necessarily fatal. Another reason has been attributed for the collapse which is so universal, which is this. Men are generally wounded while under fire, while the nervous energies are in a state of extreme tension. They are suddenly struck down, and rendered "hors de combat," and depression rapidly follows in proportion to the extent of the previous excitement, and thus we may meet with great collapse following even small injuries. Mr. Matthew considers that the shock of gunshot wounds differs from that state to which the term is applied in civil practice, in the peculiar mental condition, inasmuch as the depression which follows the high nervous excitement in which the men are at the time they are wounded, is superadded to the physical effects of the injury. He adduces, as proof of this, the fact that men were occasionally received for treatment in the Crimean hospitals before the excitement had subsided ; and they seemed to bear the operations without chloroform well, and in some instances begged that it might not be given. The depressed condition may come on immediately after an injury, or, more rarely, it may not take place until some hours afterwards, a differ- ence depending on the peculiar mental constitution and nervous development of the patient. After severe gunshot injuries patients may die from shock only. No large amount of blood may have been lost, or there may have been no destruction of parts which could cause rapid death, and yet the patient never rallies from the state of collapse, and speedily sinks. During the late war as many as 160 wounded men among the regiments of the line died within twenty-four hours, and 149 more within forty-eight hours after the infliction of their wounds, a very large majority of these deaths being due to this cause. During the stage of collapse, the patient presents a blanched surface; the face pale, pinched, and anxious ; the extremities cold ; the pulse small, weak, often irregular and fluttering; the voice feeble. Such is the usual condition of the patient, varying of course in degree, when he is first seen by the surgeon. It is a question, therefore, of great moment whether it is best to rouse him from this state of collapse. The nature of the wound must answer this question. If the ball has pene- trated the thorax or abdomen, it is best not to attempt to rally him too soon; vessels may be wounded which it is impossible for the surgeon to secure, and 1 [See Gross, op. cit. vol. i. p. 388.] 148 GUNSHOT WOUNDS. this depressed state is most favorable for nature to form a coagulum, and arrest hemorrhage. The patient should be placed in bed, with his head low, and be care- fully watched, in order, by the judicious application of stimulants, warmth to the feet, &c, to prevent the collapse proceeding to too great an extent; in fact, to save him from sinking from the effects of that which, if not carried too far, is most favorable for his ultimate recovery. The same rules apply to all cases where large vessels have been, or are supposed to be wounded. When, however, the injury is superficial, or even when it is deep without affecting important vessels, the patient should be rallied from the shock he has received as soon as possible, as reaction is generally in proportion to the amount of depression. SECTION IV.—HEMORRHAGE FROM GUNSHOT WOUNDS. Hemorrhage.—Primary or immediate hemorrhage following gunshot wounds, especially if they are severe, is of comparatively rare occurrence. There may be some slight bleeding at the time the wound is inflicted, but not, as a rule, in any dangerous quantity. During the Crimean war there were frequent instances in which the upper or lower extremities were torn off by round shot or shell, and left hanging merely by the integuments, and * yet, in the majority of such cases, no immediate hemorrhage resulted which at all jeopardized life.1 After gunshot injuries in which the bloodvessels are involved it is usually found that they are much lacerated, and retracted within their sheaths, and thus hemorrhage is checked for a time. Occasionally cases occur where the femoral or some large vessel has been wounded, and hemorrhage has rapidly proved fatal. In such instances, it is probable that the ball carried away a portion of the calibre of the artery, without entirely dividing it. Intermediary hemorrhage may occur some hours after the receipt of the wound, as soon as reaction begins, or after it has been thoroughly established. In such eases if the application of pressure fails, the best treatment is if possible to cut down upon and secure both extremities of the bleeding vessels. Secondary hemorrhage, or that which takes place at a variable period from the fifth to the twenty-fifth day after the infliction of the injury, may be produced— 1st. By any sudden or violent movement of the patient, or anything which increases the rapidity of his circulation. The coagula which had temporarily closed the extremities of the wounded vessel, are pushed away by the force of the blood, and bleeding immediately takes place. Thus patients, during the late war, frequently died of secondary hemorrhage in being conveyed from the camp to Balaklava. 2d. It may happen from sloughing, or ulceration of a large vessel. The wounded tissues may ulcerate, or else may have been so much injured by the wound as to be incapable of recovering their vitality. 1 In the 44th regiment, on the night of the 21st of June, 1855, a man had his left arm carried away at the shoulder-joint: the limb was completely separated from the trunk, leaving too little of the soft tissues to cover in the face of the stump. The.axillary artery appeared to have bled but little, if at all, at the moment of injury, and there was no sub- sequent hemorrhage. The laceration laid bare the artery and vein for full three inches of their course. The ends of the vessels for three-quarters of an inch were curved, plugged with coagula, and tapering to a point. The pulsation of the artery was full to the very base of the plug. f GUNSHOT INJURIES OF REGIONS. 149 3d. A vessel may be cut at almost any period after the injury, by a pro- jecting sharp spiculum of bone. 4th. A peculiar hemorrhagic diathesis is a frequent cause of secondary hemorrhage. This diathesis is often produced in long campaigns from improper diet, such as a deficient supply of vegetable food, which causes scurvy in the men, and renders them liable to hemorrhage from even very slight injuries. The blood, thus wanting some necessary principle, seems incapable of forming coagula sufficiently firm to seal the mouths of the divided vessels. Treatment.—In all cases, if practicable, both ends of the bleeding vessel should be tied; since, if either end is left open, the circulation may be carried on through collateral channels, and hemorrhage may return. The late Mr. Guthrie observes, in his Commentaries, that this should not be done unless the vessel bleeds, "as hemorrhage once arrested may not be renewed." A case occurred in the Crimea under Mr. Matthew which shows that even this rule will not always be the best for the patient's welfare unless he can be kept under close observation, and free from disturbance.1 In wounds of the interosseous artery of the arm, owing to the difficulty in getting at the vessel situated beneath the deep flexors of the forearm, sur- geons have been induced to tie the brachial in preference to the more difficult and tedious operation of securing both ends of the interosseous. Mr. Par- tridge, in two separate cases, tied the brachial at King's College Hospital for wounds of the interosseous, and in both instances the hemorrhage was entirely arrested, and the patients did well. For similar reasons, in wounds of the palmar arch, it is better to tie both radial and ulnar; or should it be found that pressure on these fail to arrest the hemorrhage, to proceed at once to tie the brachial, rather than explore beneath the palmar fascia for the cut ends of the bleeding vessels. SECTION V.--GUNSHOT INJURIES OF THE HEAD AND FACE. Gunshot injuries of the skull are the most unsatisfactory and fatal class of cases which it falls to the lot of the military surgeon to treat. To diagnose the extent of injury inflicted is often very difficult, and yet a correct appreciation of the nature of the wounds, and the parts implicated by them, is of paramount importance. Balls striking the skull usually cause fracture at the point they impinge against, and thus, cases of fracture of the base from contre coup are of rare occurrence in military practice. Simple flesh wounds of the scalp may be produced by the grazing of a fragment of a shell or musket ball. These injuries, if not severe, soon get well under simple dressing and quiet. If, however, there is much laceration of the scalp, suppuration and burrowing of pus is apt to occur, and death of a portion of the external table of the skull often results. Treatment.__Perfect rest, and the avoidance of all excitement. The i A man was brought in on the evening of the battle of Inkerman who had been shot through the leg at the junction of the middle and lower thirds. He had lost a large quantity of blood, and it was evident that the posterior tibial artery had been wounded, but it did not then bleed. The exhaustion was excessive. He was placed in a tent, with a pledget of lint on the wound, the leg bandaged and kept elevated, and an orderly left to watch him. On the following morning the pad of lint was removed, but no hemorrhage took place. As the wounded had to be removed from camp to Balaklava, a distance of seven miles, and thence to Scutari by ship, it was thought best to tie the vessel, notwithstanding it could not be made to bleed after all the bandages were removed from the limb. The operation was accordingly done, and it was found that a large portion of the calibre of the vessel had been shot away. Probably had not this operation been performed, secondary hemorrhage would have oome on at some later period, and through the man's feeble condition have terminated fatally. 150 gunshot injuries of the bowels should be freely opened by purgatives, and the patient kept on low diet. Fracture of the Skull without Depression.—Cases of this nature are of frequent occurrence, but are of far more serious importance than the forego- ing class of injuries. They are usually accompanied with considerable contusion or laceration of the scalp. The symptoms which such an injury produces are uncertain ; in some instances the patient is rendered insensible immediately by the blow, while in others he is apparently but little affected by it at the time of its infliction. The wound should be carefully examined with the finger, to ascertain if there is any depression. Often, when merely a fissure can be detected in the external plate of the skull, an extensive stellated fracture may exist in the inner table. This is usually referred to a greater brittleness of the inner table, but Mr. Erichsen has shown, by refer- ence to the case of a man shot through the head from the mouth, that the external table may be more extensively fractured than the internal one, when the ball impinges on it from within. The external plate may, in some cases, be grooved by a ball, imparting to the touch the sensation of a depressed fracture. The prognosis in all these cases is necessarily unfavorable, yet very many patients will recover perfectly. The external table may exfoliate, and healthy granulations and perfect cicatrization may follow. In unfavorable cases extensive suppuration beneath the scalp may come on, or the inner table of the skull may die, and abscess between the dura mater and bone, with its concomitant evils, may destroy the patient. Treatment.—If the case is clearly one of simple fracture without depres- sion, but little medicinal treatment is required. Cold applications should be kept to the head, and the bowels regularly opened, if necessary, by pur- gatives. Perfect rest should be strictly enjoined, and all means of excite- ment avoided. If, however, abscess be diagnosed beneath the inner table, it should be evacuated by the removal of a portion of bone with the trephine. The period at which urgent symptoms set in after the injury, will assist the surgeon in the formation of his opinion. The occurrence of severe rigors with head symptoms coming on from fifteen to thirty days after the injury, would give rise to a grave suspicion of the formation of pus. Fracture of the Skull with Depression.—The symptoms of such injuries are so various, that it is impossible to lay down any correct laws to guide the surgeon in his diagnosis. In some cases the indications of compression of the brain are strongly marked, while in others the patient, when first seen, appears but little affected. If symptoms be urgent, and there be much difficulty in arriving at a satis- factory conclusion, whether there is depression or not, the wound should be enlarged, so as to admit of a visual examination of the injured part. In very many instances surgical skill can avail nothing, and the surgeon has but to watch and soothe the dying man, and observe the curious physiological phenomena presented.1 Treatment.—If the usual symptoms of compression are present, and de- pressed bone be positively detected, and there is a scalp wound, the surgeon may trephine. If, however, on the other hand, the bone is found depressed, but no symptoms of compression be present, or if there be no scalp wound, the operation should be delayed until cerebral symptoms have begun to manifest themselves. The operation of trephining is so fraught with danger, and experience 1 A private of the 21st regiment in the Crimea, had the whole of the posterior half of the skull depressed by a round shot, yet he lived two hours. A private of the 89th regiment lived ten days after having, as it turned out at the post mortem, a piece of the skull driven into one of the corpora striata. different regions of the body. 151 has shown that men will recover sometimes unexpectedly from the most severe injuries, that unless there be positive indications for its use, it should not be had resort to. If the scalp be wounded and the skull comminuted, and the spicula are pressing on the brain or its membranes, these should be immediately re- moved, without waiting for symptoms. Compression of the brain from coagula of blood after injury to the skull is of not unfrequent occurrence. In such cases trephining has been recommended; but the difficulty of diagnosing correctly the seat of the coagulum, supposing hemorrhage really to have taken place, renders the operation very unsatisfactory, and one which should be seldom resorted to. Moreover, it should be noticed that Dr. Stromeyer, who was surgeon-in-chief in the Schleswig-Holstein campaign against the Danes, in 1849, protests strongly against the use of the trephine, even in cases of depression, urging that the admission of air must exert a deleterious influence on a contused portion of brain. From the campaigns of 1849 and 1850 he possesses the notes of forty-one gunshot fractures of the skull with depression, and of these only seven terminated fatally ; thirty- four were cured, of whom only one had been trephined. Balls lodging in or penetrating the skull are almost always fatal. There was no instance during the Crimean war of a man recovering from such an injury. Many survived four or five days after severe damage to the brain, but all these cases were eventually fatal. Gunshot injuries of the face are of frequent occurrence, and present a greater amount of deformity than wounds in any other part of the body; nevertheless the issue of such cases, even when the bones are severely injured, is usually favorable, and a very large majority of the patients return again to duty. During the Crimean war, out of 535 men treated for these injuries, during the second part of the campaign, only fourteen died, or 2.6 per cent., and 83 per cent, returned to duty. Any part of the face may have the integu- ments lacerated, or perforated, or the bones comminuted, yet we have not any vital organ interfered with. The parts are vascular, and it is their vascularity which accounts for the rapidity with which repair is carried on. The chief danger is hemorrhage, but still, as there are no very large arteries, the bleeding usually ceases after a while. If the lower jaw be torn away, the tendency of the tongue to fall upon the glottis will be a source of inconvenience to the patient In the case of a private in the 31st regiment, who was wounded on the 2d September in the second attack on the Redan, the lower jaw was comminuted by a grape shot, and the whole of it in front of the angles was removed in splinters by the surgeon. The tongue was apt to fall backwards on the glottis, and interfere with respiration. This defect the man used to remedy by drawing it forward with his finger, and by resting with his face as prone as possible. He ulti- mately recovered. Two cases are recorded during the late war in which grape shot weighing nearly eighteen ounces had lodged in the back of the pharynx, having entered through the face, and breaking down all the tissues with which they came in contact. One patient was a private in the 1st battalion of the Royals, and was treated in the Castle Hospital, Balaklava. The second was a private of the 31st regiment. Treatment.—Remove all loose spicula of bone, and adjust the parts as neatly as possible, covering them with some light water dressing. If the jaw be fractured, maintain it in position, either by the perforated wire or gutta- percha splint. The diet should be fluid, but good. 152 gunshot injuries of the SECTION VI.—GUNSHOT INJURIES OF THE CHEST. Gunshot wounds of the chest may be divided into, 1st. Those in which the cavity of the thorax has not been opened. 2d. Those in which the cavity has been opened ; with or without injury to its contents. In the first class the danger is less than in the latter. Yet severe contusion of the lung may result from a blow of a spent cannon shot on the thorax ; or life may be endangered from shell wounds causing severe laceration of the integument and injury to the ribs. Among wounds of the second class it most commonly happens that a ball passes through the lung. Here we have a track through the substance of the lung, and generally pieces of the patient's dress, or fragments of wadding, are found to have been carried before the bullet in its course ; vessels must be torn through, and hemorrhage, often to a great extent, will take place at some period after the receipt of the injury. This bleeding may occur in the following modes :— a. From the vessels of the chest wall. p. From the vessels of the lung. The former class (a) may be either, 1st, external through the wound; or, 2d, internal into the cavity of the pleura. The second class (j3) may be internal: 1st. If slight, into the substance of the lung. 2d. It may flow into one of the bronchi, and so be coughed up. 3d. If more severe, it may be into the cavity of the pleura, compressing the lung, and adding much to the patient's sufferings and danger; or it may be external. Possibly old adhesions of the lung to the pleura may exist, gluing the costal and pleural surfaces together, or from other causes the blood may escape through the wound inflicted by the missile. The lodgment of balls in the lung during the late war, owing to the use of rifles, was more rare than in former campaigns. The danger is much greater than when balls pass through the lung. There are, however, instances of men having lived for many years with a ball in one lung. In such cases it becomes clothed with an adventitious cyst, and thus coated, seems no longer to act as a foreign body. Symptoms of Wound of the Lung.—Great collapse; the face blanched and anxious; difficulty of breathing in proportion to the extent of the wound, and probably some bloody frothy expectoration. Frequently there is em- physema in the region of the wound, but this is by no means a necessary occurrence. The Prognosis in all penetrating wounds of the chest is unfavorable, par- ticularly if the ball has lodged. Treatment.—The patient should be placed in bed, and the wound care- fully examined, to ascertain whether the ball has lodged, or passed through the thorax; and when no counter opening can be found, it will often be de- tected lying beneath the scapula on the opposite side. The patient should not be roused from the state of collapse, if it be not severe ; a piece of light dressing should be placed on the wound, and he should be carefully watched, and the symptoms treated as they present themselves. If the surgeon has reason to believe that hemorrhage is going on into the pleura, free venesection should be had resort to, sufficient to induce syncope and favor the formation of a clot. If external hemorrhage is taking place there is no need of venesection, as sufficient blood may be lost to produce the required effect. Much has been said lately concerning the necessity or advisability of bleeding men simply because they have received a chest DIFFERENT REGIONS OF THE BODY. 153 wound. The late war in the Crimea seems to point out that large bleeding for the arrest of the inflammatory action which follows gunshot injuries of the chest, is injudicious. Adhesive inflammation along the track of the bullet is desired, and is absolutely necessary for the purpose of limiting the inflammatory action to the wounded part. By largely bleeding the patient, suppuration is induced, and general, instead of local pneumonia is the result. A low diet, perfect rest, anodynes, and diaphoretics seem to afford the patient the best chance of recovery, if he escape the first danger from hemor- rhage. The position of the patient should be that which is most comfort- able, as that will probably be the one which is most favorable for his recovery. On the wounded side is generally selected, as that position favors the dis- charge of matter, approximates the opposed surfaces of the pleura, and quiets the movements of the ribs on the affected side. Complications and unfavorable symptoms.—Suppuration must always take place along the track of the bullet. It may be profuse, and the patient may sink under it. Severe pneumonia or pleurisy may add to the danger. A very frequent cause of death after these injuries is empyema, or the secre- tion of pus from the entire surface of the pleura. SECTION VII.—GUNSHOT INJURIES OF THE ABDOMEN. Gunshot wounds of the abdomen form a very fatal class of injuries. During the Crimean war 235 cases were treated, and of these 55.7 percent. died. They may be divided into— 1st. Flesh wounds of the walls of the abdomen. 2d. Injury to the internal organs without lesion of the walls. 3d. Penetrating wounds, with or without injury to the viscera or large vgssbIs. 1st Flesh wounds of the walls of the abdomen may be caused by frag- ments of shell, by which large portions of the integuments and muscles are often torn away, and portions of the intestines sometimes exposed. Bullets will frequently traverse the abdominal walls without penetrating. No pro- tracted examination should be made by the surgeon in such cases; but failing to detect the true nature of the wound, he should leave it for time to decide whether the cavity has been opened, or the viscera wounded. 2d Injury to internal organs without lesion of the abdominal walls.— Spent round shot or spent fragments of shell may strike the abdomen and inflict severe injury on the parts within, without wounding the walls of the abdomen. The liver, kidney, or spleen, or even the intestines, may be thus ruptured The condition the abdominal muscles are in at the time the blow takes place will often determine the amount of injury. If they are perfectly relaxed at the time, the damage inflicted on the internal organs is usually severe as no resistance is offered to the violence of the missile ; whereas, if the abdominal muscles are rigid, they oppose the ball, and its impetus is ex- pended in overcoming this opposition. .,,,.. , ,, 3d Penetrating wounds of the abdomen with or without injury to the viscera or large vessels.—The fatality which follows such injuries is very trreat When the ball merely penetrates the wall and passes out of the abdomen without injuring its contents, the chief danger to the patient is from peritonitis. When, however, the viscera have been wounded the severitv of the danger will, in a great measure, depend on whether it is one of the solid organs, as the liver, spleen, or kidney, which has been injured, or whether there has been perforation of the stomach or intestines. From the reports of cases, wounds of the liver, spleen, and kidney appear more 154 gunshot injuries of the fatal than those of the hollow viscera; and wounds of the stomach and large intestine more fatal than those of the small. Symptoms.—The position of the wound is a great guide as to whether the abdominal cavity has been opened; but as it is often impossible to tell by a mere examination, the surgeon is frequently obliged to found his diag- nosis on the symptoms present. Great collapse is the first striking symptom; if the viscera have been wounded, it is very severe, indeed it is a common cause of death in wounds of this region. When death does happen from shock, it is usually found that the intestines have been largely ruptured, or there has been internal hemorrhage. Frequent vomiting is a symptom which is common in wounds of the intestine, particularly if the injured part be high in the alimentary canal. There is usually pain in the abdomen, and fre- quently passage of blood by the stools. The after symptoms, or those which manifest themselves at some short period after the infliction of the injury, are referable, 1st, to peritonitis, and 2d, to those resulting from the organ or viscera which may have been wounded : thus, the passage of blood by the urine, or the escape of urine from the wound, or of bile, or, indeed, of any special secretion, will indicate at once the organ which had suffered. Pro- trusion of the intestine through the wound is of very rare occurrence. Treatment.—Having carefully examined the wound without much mani- pulation, place the patient in bed. He should not be hurried from the state of collapse, unless it be so severe as to threaten a fatal termination. Should it be ascertained that the intestine is wounded, do not search after the wound with the view of sewing up the opening; for if the wound is small, the pro- trusion through it of the mucous membrane is usually sufficient to arrest for a while the flow of the contents until lymph seals up the opening. Few cases occurred during the Crimean war in which ligatures were used, and those were fatal. Large and repeated doses of opium are imperatively called for to relieve the pain, and to arrest the peristaltic action of the bowels; it serves also to quell the mental anxiety of the patient. The question of general bleeding must be determined by the surgeon. He should remember that it does not follow that because a man is wounded in the abdomen therefore he must be bled. In injuries of this region adhesive inflammation is earnestly desired. Prophylactic bleedings are believed by most surgeons of the present day to be positively injurious; and it is generally considered that it is sufficient to meet actively an evil when it presents itself without submitting a patient to powerful remedies in anticipation of a mischief which may never occur. Occasionally cases have been met with in which a ball after penetrating the abdomen has been lodged in the bladder. M. Baudens removed a ball from the bladder by the operation above the pubis, and the late Mr. Guthrie succeeded in getting one away by the lateral operation. Mr. Dixon1 relates ten cases in which balls were successfully removed from the bladder, and three in which the attempts failed. Instances are also on record of balls having been passed by the bowels at stool, proving that they must have lodged in the intestine. section viii.—gunshot injuries of the limbs—amputation, primary and secondary. Gunshot wounds of the extremities are met with more frequently than wounds in any other region of the body. Both the upper and lower extremities are liable to similar wounds, but the danger is far greater in wounds of the latter. We may have— 1 Med.-Chir. Trans, vol. xxxiii. different regions of the body. 155 1st. Flesh wounds, caused either by the passage or lodgment of balls, without producing any fracture of the bones, or injury to any important vessels or nerves; or they may be produced by fragments of shell. The injury inflicted by a bullet is not usually very severe, and under simple dressing may soon get well. The damage, however, which results from fragments of shell, often ends in severe sloughing and loss of parts, producing, if the patient survives the drain, great deformity from the contraction and cicatrization of the tissues which have been involved; for example, after wounds of the calf of the leg, in which there has been loss of a large portion of the gastrocnemius. 2d. Simple fractures are usually caused by spent balls; and although, in such cases, the integument may not have been broken, still sloughing often follows from the contusion. 3d. Fractures with destruction of a portion of the integument are pro- duced— (1st.) By balls penetrating the limb and striking the bone. (2d.) By fragments of shell which may produce severe contusion and lace- ration of the integuments and muscles, and fractures of the bone. (3d.) Fractures are often caused by large stones, which have been struck and set in motion by round shot, or fragments of shell. Fractures produced in either of these three ways are always compound and very generally com- minuted. The conical ball may occasionally lodge in the bone without fracturing it, but as a rule, it breaks it into many fragments, or else, in passing through, it splits it for some distance up the shaft. In the passage of the ball or fragment of shell, large vessels or nerves may be divided, adding much to the severity and danger of the injury. 4th. The whole limb may be torn away by a round shot or shell, and be left hanging merely by the integuments. Such cases are very fatal. They produce fearful collapse, from which frequently the patient never rallies. Treatment.—Simple flesh wounds, if not severe, require but little surgical aid. Foreign bodies should be removed, and the parts covered with a little water-dressing. If, however, they should slough or ulcerate, they must be treated accordingly. Fractures.—If the fracture be a simple one caused by a spent shot, with- out much injury to the superficial or deep tissues, the limb should be put up in a splint, and every endeavor made to save it; but if there is severe contu- sion and destruction of the deep structures, amputation should be resorted to. It should be remembered that in field practice the military surgeon does not enjoy the same opportunities for treating fractures which the civilian does. Men who have been wounded have to be transported to the second- ary hospitals for further treatment, or perhaps carried some distance on a march; and as it is the duty of every surgeon to look first to the safety of the life of his patient, he will frequently have to sacrifice a limb, which, under more favorable circumstances, he would endeavor to save. Compound comminuted fractures of the lower extremity in the majority of cases call for amputation. The upper is capable of sustaining and recovering from injuries which would prove fatal or require amputation in the lower extremity. The bones of the humerus or forearm may be comminuted ; but unless the integument is either severely lacerated, or torn away, or large vessels or nerves injured, the surgeon should endeavor to save the limb. The splintered and loose portions of bone should be removed, and the sharp projecting extremities cut off, and the case then treated as an ordi- nary compound fracture. Frequently, after severe comminution of the bones of the humerus, a large portion will die, but this may either come away of itself or be removed afterwards by the surgeon, and yet a useful arm may be 156 gunshot injuries of the rotal. Died. Ratio of mortality per cent. 7 7 100.0 38 31 86.8 56 31 55.3 46 23 50.0 89 28 30.3 9 2 22.2 7 1 14.2 preserved. John Bryan, of the 20th regiment, was wounded at the assault on the Redan. More than an inch of the thickness of the humerus was removed on the 6th August, yet good union followed with little loss of power of the limb. In the lower extremity the shock and effects of injuries, on the constitution are more severe, and they are attended with great danger to life ; and this danger increases the nearer the injury approaches the trunk, wounds of the upper third of the thigh being far more fatal than those in the lower third. Amputation is frequently called for, and it should be remem- bered that the danger of amputation of the lower extremity is in an increasing ratio for every inch of the limb which is taken away. This applies especially to the thigh. Thus we find in the Crimean returns the following— Amputations. Amputation of hip . 5 Upper third Middle third Lower third Leg . Ankle joint. Medio-tarsal The Cases requiring Amputation are, 1st. Those in which the limb has been torn away by a round shot or shell. 2d. Severe laceration of the integuments, with injury to both artery and vein, even though the bone be uninjured. If the artery only is wounded, both ends of it should be tied and an endeavor made to save the limb; but if both vein and artery have been torn, the injury is generally so severe that it is best to amputate. 3d. Severe compound and comminuted fractures, with destruction of the surrounding tissues, even though the vessels and nerves be not injured, de- mand amputation. Primary or secondary amputation.—By the term primary is understood an operation performed within forty-eight hours after an injury, and before fever and inflammatory symptoms have set in. Secondary amputation is that which is delayed until inflammatory symptoms have subsided and suppuration established. The experience of modern surgeons has decided that amputation, when necessary, should be primary. The late Mr. Guthrie found that the loss after secondary operations was at least three times as great as after primary. The experience of the surgeons in the Crimea corroborated this fact to a great extent. The result of the primary and secondary operations during the second period of the late war is seen in the following table, which is copied from the Crimean returns. PRIMARY OPERATIONS. SECONDARY OPERATIONS. Total. Died. Ratio of mortality per cent. Total. Died. Ratio of mortality per cent. Amputations of all kinds 690 175 25.3 89 38 42.7 The patient should, if practicable, be allowed to recover from the state of collapse. Too early an operation is liable to be attended with even worse results than one at a much later period. If, however, there is hemor- rhage, or any cause which is likely to prolong the collapsed state of the patient, the operation should be performed as soon as possible. Gunshot Wounds of Joints form a class of cases of peculiar interest, DIFFERENT REGIONS OF THE BODY. 151 inasmuch as they often allow the principles of conservative surgery to be carried out in the treatment of them. Such injuries to the joints of the lower extremities are of more serious import than those of the upper. In the former the joints are larger and the danger to life seems to be in a great measure in proportion to their size. Joints are sometimes severely injured, without any wound of the integu- ments covering them ; thus in cases where the knee has been struck by spent round shot, inflammation, perhaps terminating in suppuration, may follow. Fragments of shell or bullets may lay open a joint, causing, at the same time, severe destruction of the soft tissues, and perhaps fracturing or splin- tering the bones which enter into the formation of it. When a ball has lodged in the extremity of one of the long bones, near a joint, a fissure will often extend into the joint. In the case of a man who was shot accidentally in the streets of Balaklava, by a soldier who was firing at a fierce bullock, the ball lodged in the upper part of the tibia. With some difficulty it was removed, but severe inflammation and suppuration of the joint followed, which terminated in the death of the patient. On the post-mortem examination it was found that a fissure extended into the joint. Occasionally bullets will pass through a joint, grooving, perhaps, the arti- cular cartilage. Cases of this nature are most severe, and are more danger- ous than those in which the joint has been more fully exposed, as in shell wounds. Secondary implications of joints.—Joints are very frequently implicated, secondarily, from the inflammatory action set up by wounds in the neigh- borhood extending to them, and involving them in its destructive effects. Private Waldron, 2d battalion Rifle Brigade, received a bullet-wound over the left knee. The wound appeared superficial, and the joint not to be penetrated, but low chronic inflammation of it set in, and was followed by gelatinous degeneration. The limb was ultimately amputated, and the joint found quite disorganized. In cases of pyaemia, secondary deposits of pus may take place in any of the joints. In such, free and early incisions seem to afford the best chance to the patient. Treatment— In injury of joints, especially of the large ones, and if the damage done be severe, the question of treatment becomes, in truth, one of amputation or excision. . Wounds of the large joints produce such fearful constitutional effects, that it is best not to attempt to save them, but to resort at once to opera- It must be recollected that in campaigning great difficulty is experienced in treating cases of excision, particularly those of the lower extremity. The patient has to be shifted perhaps two or three times from one hospital to another (such was the experience of the Crimean campaign), and therefore that most important element, rest, is wanting. In injuries of the upper extremity, excision was frequently performed dur- ing the late war, and was attended with very good success. Out of thirteen cases of primary excision of the elbow-joint, only three died; and of eight cases of primary excision of the head of the humerus, only one died. The best modes of performing the operations of excision will be seen under the heading " Excision of Joints" in another portion of the book. It may however be here mentioned, that, in performing the operation of ex- cision great aid will be given to the operator by using Mr. Fergusson's lion forceps to seize hold of the articular extremities of the bones before pro- ceeding to saw them. The great use of this forceps was exemplified m the following case. A private in the 50th regiment in the Crimea was struck 158 BURNS AND SCALDS. by a round shot in the upper third of the thigh, fearfully lacerating all the tissues and comminuting the femur as high as its neck. Amputation of the [Fig. 53. Fergusson's lion forceps.] hip was performed, by Surgeon-Major Trousdell and Mr. Lawson, the head of the femur, which was separated from the shaft, being with facility turned out of its socket by the aid of this forceps, a proceeding which would have been almost impossible without them. In all operations for gunshot injuries, chloroform will be found a most useful adjunct. It not only deprives the patient of all pain during the search for balls and foreign bodies, which is often a most tedious proceeding, but it serves to quell, to a great degree, the mental anxiety which is generally present. The patients awake refreshed from a sound sleep, free from injuri- ous excitement, and animated with a hope that what has been done for them will lead to their ultimate recovery. CHAPTER IY. EFFECTS OF HEAT, BURNS, AND SCALDS.1 Division.—The most useful division of burns, for practical purposes, is the threefold one which has existed from time immemorial, into, 1st, burns producing mere redness; 2dly, those causing vesication; 3dly, those caus- ing death of the part burned. 1. The first class are attended with mere superficial inflammation, termi- nating in resolution, with or without desquamation of the cuticle. The pain is philosophically said to consist of a perpetuation of the original sense of burning. 2. In the second class there is a higher degree of inflammation, causing the cutis to exude serum and form vesicles. These in trivial cases dry up and heal; but if the injury to the cutis has been sufficient to cause it to suppurate, they will be succeeded by obstinate ulcers. 3. The third class of burns is attended with mortification from disorgan- ization of structure. These are, for obvious reasons, not attended with so much pain as the last class ; but in every other respect they are infinitely more serious, and the sores which remain after the separation of the sloughs are often months or years in healing. Constitutional Symptoms.—The constitutional symptoms of severe burns are those of great collapse. The surface is pale, the extremities cold, 1 Sir C. Blagden and Dr. Fordyce found that they could expose themselves to air heated above 212 degrees without injury; and that they could bear the contact of heated spirits when cooled down to 130 degrees ; of oil at 129 ; water at 123 ; quicksilver at 117. Vide Phil. Trans, vol. lxv. BURNS AND SCALDS. 159 the pulse quick and feeble;—there are violent and repeated shiverings, and the patient often complains most urgently of cold. In some fatal cases these symptoms are soon succeeded by laborious breathing, coma, and death; in others, dissolution is preceded by a period of imperfect reaction, with delirium, and sharp jerking pulse. Prognosis.—Extensive burns, even of small severity, are always danger- ous ; and especially if vesication has occurred early, and the cuticle has been stripped off. Burns on the trunk are always more dangerous than those of an equal extent on the extremities. With regard to the symptoms actu- ally present, it may be noticed, that although the severe pain, such as is common in burns of the second class, is in itself a source of great danger, from its tendency to exhaust the vital powers, still that it is on the whole a favorable symptom, if the injury is extensive ; and that apathy and stupor indicate urgent peril. The periods of danger in burns are three : 1st, during the first five days, from collapse or imperfect reaction; 2dly, during the sympathetic fever which follows, in which the patient may sink with an affection of the head, chest, or abdomen ; 3dly, during the suppurative stage, in which he may die from the profuse discharge or from pulmonary consumption induced by it. Kentish observes that very many cases prove fatal on the ninth day. Morbid Anatomy.—A post-mortem examination readily accounts for the coma and laborious breathing, which are such constant symptoms of fatal burns. Congestion and serous effusion are found on the surface and in the ventricles of the brain ; and the air-cells of the lungs are loaded with a thin muco-serous fluid, as in the " suffocative catarrh of the dying" of Laennec. Moreover, it has been shown by Mr. Curling,1 that severe burns in young people may be followed by an acute ulceration of the duodenum, liable to terminate fatally by perforating the intestine and causing peritonitis, or by opening some large artery and causing effusion of blood, part of which may be evacuated by vomiting and purging. Mr. Murray Humphrey has ob- served ulceration of the lower part of the oesophagus. Treatment.—The treatment of burns in their early stage has been a matter of great dispute. Some eminent surgeons3 have advocated ice or other cooling applications; others, the use of turpentine and other stimu- lants, which latter plan of treatment was advocated by Mr. Kentish, of Newcastle, at the beginning of the present century. The following, however, seem to be the principles of treatment deducible from the conflicting theories and practices which have been proposed, viz:— 1st, that the first applications should be pf a mildly-stimulating nature : 2dly, that after the first two or three days, they should be soothing; till, 3dly, slight astringents may be applied to expedite the healing; and, 4thly, that the part should throughout be most carefully preserved from the atmo- spheric air and from cold. If these principles are held in view, the surgeon will have no difficulty in finding appropriate remedies. Local Treatment of minor cases. — The vesications may, if tense, be pricked with a needle, and the whole part be covered with lint soaked in Carron oil; that is, a liniment of equal parts of oil and lime-water, and then be wrapped in soft cotton wool. After the first two days poppy lotion, or the water-dressing, F. 121, may be applied on lint covered with oil-silk; or a poultice of bread and water, till suppuration is established ; the chalk ointment, or zinc lotion, may be applied afterwards till the cure is complete. The part should be kept thickly wrapped in cotton wool during the whole period, to preserve it from the air and from cold or injury. 1 Med.-Chir. Trans, vol. xxv.: Humphrey, Association Journ., Oct. 19, 1855. 2 Earle's Lectures on Burns, Lond. 1832. 160 BURNS AND SCALDS. [As an excellent application in burns and scalds we may call attention to the carbonate of lead, incorporated with a sufficient quantity of linseed oil to make it of the consistence of thick cream. It is highly spoken of by Dr. Gross (op. cit. vol. i. p. 710).] Of severe cases.—When a burn is severe or extensive enough to cause danger to life, Kentish's plan of first bathing the burnt parts with tepid tur- pentine, then with all possible expedition applying a liniment composed of ung. resinse ^j ; ol. terebinth £ss, thickly spread on lint, and lastly, wrapping them up warmly in cotton or flannel, seems to be the most judicious. These dressings should be allowed to remain as long as possible, and should not be removed unless there is a profuse discharge or bad smell from the wound. Great care should be taken, when the wound is first examined, not to strip off the cuticle, whilst taking off the patient's clothes. Constitutional Treatment.—If there is an urgent degree of collapse (see Part I. Chapter I.), brandy and beef-tea must be given. If there be much pain it should be quelled by opium. Children are com- monly said not to bear opium well, but this is a vulgar error; they bear it well if there is adequate reason. The writer has administered Tti_x of Batt- ley's sedative, in divided doses every night for a fortnight to a child of three years old, who had been badly burned, besides putting the child daily under chloroform whilst the wound was dressed. If the child is out of pain, or drowsy, of course there is no need for opium ; and in all cases it should be given in the smallest doses that will suffice. The bowels must be kept open by castor oil or rhubarb ; and the diet be plain but not too low. In the event of any inflammatory or congestive attack of the head or chest, purgatives and leeches or bleeding must be cau- tiously employed, according to circumstances. If there is any tenderness under the right hypochondrium, or vomiting, or other sign of irritation of the duodenum, the diet should be of the blandest description, and small doses of hyd. c. creta and henbane be administered. Treatment of the remaining Ulcers.—The ulcers resulting from burns are often extremely intractable. The granulations are pale, flabby, and exuberant; they secrete pus profusely ; and many months often elapse before they are healed. The cause of this disinclination to heal is not well under- stood ; but one cause there is which may be easily detected and remedied, namely, too full a diet, which is often needlessly used on the plea of sup- porting the strength under the profuse discharge. " There can be no doubt," says Kentish, " that full diet and stimulants, during the suppurative stage, keep up irritation in the system, and cause the immense continued discharge by the exposed surfaces of the wound."1 And it is equally certain that many cases will rapidly get well when the diet is lowered and purgatives are ad- ministered. The binding down of the edges of the ulcer to the condensed tissue beneath is another cause of delay. There should be no hurry in removing the first dressings; but when they are removed, the succeeding applications must be suited to the state of it. If the ulcer is irritable and painful, or hot and swelled, or seems inclined to spread by ulceration, or if small abscesses threaten to form under the skin, poultices, or water-dressing, or F. 121, Dover's powder at bed-time, and aperients should be resorted to. If sloughs are tardy in separating, the case must be treated like the sloughing ulcer. When the irritable state is removed, a succession of mild stimulants and astringents will be advisable : especially the zinc lotion; chalk, bismuth, zinc, or calamine ointment; simple lint; and pressure with sheet lead or 1 Second Essay on Burns, Newcastle, 1800, p. 64. TEE EFFECTS OF COLD. 161 strips of plaster. When the discharge is very profuse, the sore should be constantly kept thinly covered with very finely-powdered chalk. Treatment of the Cicatrix.—The cicatrix of severe burns is very liable to become excessively hard, dense, and cartilaginous, and to contract in such a way as to occasion the most serious deformities. Thus, the eyelids or mouth may be rendered incapable of closing; the chin may be fixed to the breast, or a limb be rigidly and immovably bent. This contraction may, perhaps, be sometimes successfully opposed by keeping up extension with a splint, or, if the neck is the part burned, by making the patient wear a stiff collar, and by frequently moving the part during cicatrization; and the cicatrix may be lubricated with pure oil. If the fingers are severely burned, lint should be interposed between them, and they should be kept apart as much as possible, although it will be very difficult to prevent them from adhering together.1 In burns of the head or face, the edges of the ulcer may be drawn asunder by strips of adhesive plaster. When any of the orifices of the body are involved, they should be kept dilated with canulse, or plugs of oiled lint. But if, notwithstanding every precaution, the cicatrix contracts, and produces deformity, or prevents any necessary motion, the knife should be resorted to. Sometimes the whole cicatrix may be extir- pated, the wound being treated by water-dressing, and the parts kept in a proper position during the cure. Sometimes an incision may be made in the sound skin on each side so as to form gaps, which will be filled with new and more pliant cicatricial tissue. Sometimes it will be useful to divide the cicatrix transversely by several incisions, at the same time dis- secting it up from the parts beneath if it firmly adheres to them. But it must be remembered that operations which interfere with large portions of skin are very dangerous to life ; and that the subcutaneous method should be employed where practicable. And, lastly, there is a plan which has been adopted with success by Dr. Mutter, an American surgeon, of dividing the cicatrix, dissecting it up, where adherent, and even dividing any mus- cular fibres in order to liberate the parts completely, and then filling up the gap by means of a Taliacotian operation ; that is, by transplanting a portion of sound skin from some neighboring part.8 CHAPTER Y. THE EFFECTS OF COLD. I. Effects of Severe Cold.—When a person is exposed to very severe cold, especially if it be accompanied with wind,—or if it be during the night,— or if he have been exhausted by hunger, watching, and fatigue—he feels almost an irresistible impulse to sleep, which, if yielded to, is soon succeeded by coma and death. During the state of coma, the body of the sufferer is found to be very pale and cold : the respiration and pulse almost imperceptible, and the pupils dilated ; but the limbs are flexible as long as life remains, unless the degree of cold be very great indeed. On a post-mortem examination, the chief morbid appearances observed are great venous congestion and serous effusion in the head. • Vide Part IV. chapter xxiv. 2 Vide Earle's Lectures on Burns, Lond. 1832; Dupuytren, Clmique Chirurg. ; Mutter on Deformities from Burns, in the American Journ. of Med. Sci. July, 1842. Several successful cases by Mr. Parker, of Bridgewater, are quoted in Ranking's Half-yearly Abstract, vol. iii. p. 106. 11 162 THE EFFECTS OF COLD. II. Frost-bite.—But if the trunk of the body be well protected, the cold may affect some exposed part only, such as the nose, ears, or extremities. The first visible effect is, that the part becomes of a dull-red color; an effect of cold which is notoriously frequent, and which depends on a di- minution of the quantity of blood conveyed by the arteries, and a stagnation of it in the veins. If the cold continue, the venous blood will be gradually expelled by a contraction of the tissues, and the part will become of a livid, tallowy paleness, perfectly insensible, and motionless, and much reduced in bulk. When in this condition, a part is said to he frost-bitten. The patient may be quite unconscious of the accident that has befallen him until he is told of it by some other person ; especially if it be his nose or ear that is affected, or some other part that he does not move. It was shown by Hunter that the ears of rabbits and combs of cocks may be frozen so as to be quite white and hard and brittle, and yet recover with proper care. And some of the lower orders of animals may be entirely frozen and yet survive. But it is not credible that a whole limb of a human being, much less that the whole body, could be frozen without death ensuing— although stories of such occurrences have long been current amongst authors.1 The indications are to promote reaction, but to avoid too sudden a transi- tion from one extreme to the opposite. Of Frost-bite.—The best remedy for a frost-bite is to rub the part well with snow. After a time cold water may be substituted for the snow, and the friction may be rendered brisker. These applications must be made in a room without a fire; and a high or even a moderate temperature must be avoided for some time. By these means no other inconvenience will ensue, save slight swelling and tingling, with vesication and desquamation of the cuticle; although the part will remain weak and sensible to cold for some time.3 For the coma induced by cold the best remedy is friction with flannel all over the surface of the body; the patient should be put to bed in a room of moderate temperature, ammonia and weak wine and water be administered, and, provided the breathing is restored, a warm bath may be given. The contact of any intensely-cold body (such as frozen mercury) causes severe burning pain, followed by vesication. It thus appears that the effects of sudden abstraction may be similar to those of too great communication of heat. The best application is ice gradually permitted to thaw. III. Gangrene may be caused if cold be applied continuously to the ex- tremities, especially of ill-fed persons; hence the frequency of gangrene of the feet (gelatio) amongst the starved soldiers in the Crimea. It may be caused, too, if heat be injudiciously applied to frozen or frost-bitten parts. It may also ensue if a part has been exposed for a long period to a low temperature which is suddenly raised; although the cold may not have been sufficient to cause actual frost-bite, and may have been tolerated without inconvenience. A good example of this accident is narrated by Baron Larrey,3 as it affected the French troops during their campaign in Poland in 1807. During the few days preceding and following the battle of Eylau, the cold was most intense, ranging from ten to fifteen degrees below the zero of Reaumur.4 But although the troops were day and night exposed to this inclement weather, and the soldiers of the Imperial Guard, in particular, were nearly motionless for more than twenty-four hours, there were no coni- 1 See an account of some experiments on the revival of toads after freezing in the Lond. and Ed. Journ. Med. Sci. Feb. 1843. 2 [Gross, loc. cit. vol. i. p. 715.] 3 Med. de Chir. Mil. torn. iii. p. 61. 4 From 20 to 25 degrees below the freezing-point of Fahrenheit. MINERAL AND VEGETABLE IRRITANTS. 163 plaints of its effects. On the night of the 9th of February, however, a sudden thaw commenced, and immediately a great number of soldiers presented themselves at the "ambulances," complaining of severe numbness, weight, and pricking pain in the feet. On examination, some were found to have slight swelling and redness at the base of the toes and dorsum of the foot; whilst the toes of others had already become black and dry. And in this manner, the toes, and sometimes the whole foot perished. One case, exactly similar, was treated by Mr. Solly in St. Thomas's Hospital in 1845. The patient, not very temperate, had been employed a whole day in January in handling raw cow-hides. In the evening, feeling his left hand excessively cold and stiff, he put it into warm water, and held it to the fire, which excited great pain and inflammation, ending in gangrene, which spread up to the middle of the fore-arm.1 The best treatment for such cases is the applica- tion of snow or very cold water, followed by evaporating lotions. These, if employed early enough, may prevent gangrene ; or even if that have actually occurred, they should be used as long as it appears spreading. Subsequently, the part should be wrapped up in resin ointment and cotton wool, and not be disturbed, more than is necessary for cleanliness' sake ; in most respects, the treatment of senile gangrene should be followed. IY. Chilblains consist in an atonic inflammation of the skin, induced in delicate persons by sudden alternations of temperature ; such as warming the feet and hands by the fire when cold and damp. They may present themselves in three degrees. In the first, the skin is red in patches, and slightly swelled ; with more or less itching or tingling, or perhaps pain and lameness. In the second, there are vesications—the skin around being bluish or purple. In the third degree there is ulceration or sloughing. Treatment.—Friction, with stimulating liniments, such as F. 146; or lini- ment of turpentine, or of camphorated spirit, is the proper remedy. In most cases, port wine, bark, and cod-liver oil will be of great service. If there are vesications, care must be taken not to break them; and the liniments must be applied lightly with a feather. If there are ulcers or sloughs, and they are attended with much heat, pain, and irritation, poultices are required. But as a general rule, poultices are too relaxing; and stimulating ointments or lotions (such as ung. resinae, calaminae, zinci, &c.) should be preferred. CHAPTER YI. THE EFFECTS OF MINERAL AND VEGETABLE IRRITANTS. Of these substances, some appear to act by their power of combining with, or of decomposing, the animal textures. Of others, especially the vegetable poisons, the reason of their hostility to animal life has yet to be discovered. I. Acids.__This decomposing agency of the concentrated acids appears to depend mainly on their affinity for water. The sulphuric acid blackens or chars the tissues in destroying them; that is, separates the water and other constituent elements, and sets free the carbon. The nitric turns them per- manently yellow. The hydrochloric leaves a dead white stain. The hydro- fluoric "is, of all known substances," says Turner, "the most destructive. 1 Quoted in South's Chelius, vol. i. p. 128. 164 MINERAL AND VEGETABLE IRRITANTS. When a drop of the concentrated acid of the size of a pin's head comes in contact with the skin, instantaneous disorganization ensues, and deep ulce- ration of a malignant character is produced."1 Phosphorus seems to act by the heat disengaged in its combustion. Treatment—After injury from any of these acids, the first thing to be done is to wash it away, and neutralize it by repeated ablution with warm soap and water, with a little carbonate of soda; then to apply poultices or any simple dressings to the ulcers that remain. The pain of these injuries is greatly increased by cold. II. Alkalies and Caustic Earths.—These, like the acids, appear to destroy animal matter by combining with its water. They also form a soap with the fat. Caustic potass, in the form of liquor potassas and quicklime, are the substances of this class which most frequently give rise to accidents. The liquor ammonias produces almost instant vesication and great pain when it touches the skin; it is, therefore, much to be prized as a speedy and efficient counter-irritant. Treatment.—Ablution with weak warm vinegar and water, followed by poultices and simple dressings. III. Metallic Compounds.—The bichloride of mercury acts by its tendency to combine with albumen; and the chloride of zinc and chloride (or butter) of antimony probably produce their cauterant effects in a similar manner. The nitrate of silver is remarkable for the superficiality of its effects. It may vesicate the skin, or destroy a film on the surface of a sore, but its action does not spread. It suffers decomposition at the moment of its contact with the animal tissue ; its acid appearing to be separated, whilst the metallic oxide combines and forms a white crust with the animal matter: and this soon becomes black, because the silver loses its oxygen, and is re- duced to the metallic state. Treatment.—The bichloride of mercury is rendered inert by white of egg mixed with water ; the chloride of antimony is decomposed by water ; the nitrate of silver by common salt; and the chloride of zinc by a solution of alkaline carbonate. These, therefore, would respectively be the proper ap- plications for external injuries caused by these metallic compounds ; although such cases very rarely come under the surgeon's cognizance. Arsenic, locally applied, not only produces inflammation, or sphacelus, but may also be absorbed into the circulation, and produce its ordinary con- stitutional effects as well. The surgical treatment of any local injury from this mineral must consist in removing it as much as possible by ablution with lime-water, or with water holding the hydrated peroxide of iron in suspen- sion, and then applying fomentations, or whatever other dressings may be most appropriate. IY. Acrid Yegetables.—The inflammation excited by these substances requires merely soothing fomentations and emollient dressings. The smart from the sting of nettles may, it is said, be allayed by a weak infusion of tobacco, if severe enough to require any remedy at all. If an irritating fluid have been injected into the cellular tissue, free in- cisions must be made, both to allow its escape and to afford exit to pus. By this means sloughing of the skin may often be avoided, although very likely to occur when the subjacent tissue is extensively disorganized. 1 Elements of Chemistry, 5th edit. p. 377. poison of insects. 165 CHAPTER VII. effects of the poison of healthy animals, and treat- ment OF POISONED WOUNDS GENERALLY. SECTION I.--EFFECTS OF POISONOUS INSECTS AND SERPENTS. I. Insects.—The bites or stings of any insects that are met with in England are not of sufficient importance to need surgical assistance, unless inflicted in extraordinary numbers, or in peculiar situations. Mr. Lawrence1 mentions the case of a French gentleman who was so severely stung by bees about the upper part of the chest, that he died in fifteen minutes, with all the symptoms of mortal collapse usually produced by the bite of ven- omous serpents. Children, if much stung by bees or wasps, may suffer severely from headache and fever. But the most common instance of dan- ger from these insects is the alarming suffocation produced when their sting is inflicted in the pharynx or back part of the mouth, which sometimes happens when they are concealed in fruit, and are incautiously taken into the mouth. Treatment.—If a person have been stung sufficiently to cause faintness or constitutional depression, cordials and opiates must be administered with- out delay. Respecting the local treatment, the first thing to be done is to examine the parts with a lens, and extract the stings with a fine forceps, if they have been left in the wound, as they very frequently are. Then the best applications are the diluted liquor ammonias, spirit of hartshorn, or spirit of sal-volatile ; carbonate of soda or chalk; vinegar, or eau de Co- logne ; also, soap liniment, or compound camphor liniment, may be used to remove the cedematous swelling that remains. The author has been in- formed by a friend at Sydney, that a poultice of ipecacuanha is there con- sidered to be a specific for almost every kind of venomous bite. In the case of a wasp or bee-sting in the fauces, with urgent danger of suffocation, leeches may be applied externally; and gargles (especially hot salt and water) should be frequently used, in the hope of reducing the tume- faction, by causing a copious flow of blood and of saliva : but if these measures fail of affording relief, an opening must be made into the larynx or trachea. For the bites of bugs, fleas, gnats, mosquitoes, &c, the treatment is the same. II. Spiders.—The most celebrated of this class is the tarantula, the miraculous effects imputed to the bite of which are too well known to need repetition here; and we can feel but little hesitation in subscribing to the opinion of Ray, " that the dancing of the Tarantati to certain tunes and instruments, and that these fits continue to recur yearly as long as the tarantula that bit them lives and then cease, are no other than acting fictions, and tricks to get money." We learn, however, from the least romancing of the old writers, that it produced swelling, lividity, and cramps, which were cured by scarifications and wine ; and these are just the symptoms it might be expected to cause, and the most rational cure. The effects of the scorpion are similar. There is one very singular case on record, of a gentleman bitten on the penis by a spider, in America, suffering 1 Lecture, Med. Gaz. vol. v. p. 582. 166 poison of serpents. from violent vomiting, deep-seated abdominal pain, and suffocative spasms in consequence. He was relieved in thirty-six hours by bleeding, opium, and ammonia.1 [We have been informed by a friend of high scientific acquirements, and who by a long residence in Central America has had ample opportunity of observing the effect of the bite of the tarantula, that it is followed by no particular bad effect. The common belief in the poisonous effect of the bite of spiders is in all probability incorrect; certain insects that resemble spiders, and whose bite is poisonous, have been mis- taken for them.] III. Serpents.—The venom of these animals operates, as Fontana ob- served, by "destroying the irritability of the nerves, and disposing the humors to speedy corruption." The symptoms produced vary in their nature and degree, according to the species of serpent, its degree of vigor, the frequency with which it may have bitten, and the strength of the suf- ferer. Some serpents can kill only small animals : the poison of some is very virulent, but soon exhausted by frequent biting : that of others is mild but not easily exhausted ; some, again, act so energetically oo the nerves, as to cause death speedily by convulsions; others produce inflammation of the lungs ; and others, whose venom is insufficient to annihilate the nervous functions at once, kill more slowly by the unhealthy or diffuse inflammation which they excite at the bitten part. Viper.—This is the only poisonous snake in the British Isles, but it is not often that it kills human beings. The properties of its venom were most painfully investigated, in every possible point of view, by the Abbe Fontana ;2 who ascertained that it is a yellow viscous liquid, not inflam- mable, and neither acid nor alkaline ; that it contains no salts ; and that it has no taste, except perhaps a slight astringent sensation if it is kept in the mouth for some time. It is not hurtful to another viper, nor does it appear to affect certain cold-blooded animals, as leeches and frogs. Moreover, it is perfectly harmless if applied to any natural mucous or cutaneous surface ; so that large quantities of it have been swallowed with impunity. Cobra di Capello.—Dr. Russell found that this was capable of killing a serpent called Nooni Paragoodo, but not another cobra; and that its poison was insipid when taken into the mouth, and productive of no ill consequences when applied to the eyes of chickens. The symptoms pro- duced on animals bitten by it are fainting and convulsions, but no swelling; the lungs are stuffed with blood.3 In the well-known case of the keeper at the Zoological Gardens who was bitten on the root of the nose by a cobra, on the 20th October, 1852, there was no swelling, though there was a slightly-pinkish hue of the eyelids; dyspnoea, stupor, paralysis of the ex- tremities, and coma came on, and the patient died in 95 minutes. Artificial respiration and galvanism were the remedies employed. The chief points of interest in the post-mortem examination were a dark, alkaline, and fluid state of the blood, which emitted a peculiarly sour and sickly smell; and intense congestion of the lungs, spleen, and other internal organs.4 Mr. Buckland, in dissecting an animal which had been bitten by a cobra, be- came infected through a scratch on the finger, and felt great prostration, which he relieved by ammonia.5 1 Ray, Phil. Trans. 1698, vol. xxi. p. 47 ; Boccone, Museo di Fisica ; Hulse, Am. Joum. Med. Sci. May, 1839 ; Gozzo, Gaz. M6d. 1845, quoted in Ranking, vol. ii. 2 Felix Fontana, Treatise on the Venom of the Viper, translated by Joseph Skinner, 2d edit. Lond. 1795. 3 Patrick Russell, M.D., F.R.S., An Account of Indian Serpents, 2 vols, folio, Lond. 1796. Davy, Physiological Researches, Lond. 1839. 4 Lancet, Oct. 30, 1852. 5 Bucklaud, F., Curiosities of Natural History, Lond. 1857. POISON OF SERPENTS. 167 Rattlesnake.—This snake, unlike most others, is capable of poisoning itself. Capt. Hall made one bite itself, and it died in eight minutes. Its effects, according to Sir E. Home, may be divided into two stages, either of which may prove fatal. During the first, which may last for sixty-two hours, the symptoms are those of great prostration of the neryous system, and contamination of the blood ; vomiting, deadly coldness, faltering pulse, the skin livid or jaundiced, bleeding from the nose, fainting fits, convulsions, and delirium. Meanwhile the bitten part swells immensely from effusion of acrid serum, and becomes mottled with blood, extravasated under the skin; and this swelling extends to the trunk. Sometimes it is attended with excru- ciating pain, sometimes with mere numbness or coldness. During the second stage, large diffused abscesses form in the swelled parts, which contain bloody unhealthy pus and sloughs of cellular tissue, and are attended with low fever. After death the body putrefies very rapidly.1 SECTION II.—TREATMENT OF POISONED WOUNDS. In the first place, measures must be taken to remove the poison from the wound or to destroy it. This may be attempted by passing a ligature tightly round the limb, as near as possible to the wound, and between it and the heart, or by cutting the poisoned part clean out; then by thoroughly sucking the wound and bathing in hot water, to encourage bleeding; or by putting an exhausted cupping-glass over it; or, lastly, by cauterizing it. This may be done by liq. ammonia? or nitric acid ; or if the patient can be chloroformed, there need be no scruple in using a red-hot iron. The treatment of snake-bites consists in the administration of powerful diffusive stimulants, such as hot brandy and water, whisky, ammonia, or the eau de luce, which should be given abundantly, in as large quantities as the patient can swallow them. In America, what is called the Western Cure consists in making the patient drunk; and very large quantities are required. Vomiting of bile seems to be a favorable symptom and effort at elimination, and may be treated by more brandy and by a mustard poultice to the epigas- trium. If the patient can swallow, spirits and ammonia may be injected into the stomach and rectum ; and if the breathing flags, it must be kept up by galvanism, or artificial respiration. Arsenic, in doses of a grain in solution every half-hour, for five or six doses, is a remedy which has proved successful ;9 but spirits and ammonia are less hazardous. Parts that are swelled should be well rubbed with liniment of ammonia : if abscesses form, early incisions will be requisite. [There is every reason to believe the bromine mixture of Professor Bibron to be an effectual antidote to the bite of the rattlesnake. It is prepared according to the following recipe : R.—Potassii iodidi gr. iv; hydrarg. chloridi corros. gr. ij ; brominii 3iv.—M. Ten drops of this mixture diluted with a tablespoonful of wine or brandy constitute a dose, to be repeated if necessary. See the papers of Dr. Hammond, in the Amer. Journal of Med. Sci. for January, 1858, and of M. de Yesey, in same journal for April, 1858, also Dr. Gross, op. cit. vol. i. page 407.] 1 Sir Everard Home, Phil. Trans, vol. c. Case of T. Soper, who was bitten by a rat- tlesnake. Hall on the Poison of Rattlesnakes, Phil. Trans, vol. xxx. p. 309. Case of Mr. J. Brieutal, who was bitten by a rattlesnake, reported by himself, Phil. Trans. vol. xliv. p. 147. Case of a man bitten by a rattlesnake to cure lepra, Clarke, Lancet, Dec. 15, 1838. [Gross, op. cit. vol. i. p. 402.] 2 A letter to T. Chevalier, Esq., on the effects of arsenic in counteracting the poison of serpents, Med.-Chir. Trans. 1813, vol. ii. p. 396. 168 POISON OF INSECTS. SECTION III.—ENTOZOA. I. The Guinea Worm.—Dracunculus, or Filaria Medinensis, is a cylin- drical thread-like worm, but sometimes as thick as a crow-quill, and several feet long. It is endemic in Africa, India, and other hot countries, whence persons often return to England with this pest about them. The worm appears, whilst exceedingly small, to penetrate the skin and effect a lodg- ment in the cellular tissue, where it remains dormant for some time, and gradually increases in size till it can be felt as a little tumor, or perhaps as a cord-like ridge under the skin, feeling like a varicose vein. At last a very painful boil forms, which breaks, and allows the animal's head to protude. Often, at this time, if injured, a considerable quantity of milky fluid exudes from it, which, on examination, is found to be full of small filaria?. If the case is neglected, violent inflammation and abscesses ensue; to prevent which the animal must be carefully extracted entire. If the head does not pro- trude, a cut should be made across the track of the animal, which should be gently lifted up, and then a small roll of plaster be put under it, round which it should be carefully wound, day after day till it is extracted. Ex- treme cleanliness, and the application of assafcetida, are said to act as preventives.1 II. The Chigoe (Pulex Penetrans) is a minute insect, abundant in the West Indies, which penetrates the skin of the feet, and forms a little cyst beneath it, in which it deposits its eggs. When the cyst is fully formed, it may be of the size of a pea, and is of a bluish color. The symptoms are a violent itching. The treatment consists in extracting the bag containing the creature and its eggs, which operation is dexterously enough performed by the negroes with the point of a needle, and the cavity left is filled with to- bacco ashes. If the bag is broken in the extraction, so that the young chigoes escape, violent inflammation is the result. III. The Echinococcus.—This is a minute gregarious animal, inhabiting a cyst, filled with a watery fluid, which is commonly known by the term hydatid "The cyst of the echinococcus," says Mr. Busk, "is contained either singly or in numbers in the interior of a cavity, lined with an organized false membrane, to which it has no kind of adhesion whatever. It is found of all sizes, from that of a pin's head to that of many inches in diameter." When recent it is transparent and colorless ; immersed in spirit, or in water, it becomes opaque; and flaccid from exosmosis in the former, distended from imbibition in the latter. The walls of the cyst are laminated, and of variable thickness; it contains a perfectly-limpid liquid. On its inner sur- face may be seen, scattered irregularly, a number of minute opaque granules, like grains of sand; they are covered by the innermost layer of the cyst, but are detached by the slightest force, or by incipient decom- position. Each of these granules consists of a deli- cate membrane, containing a mass of echinococci, all attached by short pedicles to a central stem of gran- ular matter, which also attaches them to the inside of the hydatid cyst. Each echinococcus consists of a rounded body of tolerably solid matter, containing numerous ovoid bodies under its outer coat, aud of a head surrounded with Fig. 54. The uppermost has its head protruded ; the lower oue shows the teeth in its inside as usual while living, and the neck a little pro- truding. 200 diameters. 1 See a paper by M. Maisonneuve in the Lancet for 1845, vol. i. p. 152. dissection wounds. 169 a circle of teeth or spines, precisely resembling those of the taenia and cysti- cerci. These teeth are perfectly characteristic, and not easily decomposed. The echinococcus cyst is most frequently found in the liver ; it may, how- ever, occur in the bones, or in the areolar tissue ; especially about the eye, and deep amongst the muscles at the root of the neck. The outward symp- toms are those of an encysted tumor, which, if punctured, gives exit to a clear serous or purulent offensive fluid (for the condensed sac containing the hydatids may suppurate) ; and the hydatid cysts themselves, or portions of them, will shortly protrude. The diagnosis in doubtful cases will be deter- mined by finding the teeth : of the treatment little can be said beyond free incisions if possible, and the injections of creasote and other lotions, to kill the parasites, and check putrescence.1 IV. The Cysticercus Cellulose is an animal of the same description as the preceding, but larger, of the size of a pea. It has been found in the anterior chamber of the eye, the cellular tissue of the lids, the pia mater, tongue, the areolar tissue and muscles. It should, when detected, be re- moved by incision.a CHAPTER VIII. POISONS contained indead human bodies, and dissection WOUNDS. During the decomposition of animal matter, a number of complex sub- stances are formed, which have a most deleterious effect if introduced into the blood of living animals. If inhaled, and especially if inhaled continu- ously, as they are in the dissecting-room, they are capable of producing sickness, dyspepsia, diarrhoea, nauseous taste in the mouth, and other symp- toms indicative of the presence of deleterious miasmata in the blood. But these poisons are usually quickly eliminated, and their effects removed by fresh air, aperients, and stimulants. Sometimes also by inhalation,3 but more particularly, if inoculated, they produce most disastrous effects in the form of inflammation of the lymphatics (see Part III. chap. IV.), and of diffuse cellular inflammation, with pyaemia. We have already spoken of the latter maladies, generally; now we propose to describe them more particu- larly as they occur from dissection wounds, remarking that the bodies of persons who have died from disorders of an erysipelatous nature, or from puerperal fever, are pre-eminently contagious, and much more dangerous than bodies usually are from mere putridity. Symptoms.—Supposing the patient to have infected his finger through a wound (which is in most cases so slight as to pass unheeded), at a period i Vide Busk in Trans, of Microscop. Society, vol. ii. p. 14; Dixon, Med.-Chir. Trans. vol xxxv» «" See a paper by E. Canton, Lanoet, 1848, vol. ii. p. 91; Gulliver, M. C. T. vol. xxiv.; Haynes Walton on the Operative Surgery of the Eye p 502 a Travers gives two cases. A Mrs. Clifton died of diffused cellular inflammation fol- lowing a prick. Two of her attendants became ill from the contact and effluvium of the discharge although neither had any wound through which a poison might be inocu- lated One of them suffered from acute fascial inflammation of the arm ; the other from low fever, and abscess in the axilla. The latter was engaged in unfolding some sheets from which a most noisome smell proceeded, when she was all at once seized with sickness and faintness, and excruciating pain in the axilla.— Constitutional Irritation, p. 373, 3d ed. See also Tyrrel's edition of Sir A. Cooper's Lectures, vol. m. ; Nun- neley on Erysipelas ; Copland's Diet. p. 304. 170 DISSECTION WOUNDS. varying from six to eighteen hours subsequently, he feels altogether unwell: he is depressed, faint, and chilly, and complains of lowness of spirits and nausea. These symptoms are soon succeeded by rigors, severe headache, and vomiting; the pulse is frequent and sharp, but weak ; the tongue is coated, and there is the greatest restlessness and despondency. Then the first local symptom appears in the form of a most excruciating pain and tenderness of the shoulder, corresponding to the hand that was wounded. And in some cases there soon afterwards arises a pustule or fester, on or near the wound. But this may be unattended with any pain, and the patient may be ignorant of its existence, or may not even be aware that he has re- ceived a wound, till his attention is directed to it by his attendants. As the case proceeds, the pain in the shoulder becomes more excruciating, and is attended with fulness of the axilla and neck; and a doughy swelling appears on the side of the trunk, often extending from the axilla to the ilium. At first it is pale ; but it soon assumes an erysipelatous redness, or rather a pinkish tint, like that of peach-blossoms. The breathing now becomes diffi- cult ; the pulse quicker and weaker; the tongue dry, brown, and tremulous; the mental distress is truly appalling, although there is seldom delirium ; the countenance is haggard, and the skin yellow; and the patient often expires before the local disease has made further progress. Varieties.—1. In one small class of cases, the influence of the morbid poison is so virulent that the patient actually dies of the precursory fever, before sufficient time has elapsed for any local disease to appear—either in the axilla, or in the wound, or elsewhere. The most speedily fatal case on record, that of Mr. Elcock, was of this variety. He died in forty hours from the receipt of the dissection wound ; and the nervous commotion and mental despondency which he suffered were even parallel to those of hydro- phobia. Dr. Bell, of Plymouth, died in the same manner. 2. In another class, diffuse cellular abscesses occur in several remote parts —the knee, or elbow, for instance, as well as in the axilla, as in the case of Mr. Shekelton.1 3. In other cases the wounded finger inflames violently, and suppurates or sloughs; or the diffuse inflammation begins at the wrist, and extends up the arm, or an attack of cutaneous erysipelas accompanies the mischief in the subcutaneous tissue. 4. In a fourth class, inflammation and abscess of the lymphatic vessels and glands may be superadded. Termination and Consequences.—If the case do not terminate fatally at an early period, extensive and foul collections of matter form in the parts that have swelled; and abscesses continue to gather under the skin, or be- tween the muscles of the trunk and limbs ; and from these the patient may slowly sink;—or, if he survive, his existence may be a mere burden; one or more of the fingers may perish by gangrene, the arm may remain stiff and useless, or the seeds of consumption or dropsy may be left in the system. Morbid Anatomy.—The morbid appearances are those of the various grades of diffuse cellular inflammation. The following may be quoted as a fair description of an advanced stage.2 The cuticle covering the affected side of the trunk, vesicated and wrinkled ;—the cutis mottled and gangrenous in patches ; the subcutaneous cellular tissue, in some parts distended with serum, in others, softened and turgid with pus; the tissue between the muscles 1 The case of Dr. Bell may be found in Butter on Irritative Fever. Those of Mr. Elcock and Mr. Shekelton are quoted at length (with many others) in Travers on Con- stitutional Irritation. See also a paper by Mr. Adam, in the Glasgow Medical Journal, August, 1830; Stafford in Med.-Chir. Trans, vol. xx. 1836. 2 Abridged from the case of Mr. Young, in Duncan's paper in the Edinburgh Med.- Chir. Trans, vol. i. Quoted also in Travers, op. cit. / dissection wounds. 171 of the trunk, as well as that which separates the different muscular fasciculi, also softened and purulent;—the muscular fibres, of a dirty yellow color, and softened;—the axillary glands enlarged, but not suppurating;—the axillary artery and nerves healthy;—but the veins (especially the smaller branches) dirty red, and softened ;—the brachial and median-cephalic veins of the wounded arm, slightly red, but the fore-arm healthy ; and no con- nection ivhatever to be discovered between the abrasion on the finger and the morbid parts in the axilla; the pleura of the affected side greatly . inflamed;—the lung covered with lymph, and much serum effused into the cavity of the chest.1 Treatment.—This is identical with that of erysipelas and pyaemia. (See p. 86.) The indications clearly are, to eliminate the poison from the blood ; to support the strength; and to relieve pain and promote the discharge of pus or sloughs. First purify the blood by a dose of calomel and by enemata, bearing in mind the experiments of Gaspard and Cruveilhier, in which dogs, into whose veins putrid pus had been injected, recovered on passing black and fetid evacuations.9 The thirst must be quenched with lemonade, soda- water, and effervescing draughts ; beef-tea, and other forms of nourishment, be liberally given ; wine, or brandy, or beer, be administered in sufficient quantity to support the pulse ; and opium, to render the patient unconscious of his severe pain. This should be given in a full dose at bed-time, and in smaller ones during the day. Local Treatment.—So soon as pain is first experienced in the axilla, warm poppy fomentations should be applied. But so soon as any distinct swelling can be detected, an incision should be made into it,—in order to relieve pain and tension, and to prevent the diffusion of serum or pus that may have been formed in the meshes of the cellular tissue. Incisions are the sine qua non of the treatment; the point on which success mainly depends : and it is most truly observed by Mr. Stafford, that, in most of the cases that have hitherto occurred, if swelling or abscess formed and were not opened, the result was fatal. If the patient survive, he should as soon as possible be removed into the country, and be put on a course of tonics and liberal diet. All the col- lections of matter, which sometimes continue to form for months, should be opened as soon as they are detected ; and the ulcers that remain be dressed with stimulating lotions and bandages. Precautionary Measures.—We need scarcely comment on the expe- diency of using some precautions in performing post-mortem examinations, especially if the operator be out of health, or if the patient have died of any disease of an erysipelatous character. Scratches on the fingers, and hang- nails, should be covered with adhesive plaster or collodion, or be touched with the nitrate of silver to form an eschar, and the entire hands should be well smeared with lard. If the operator should puncture himself, or should suffer a scratch or abrasion to come in contact with the fluids of the subject, he should immediately wash his hands, and thoroughly suck the wound. Then the nitrate of silver should be applied to it, in order to decompose the poison and excite a slight inflammation, which will prevent imbibition. ' Dr Law in a valuable paper in the Dub. Med. Journal, Nov. 1839, gives several cases of glanders and diffuse cellular inflammation mistaken for acute rheumatism. 2 Quoted in Ferguson on Puerperal Fever, p. 54. 172 hydrophobia. CHAPTER IX. effects of poisons generated by diseased animals. section i.--hydrophobia. Definition.—Hydrophobia is a disease caused by inoculation with the saliva of a rabid animal, and characterized by intermitting spasms of the muscles of respiration, together with a peculiar irritability of the body and disturbance of the mind. Symptoms in the Dog:—Since prevention is better than cure, it is very desirable that every medical practitioner should know the symptoms of rabies in the dog, and most especially the earliest symptoms. These, according to Mr. Youatt, are "unusual sullenness, fidgeting, and continual shifting of posture." The dog retreats to his basket or bed for several hours, where he lies curled up, with his face buried between his paws. Then he becomes fidgety, continually changing his resting-place ; appears clouded and sus- picious in his countenance, and gazes strangely about him as he lies on his bed. A peculiar delirium is also an early symptom: the dog perhaps springing up and giving an angry bark at some imaginary object. "I have again and again," says Mr. Youatt, "seen the rabid dog start up after a momentary quietude, with unmingled ferocity depicted on his countenance, and plunge with a savage howl to the end of his chain." But if his master speaks to him every fancied object of terror disappears, and he crawls towards him with his usual expression of attachment. Then comes a moment's pause,—a moment of actual vacuity,—"the eye slowly closes, the head droops, and he seems as if his fore-feet would give way and he would fall; but he springs up again, every object of terror once more surrounds him, he gazes wildly around, he snaps, he barks, and he rushes again to the end of his chain to meet his imaginary foe." The amount of ferocity displayed by rabid dogs varies extremely. Some there are whose fury knows no bounds, and who, if loose, rush out, biting every man and beast in their way. Others, on the contrary, not only cannot be made to bite, but, in the very earliest stage of the disease, show an increased fondness, and are perpetually trying to lick their owners' hands and face. Many cases are on record of persons who have been thus infected through some accidental scratch or abrasion ; and hence when rabies has been detected in a dog, it is most important to inquire whether any persons have scratches which he may have licked, and if so, these should be cauter- ized at once. Another early and constant symptom of rabies is change of voice. Every sound uttered by a rabid dog, says Mr. Youatt, is more or less changed. But there are two sounds in particular that deserve notice ; one of which is described as a "hoarse inward bark, with a slight elevation of tone ;" and the other a most peculiar and characteristic combination of "a perfect bark, ending abruptly and very singularly in a howl, a fifth, sixth, or eighth higher than the commencement." Other symptoms, observed at the commencement of the disease, are, loss of appetite, propensity to lick cold surfaces, such as stones or iron, and to devour straws, litter, and similar rubbish; and peculiar eagerness, in scent- ing at and licking not only the common urining places, but corners in rooms that are not usually disgraced by this evacuation. This is considered a IN THE DOG. 173 highly-important symptom. There is no dread of water as in the human being; on the contrary, an insatiable thirst, which the dog endeavors to allay by lapping as long as he has power over his jaws. The mouth is dry, and the saliva exceedingly viscid ; at first, perhaps, it is slightly increased in quantity, but this increase soon passes off, and the secretion becomes ex- tremely viscid and scanty, sticking in the corners of the mouth, and annoying the poor dog extremely, who may be seen fighting with his paws at the corners of his mouth, as if trying to dislodge some bone which had stuck between his teeth. Thus, the disease, when fully formed, is characterized by delirium with more or less ferocity, alteration of the voice, great thirst, and viscidity of the saliva, to which may be added perfect insensibility to pain. As it ap- proaches its termination, the eye becomes dull; the hind legs first, and then the muscles of the jaws are paralyzed, and at length the poor animal dies exhausted. But there are some cases in which paralysis of the muscles of the mouth and jaws is a very early symptom; the mouth being open and the tongue protruding. A poor dog in this condition will plunge his muzzle into water up to the very eyes in order that he may get one drop into the back part of his mouth to cool his parched throat. This form of the disease is generally called dumb madness. The usual duration of rabies is from four to six days. The post-mortem appearances show merely the effects of the malady, in various degrees of congestion of the mucous membrane of the respiratory and alimentary surfaces. The tongue, often torn and bruised, and covered with filth ; its papillae prominent and reddened, the mucous follicles about the fraenum enlarged. In the dumb madness, the tongue hangs from the mouth, and is swelled and dark-colored. The fauces show a more or less partial blush, and the epiglottis and larynx are usually much injected. The trachea, bronchi, and lungs, are sometimes much congested, sometimes the reverse. The stomach generally shows vivid redness, or sometimes patches of ecchymosis on the summit of its rugae ; the brain, intestines, bladder, and heart display no appreciable or constant morbid signs whatever. Perhaps one of the most characteristic evidences of rabies that dissection affords is the presence of a peculiarly-mingled mass of hay, and hair, and straw, and earth, and excrement in the stomach, or perhaps in the fauces, where it may have lodged from defect in the power of deglutition.1 Causes.—The cause of this malady in dogs is most frequently a bite from another animal already diseased; yet it must occasionally arise spontaneously. And the most probable sources of its origin are close confinement, rank, un- wholesome food, want of the couch grass, the natural medicine of the dog, and deprivation of sexual intercourse. Besides the dog, it is probable that hydrophobia arises spontaneously in the wolf, jackall, badger, and perhaps the cat. But it may be communicated to many other mammiferous animals, and there is no doubt but that every animal capable of taking the disease can also propagate it. This is equally true with regard to human beings as to animals. MM. Magendie and Breschet inoculated two healthy dogs on the 9th of June, 1813, with the saliva of a man who was laboring under the disease, and who died of it the same day at the Hotel Dieu. One of the dogs ran away, but the other was affected with decided rabies on the 27th of July following, and died of it; and some other dogs, which it was made to bite, died also. Well-authenti- cated cases are recorded, in which the disease was communicated to man by pigs and horses; and there is no doubt but that it would be so much more 1 See The Dog, by W. Youatt, Lond. 1845. 174 HYDROPHOBIA. frequently, if it were the instinct of herbivorous animals to show their rage by biting. Breschet, in the course of numerous experiments on the subject, repeatedly infected dogs with the saliva of rabid horses and asses. One curious fact demonstrated by these experiments is, that when rabbits, or other rodentia, and birds, are inoculated with the saliva of rabid animals, they very soon die, but without exhibiting any of the ordinary symptoms of hydrophobia.1 In the horse the disease commences with great distress and terror, and profuse sweating; he soon becomes frantic and outrageous, stamping, snort- ing, and kicking.2 In the sheep, the symptoms are similar. An instance is recorded in which eight sheep were bitten, and became rabid ; they were exceedingly furious, running and butting at every person and thing, but did not bite. They drank freely.3 There are several points connected with the propagation of hydrophobia which are still involved in great uncertainty. It is not known whether the saliva is the poisonous agent, or whether some poisonous matter may be secreted by the mouth, fauces, or lungs, and mixed with it. This, however, is not a point of much consequence ; but again, it is uncertain whether the whole solids and fluids of the animal are not poisonous also. In fact, there is some reason for believing that the disease may be communicated by the mother's milk.4 Moreover, it appears that it may be communicated by con- tact of the dog's saliva with the skin, or mucous membrane, without any wound or abrasion.5 In a case related by Dr. Watson,8 the dog's tooth merely indented the skin of the back of the hand, but made no wound. Lastly, a point of more importance and uncertainty than any is, whether the bite of an animal in health, or of one merely enraged, may not cause the disease : it is very certain, at all events, that the bite of an animal will prove fatal long before it exhibits any outward symptoms of rabies. Symptoms in Man.—At a variable period after a bite, or after some other mode of inoculation with the saliva of a rabid animal (which period is generally from five weeks to three months, sometimes much longer, pos- sibly even one or two years), the attention of the patient is directed to a peculiar pain of the wounded part, together with slight heat, redness, and swelling. The pain is observed to shoot in the course of the nervous trunks, and has in general a rheumatic character. Sometimes, instead of it, there is a stiffness or numbness, or partial palsy. In some cases it is unattended with redness or swelling; in others, on the contrary, the wound has thoroughly inflamed, and has broken out into suppuration afresh, although healed long before. In some instances these premonitory symptoms have not appeared at all, or have been so slight as to pass unheeded ; in a few instances they have not appeared till after the accession of the genuine hydrophobic symp- toms ; but in general they are observed from two to five days previously to the actual symptoms of hydrophobia. Of these, the first is a vague feeling of uneasiness and anxiety. The patient finds himself generally unwell; his mind is irritable, and his countenance gloomy ; he experiences a succession of chills and flushes, with transient headache; the appetite fails : there is frequently vomiting, and sometimes a well-marked accession of fever. Next, the sufferer complains of stiffness of the neck and soreness of the throat, with 1 Breschet sur quelques Recherches experimentales sur la Rage. L'Experience, Oct. 8th, 1840. 2 Blaine's Outlines of the Veterinary Art, 2d edit. Lond. 1816. 3 Lancet, 1829-30, vol. ii. p. 511. 4 Two ewes were bitten by a mad dog, and died hydrophobic. One had two lambs, the other one ; all three of which were seized with the disease a week afterwards, although they had not been bitten by the dog, nor, as was supposed, by the mothers.— Steele, Med. Gaz. Oct. 25th, 1839. 5 Hutchinson, Lancet, Dec. 8th, 1838. 6 Lectures, Med. Gaz. May 7th, 1841. hydrophobia. 175 severe spasmodic pains at the epigastrium; the respiration also is embar- rassed, and frequently interrupted by sighing. But these symptoms are in most cases attributed to cold, and their real nature is not suspected for a day or two, till, all on a sudden, on attempting to drink, the patient is seized with a fit of suffocating spasm, and manifests extreme horror at the sight of fluids. The most prominent symptoms that henceforth present themselves, are three, viz., difficulty of breathing and swallowing, extreme irritability of the body, and peculiar disorder of the mind. (a.) The difficulty of breathing and swallowing depends on spasm of the muscles of the pharynx and larynx. Sometimes the patient can swallow neither solids nor liquids, but more frequently the disability extends to liquids only; because they require a greater exertion of those muscles, and are consequently more liable to excite spasms. It is this circumstance that causes the aversion to fluids, and the alarm at the sight of them, which so generally characterize the disease. At first the spasms are excited only by attempts to swallow fluids ; then they are brought on by the sight or thought of them ; or by the motions of spontaneous deglutition ; but as the malady advances, they recur in frequent paroxysms—sometimes spontaneously, some- times excited by the slightest noise or touch. When the paroxysms have become fully developed, they cause the most frightful struggles for breath. All the muscles are convulsed, the face is black and turgid, and the eyeballs protrude from their sockets. They may come on either during inspiration or expiration, but more frequently the latter; the patient struggling most violently to expel the air that is confined in his chest through the closure of the larynx. In this disease, as in tetanus, the fatal termination may ensue from suffocation in the middle of a paroxysm, although it more frequently happens during an interval, from exhaustion. (b.) Next to the spasm, the astonishing irritability of the surface of the body is the most prominent symptom of hydrophobia, The slightest im- pressions on the senses affect the sufferer most intensely. A look, or a sound ; the opening and shutting of the door of his apartment; the motions of his attendants ; the reflection of light from a mirror ; the least impression on the skin ; the touch of a feather, or impulse of the gentlest current of air, are sufficient to bring on the convulsive fits, and are most earnestly deprecated by the patient. (c.) The state of mind is in most cases one of most profound despair. Sometimes there is great restlessness and talkativeness; sometimes ma- niacal fury; more rarely entire composure and tranquillity throughout the Progress and Termination.—When the disease is fully established, its torments are aggravated by extreme thirst; and still more by a peculiar viscid secretion from the fauces, the irritation of which brings on the con- vulsive fits, and causes a perpetual hawking and spitting, which are very constant symptoms. Not unfrequently there is vomiting of greenish matter mixed with blood. As the disease advances, the convulsions increase in fre- quency and violence ; there is constant restlessness and tremor; the lips and cheeks become livid, and perpetually quiver; till at length one fit lasts long enough to exhaust the remaining strength, and release the patient from his misery. An entire and remarkable remission (perhaps from the use of medicine), sometimes occurs, and the patient enjoys perfect ease, or per- haps sleeps for some hours; but yet the symptoms return, after a time, with aggravated violence. Again, in some cases, there is a perfect calm before dissolution ; " the patient becomes tranquil, and most of his sufferings subside or vanish ; he can eat, nay, drink or converse with facility; and former objects associated with the excruciating torture of attempting to 176 HYDROPHOBIA. swallow liquids no longer disturb his feelings. From this calm he sinks into repose, and, suddenly waking from his sleep, expires."1 Morbid Anatomy.—The morbid appearances most frequently found are, congestion of the membranes and substance of the brain and spinal cord, and effusion of serum. Sometimes blood is extravasated around the cervical portion of the cord. The lining membrane of the fauces, oesophagus, tra- chea, and bronchi, are most highly vascular, the papillae at the root of the tongue large, and the lungs congested. The stomach often contains a darkish fluid, and patches of vascularity of a dark-purple color are found in it and in the intestines. But although some one or more of these morbid appear- ances are detected in most cases, still there is not one of them that is pre- sent invariably. The brain, spinal cord, and fauces have been found pale, and the stomach without spots. Hydrocyanic acid has been detected in the blood after death, but this is not peculiar to hydrophobia.8 Pathology.—It is quite clear, therefore, that no change of structure that has yet been discovered can be considered essential to the existence of hydro- phobia. It is true that the difficulty of breathing and swallowing may be partially accounted for by the inflammation about the fauces, and the great irritability of the surface is symptomatic of irritation of the spinal cord. But still no mere local changes can explain the mass of symptoms, which must depend on a peculiar change in the blood, or nervous system, or both.3 Diagnosis.—The chief diagnostic signs are the spitting, and especially the influence of slight currents of air in bringing on the convulsive attacks. In July, 1854, the writer saw a case with his friend Dr. Challice, of Ber- mondsey. The patient, a middle-aged woman, had been bitten in the foot by a cat in the April preceding. She was lying in bed, rational and tranquil, and nobody could have seen at the first glance that she ailed much. The writer took her hand to feel her pulse ; and whilst doing so, breathed on it as gently as possible. Instantly the poor woman started up in bed choking with spasm in the throat. This was sufficient for the diagnosis. Preventive Treatment.—As soon as possible after the bite of a sus- pected animal, the whole wound should be sucked, and so soon after as may be, should be excised or cauterized, or both. Mr. Youatt recommended the nitrate of silver ; and he certainly had a right to speak in favor of it, since he was bitten many times, and escaped, though he used no other preventive; and since he gives instances in which out of several animals bitten by the same dog, those which were cauterized by the nitrate of silver escaped all further mischief, whilst some which had the wound excised, or cauterized with a hot iron, were subsequently infected with rabies. These are certainly strong facts in favor of using the nitrate of silver; but cases have occurred in which the immediate and free application of it was useless. The rule generally given, however, is that the bitten part should be cut out, care being taken to carry the knife wide of the bite. After this, bleed- ing should be encouraged by the application of a cupping-glass; or the wound should be long and diligently washed in warm water. And then (especially if the bite has been irregular, so that it is uncertain whether the excision has been complete) the raw surface may be cauterized by the nitrate, or by nitric acid ; or by caustic potass. Chloroform will aid the surgeon in carrying out these disagreeable processes coolly and efficiently. 1 Bardsley, Cycl. Pract. Med. Art. Hydrophobia. 2 Med. Gaz., 5th September, 1840. 3 A case of real hydrophobia, supposed to have occurred without any infection, is quoted from the Trans, of the Coll. of Phys. of Philadelphia, in Prov. Med. Journ. for 1850, p. 225. But if the poison can be so readily imbibed, as we have shown, through a slight scratch, or through the unbroken skin, it is more probable that the disease in this case arose from infection, unsuspected, than that it was of spontaneous origin. THE GLANDERS. 177 When we consider that substances introduced fairly into the blood may find their way all over the body in an inconceivably short space of time (probably in nine seconds'), it will be.readily seen that excision or cauteriza- tion, although performed as soon as possible after the bite, may be of no avail. Yet they should never be omitted let the interval be what it may. And one case is recorded in which it is said that the patient was saved al- though the parts were not cut out till the thirty-first day, and not till the symptoms had actually made their appearance. This, however, is doubtful.3 Whether the wound, after excision or caustic, should be allowed to heal, or be kept open, and made to suppurate by irritating ointments, is a dis- puted point. The weight of authority certainly favors the latter practice, and beyond the inconvenience it can do no harm. As for any other preventive treatment, all that can be done is to keep the patient in as good a state of health, and in as good spirits as possible. But there is not one of the innumerable so-called specifics that is worth a moment's trial. Curative Treatment.—Here we are met at the outset with the doubt whether hydrophobia can be cured at all; whether, like the plague and smallpox, it will not run its course, without the possibility of checking it. Mr. Youatt says that he believes he has occasionally prevented it in the dog, and that he has occasionally seen a case of spontaneous recovery; but that he has never cured it. Dr. Elliotson believes that the premonitory symptoms may show themselves in men and the disease go no further. But although it cannot be denied that a few rare cases have recovered, or have been re- ported as recoveries ; for instance, one after enormous bleeding ; one from violent salivation ;3 one from the use of lead in large doses ;* still, as the remedies that were supposed to be successful in these cases have been used again and again in others without benefit, the recoveries must fairly be con- sidered accidental and spontaneous. Pages might, be filled with an account of the remedies which have been resorted to in vain. Bleeding, which is quite inadmissible ; the injection of warm water into the veins, which in Majendie's hands certainly proved a palliative ; opium, which sometimes affords temporary relief; ice crunched in the mouth and swallowed, and applied in bladders to the spine ; Indian hemp and chloroform: of all these it may be said, that although they may mitigate the patient's suffering, yet, that the disease seems to have in it some source of mortality quite independent of outward or local symptoms, and not to be neutralized by any remedy yet within our reach. In the present state of our knowledge, the principal object is to allay the patient's sufferings. This should be done by keeping him perfectly quiet, and in the dark; and by the administration of opium, chloroform, Indian hemp, and other sedatives and narcotics. The strength should be kept up with whatever nutriment can be taken, and by tonics. For further details we may refer to the Chapter on Tetanus, with which this disease has the closest analogy. SECTION II.—THE GLANDERS. Definition.—The glanders is a disease of the horse tribe, communicable to man and other animals. It is chiefly manifested by unhealthy suppura- tion of the mucous membrane of the nasal cavities, pustular eruptions on the skin, and unhealthy abscesses in the lymphatic system. 1 Blake, Edin. Med. and Surg. Journ., Jan. 1840. 2 Thompson, Med.-Chir. Trans, vol. xiii., and Lancet, Sept. 23, 1837. 3 Account of the effects of a bite of a wild jackal in a rabid state, as the same oc- curred at Kattywar, in the East Indies, in 1822. Med.-Chir. Trans, vol. xiii. 1825. * Med. Gaz., April 14, 1838. 12 17* THE GLANDERS. Symptoms in the Horse.—It may occur in two forms, which, however, are merely manifestations of the same disease in different parts. When seated in the lymphatic system, it is called farcy—when in the nasal cavities, glanders. But these two forms are essentially identical; the pus of either of them will reproduce the other; and farcy always terminates in glanders, if the animal live long enough, and its progress is not arrested. Farcy begins with hard, cord-like swellings of the lymphatic vessels and glands, called farcy-buds. These slowly suppurate, and form unhealthy fistulous sores, which discharge a copious thin sanious matter. If suffered to proceed unchecked, farcy leads to glanders, although more frequently the latter arises first. Glanders.—Its symptoms are, a continued flow of discharge from one or both the nostrils (generally the left), which discharge is at first thin and serous; then thick and glairy, like the white of egg; but after a time be- comes opaque, purulent, bloody, and horribly offensive, retaining, however, its viscidity. Soon after it commences, an enlarged gland may be felt under the lower jaw adhering to the bone. The next things noticed are one or more ulcers on the Schneiderian membrane, having the sharp edges and scooped-out character of chancre ; these spread widely and deeply, and lead to caries of the bone. Then the lips and eyelids swell, and the conjunctivae suppurate ; and the external parts of the face may become gangrenous, and the animal may die in a few days with putrid fever; or he may perish more slowly;—the disease spreading to the lungs, and death being induced by cough, emaciation, hectic, and the formation of unhealthy abscesses in the lungs and all over the body. The distinctive symptoms, according to Youatt, are the continuousness of the discharge, and the adherence of the enlarged submaxillary gland.1 Symptoms in Man.—This disease may appear either as glanders or farcy; either of which may be acute or chronic. (1.) The acute glanders begins with all the symptoms that indicate the absorption of a putrid poison. There are general feelings of indisposition, lowness of spirits, and wandering pains; followed by fever, furred tongue, great thirst, profuse perspirations at night, great pain in the head, back, and limbs, and tightness of the chest. After some days these symptoms increase: there are severe rigors and delirium, often of a phrenitic character; the per- spirations become more profuse, and sour and offensive, and are attended with diarrhoea of a similar character. Then diffused abscesses appear in the form of red swellings about the joints, especially the knees and elbows— the patient complains of heat and soreness in the throat; the tongue be- comes dry and brown, the respiration more oppressed, and the fever assumes a decidedly low malignant character. Next (perhaps a fortnight from the commencement of the illness, sooner or later in different cases) a dusky shining swelling appears on the face, especially on one side, extends over the scalp, and closes the eyes. Then the characteristic features of the disease appear;—an offensive, viscid, yellowish discharge, streaked with blood, issues from the nostrils; and a crop of large and remarkably hard pustules (compared by some to those of small-pox, and said by others to be about the size of a pea) appears on the face. In the meanwhile the swelling and inflammation increase; a portion of the nose or eyelids mortifies;—the dis- charge becomes more and more profuse and offensive ;—the pustules spread, and extend over the neck and body; fresh abscesses form and suppurate; the thirst is most excruciating; and low murmuring delirium and tremors usher in death—much to be wished for. (2.) The chronic glanders is characterized by a viscid and peculiar fetid 1 Blaine, op. cit.; Youatt on the Horse. THE GLANDERS. 179 discharge from one nostril, with pain and swelling of the nose and eyes;— and emaciation, profuse perspiration, and abscesses near the joints, from which the patient slowly sinks. [We have seen a case of chronic glanders that began by the appearance of a lachrymal fistula on each side. It was at first regarded by M. Nelaton, the celebrated surgeon of Paris, as undoubtedly syphilitic, from the fact of there being two fistulas, with ulceration around them, in a patient having no signs of scrofulous diathesis. In the course of time the ordinary symptoms of chronic glanders manifested themselves, and the patient died at the expiration of four or five months. In connection with this case it is worth while to notice that Ricord is of opinion that the great epidemic that burst out in Europe at the close of the fifteenth century, or about the time of the discovery of America, was one of glanders or of farcy. See Ricord's Letters on Syphilis, the Xth letter.] (3.) In the acute farcy, the patient receives the poison through a wound or abrasion, which inflames violently, together with the lymphatics leading from it. The symptoms are attended with considerable fever, and are gene- rally soon followed by the diffused abscesses, pustular eruption, and nasal discharge, that characterize acute glanders. (4.) In the chronic farcy, a wound poisoned by glanderous matter de- generates into a foul ulcer; the lymphatic vessels and glands swell and suppurate ; abscesses form in different parts of the body ; and if the disease is not cured, or does not destroy the patient first, it terminates in acute glanders.1 Causes.—In the horse this disease may, without doubt, arise sponta- neously, when the animal is subjected to the usual influences that generate putrid poisons;—namely, insufficient and unwholesome food, close confine- ment, and ill ventilation, especially on board ship. Mr. Youatt believes that it may arise, if the animal is kept in a poor state of health, as the climax of constitutional weakness and derangement. In man, it is gene- rally produced through inoculation of the matter into a wound ; and the matter from the abscesses or nasal cavities of human beings is capable of communicating the disease both to men and animals. A man died of glanders in St. Bartholomew's Hospital, in. 1840, and the nurse who at- tended him inoculated her hand, and died of it also in a very few days ; and two kittens which were inoculated from the nurse, became affected likewise. Moreover, the blood of a glandered horse injected into the veins of a healthy one communicated the disease, although no abnormal appearance could be detected in it by the microscope.3 The time at which the disease appears after inoculation varies from three days to a month. Prognosis.—This, in the acute disease, is highly unfavorable; the chronic, however, may be recovered from. Morbid Anatomy.—The morbid appearances are the same both in man and in the horse. Clusters of white granules, or tubercles, or, as Dr. Craigie describes it, of matter like putty or thick pus, are found in whatever tissues the disease has invaded ; in the Schneiderian membrane, in the antrum and frontal sinuses, and in the vicinity of the different abscesses. The nasal cavities mostly contain a thick brown gelatinous secretion, and are studded with foul gangrenous ulcers, from which project fungous clusters of tuber- cular matter. Treatment.—The chief points are, to open all abscesses as soon as pos- sible; to syringe the nasal cavities with solutions of creasote, or F. 117, 127 • and to support the strength and abate the thirst with wine or brandy 1 Case of Mr. Turner, Travers, Constitutional Irritation, p. 399 : Case of Farcy ending in Acute Glanders in seven months, L'Experience, Jan. 1839. 2 Keynault, quoted in Provincial Medical Journal, 18th Feb. 1843, from the Report of the French Academy for Feb. 2, 1843. 180 THE VENEREAL DISEASE. and soda-water, beef-tea, &c. The effluvia must be counteracted by fumi- gations of chlorine and aromatics. In fact, in every variety and stage of this horrible disease, the strength must be kept up, and the poisonous discharges neutralized. Creasote injections, the administration of iodide of potassium with iodine, and mercurial salivation, in different cases re- spectively are said to have effected cures.1 CHAPTER X. THE VENEREAL DISEASE. SECTION I.—GENERAL HISTORY AND PATHOLOGY. Definition.—The venereal disease, using the term in its widest accepta- tion, consists in the effects of certain morbid poisons, generated and usually communicated by promiscuous sexual intercourse. It includes two distinct diseases—'-gonorrhoea and syphilis, each of which presents two classes of symptoms—the primary and the secondary; the primary being the effects of the morbid poison on the parts to which it is actually applied ; the secondary being the subsequent results of some general disorder of the constitution. Gonorrhoea is an inflammation of the mucous membrane of the genitals, which is occasionally succeeded by papillary eruption and by various rheu- matic affections, as secondary symptoms. Syphilis consists, first, of ulceration of the parts to which the morbid poison is applied, and inflammation of the neighboring lymphatics, which are the primary symptoms; and secondly, of sundry eruptions of the skin, ulcerations of the throat, inflammations of the eyes, and "inflammation and caries of the bones and joints, which are the secondary symptoms. The primary symptoms of syphilis are undoubtedly contagious, and com- municable by inoculation with the matter from the ulcers. The secondary symptoms, which depend on a general contamination of the constitution, are commonly supposed, on the authority of Ricord, not to be communicable by inoculation ; but they are certainly capable of transmission from a father or mother to the foetus in utero ; from a nurse to a suckling infant, or from an infant to its nurse ; and it is suspected, but not proved, that they may be communicated from husband to wife. There is, moreover, a third class of symptoms, which may be called ter- tiary ; consisting of various eruptions, rheumatic pains, falling off of the hair, deafness, ulceration of mucous membranes, and all kinds of anomalous cachectic complaints, which are the sequelae of syphilis when it operates on an originally bad constitution, or is aggravated by ill treatment. The history and origin of venereal diseases are involved in the deepest ! Vide Elliotson's papers in the Med.-Chir. Trans, vols. xiii. xviii. (with a colored plate) and xix.; the Med. Gaz. vol. xix. p. 939 ; case communicated from father to son, Lancet for 1831-32, vol. i. p. 698: Raver, de la morve et du farcin chez Hiomme, Mem. de 1'Acad. de Med. 1837; the cases of the patient and nurse in St. Bartholomew's Hospital above quoted, in the Lond. Med. Gaz., April 18th and 25th, 1840; case of acute glanders cured by injections of creasote by Mr. Ions, Lancet, April 30th, 1839; case of acute farcy cured by iodide of potassium with iodine, Arch. Gen. de Med. Jan. 1843 ; Youatt's book on the horse, 1845 ; Burgess's Translation of Cazenave on Diseases of the Skin, Lond. 1842. Case treated by mercury, recovery ; Mr. Carpenter of Croydon, Med. Times, Aug. 4,1855. [Memoir of Tardieu in the Arch. Gen. de Med. for 1841; the case of Richard in the same publication for 1851.] THE VENEREAL DISEASE. 181 uncertainty ; and it is scarcely possible, in the compass of this work, to do more than show how difficult it is to arrive at satisfactory conclusions on the subject. 1st. As to their origin; it is disputed whether these, like other diseases generated by morbid poisons, are ever produced de novo; or whether they are produced in all cases by infection from a similar previously-existing disease. " I believe with my friend, Mr. Guthrie," says the late eminent army- surgeon, W. Fergusson, "that wherever prostitution is foul and unclean, restricted to few women amongst crowds of men, there the infection will be generated ; which afterwards spreads through society at large. The irregu- larities of man are at all times punished by the generation of diseases and loss of the health ; and it would be difficult to believe in a superintending providence if this transgression of divine and human law should be allowed to pass unpunished."1 The author fully concurs in this opinion. Respecting gonorrhoea, there seems but little doubt that it may be induced without contagion, both in man and in animals; in stallions, for example, which are made too rapidly to cover different mares in succession. The writer does not hesitate to state his belief that almost any surface in a state of suppuration and disintegra- tion is capable of infecting any other. Instances are well known of cutane- ous eruptions, such as ecthyma and psoriasis, following the contact of dis- eased secretions of animals.3 Contagion is probably the rule rather than the exception, with diseased surfaces. And foul promiscuous intercourse, producing suppurating and abraded surfaces, in dirty persons, whose health is out of order, will, he believes, under some circumstances generate syphilitic poison. Seventeen galley-slaves were inoculated by M. Hernandez with gonorrhceal matter. Slight ulcers were produced, which in five of the cases healed readily enough. But the remaining twelve patients were either scro- fulous or scorbutic, or in an ill state of health, and seven of these suffered from eruptions and wandering pains. And it is confessed by Ricord and Egan, that many cases of gonorrhoea, with abrasion of the vaginal mucous membrane, were followed by mild, but well-marked secondary symptoms. But this, like most other points in the history of syphilis, belongs to the domain of reasonable hypothesis, rather than of demonstrated truth. 2dly. The history of venereal diseases is a perfect battle-field for authors: some contending that they were known from the earliest ages ; others that they were unknown till the fifteenth century. Respecting gonorrhoea, it is highly probable that it is alluded to in Leviticus, chap, xiii and xv., and that it was well known in England in the middle ages, under the term burn- ing or brenning. It is fairly argued also that some of the ulcers on the genitals which are mentioned by the earliest writers, by Celsus,3 for instance, were probably syphilitic; that ulcers arising from sexual commerce were well known in the middle ages; and that both the primary and secondary effects of syphilis were, in those days, like many other diseases', confounded with leprosy. Syphilis appears also to have been known almost from time immemorial in China. The arguments against the antiquity of venereal diseases are partly nega- tive and partly positive. On the negative side it is alleged, that although ulcers or pustules on the genital organs and sundry discharges were not un- known, still that neither in Celsus, nor in any other ancient writer, do we 1 Notes and Recollections of a Professional Life, by the late W. Fergusson, M. D. Lond. 1846. 2 See Edinburgh Veterinary Review, No. 1, July, 1858. Case of Gangrenous Ecthyma of the Arm, from attending cattle in protracted labor. s De Medicina, lib. vi. cap. 18. 182 THE VENEREAL DISEASE. find mention that such maladies were solely, or even frequently, the pro- duce of sexual commerce; or that they were peculiarly difficult to heal; or that they were frequently, or indeed ever, followed by constitutional dis- eases. Whilst there is positive evidence that all at once, whilst the French army, between the years 1494 and 1496, under Charles VIII., was besieging Naples, a new and terrible disease sprang up, rebellious to every known method of treatment; attacking high and low, rich and poor; sparing neither age nor sex : consisting of ulcers on the parts of generation in both sexes, which were speedily followed by affections of the throat and nose; by corroding ulcers over the whole body ; by excruciating nocturnal pains, and frequently by death. Whereas " not one word that can be construed into any similar affection is to be met with distinctly stated in any writer before that period." Our own supposition is, that syphilis did exist from very early ages, but that it received increased virulence in the fifteenth century in consequence of war, famine, and the intercourse of foreigners; circumstances which in all times have produced an aggravated type of the disease. 3dly. Another disputed question is, whether syphilis was or was not im- ported from America ? for it will be recollected that Columbus returned from his first voyage in 1493, that is, just before the alleged European out- break of the disease. The greatest weight of evidence is certainly opposed to this supposition; because no such disease is mentioned by the very earliest historians of the discovery of that continent;—neither is it mentioned by the earliest writers on America. But besides—of the earliest authors on the venereal disease, almost all refer its outbreak to the siege of Naples—but not one for the first thirty or forty years derives it from the West Indies. And it appears pretty certain that the disease prevalent in the West Indies, which might have been brought home, was not syphilis, but the epian or yaws, or sivvens ; a disease often communicated to the very young or old, and to persons who do not catch it by carnal conversation. 4thly. Are the poisons of gonorrhoea and syphilis identical ?—Our own opinion is, that the two poisons certainly are not identical: but that they are most probably elaborated under similar conditions; and that, as happens in scarlatina, both poisons may have, under different circumstances, infinite varieties of effects and infinite degrees of intensity. Hunter believed that gonorrhoea and syphilis were identical, for he produced a chancre by inocu- lation with gonorrhoeal matter, which was followed in three months by sore throat and eruptions. But the doctrine of Ricord is, that, although the pus of a syphilitic ulcer, like any other morbid secretion, may irritate a mucous membrane and produce gonorrhoea, still that gonorrhoeal matter will not produce primary syphilitic ulcers; and that gonorrhoea will not be followed by secondary syphilitic symptoms, unless there is also a chancre or syphilitic sore in the urethra; which was probably the case with the patient from whom Hunter took the gonorrhoeal matter.1 1 Vide Astruc on the Venereal Disease, Lond. 1754; Hunter on the Venereal; Hen- nen's Military Surgery ; Carmichael on Syphilis ; Bacot'3 Treatise on Syphilis ; Travers on the Venereal; Titley on Diseases of the Genitals of the Male ; Wallace on the Vene- real (Plates); Judd's Treatise on Urethritis and Syphilis (Plates); H. J. Johnson, in Med.-Chir. Review ; Colles on the Venereal ; Ricord, Traite des Maladies Veneriennes, Paris, 1839 ; Mayo on Syphilis, Lond. 1840; Mr. Lane's Lectures in the Lancet, 1841 and 1842; Acton's Treatise on Venereal Diseases, with an Atlas of Plates, Lond. 1841; Egan on Syphilis and Inoculation, Lond. 1853; Tyler Smith, Lancet, 1853, vol. ii.; Henry Lee, Lectures in Prov. Med. Journ., 1854. [Hunter's Treatise on the Venereal Disease, with copious additions by Ricord ; translated and edited with notes by Dr. Bumstead, 2d edition, Philadelphia, 1859.] GONORRHOEA. 183 SECTION II.—GONORRHOEA. Definition.—A gonorrhoea signifies a discharge from the mucous mem- brane of the male or female genitals; usually produced by contagion from a similar discharge. Symptoms.—These may be conveniently divided into three stages. In the first stage, the patient merely notices a little itching at the orifice of the urethra, with a slight serous or thin whitish discharge. If the disease is not checked at once, it passes after a few days into the second, or acutely inflam- matory stage. The discharge becomes thick and purulent, and when the disease is at its height is greenish, or tinged with blood. The penis swells; the glans becomes of a peculiarly cherry color, is intensely tender, and often excoriated. In consequence of the tumefied state of the urethra, the stream of urine is small and forked, and passed with much straining and severe pain and scalding. All the parts in the vicinity of the genitals, the groins, thighs, perineum, and testicles, ache and feel tender; and the patient's nightly rest is disturbed by long-continued and painful erections, and by chordee, that is, a highly painful and crooked state of the penis during erection. This arises from a deposit of lymph in the corpus spongiosum urethras, which glues together the cells, and prevents their distension, so that when the penis is turgid with blood, it is bent at one part, and horribly painful. In the third stage, the inflammatory symptoms and chordee abate, and a muco-purulent discharge is left, which, when obstinate and thin, is called a gleet COMPLICATIONS OF GONORRHOEA. 1. There may be severe irritation or actual inflammation of the urinary organs; sometimes of the deeper portion of the urethra, producing great pain in the perineum, and spasm of the accelerators and other muscles during micturition, so as to interrupt the stream of urine, and cause the most exquisite agony,—or even complete retention of urine;—sometimes of the bladder, causing a very frequent desire to make water and great pain in doing so, which lasts for some time afterwards, together with a white mucous cloud in the urine ; or there may be shivering, pain in the loins, albuminous or purulent urine, tenderness of the abdomen, vomiting, and other signs of severe irritation of the kidneys. 2. Hemorrhage from the urethra; from rupture of the distended capilla- ries during violent erection. The loss of blood generally gives relief. 3. Inflammation and obstruction of the mucous follicles of the urethra, which may suppurate and burst either into the urethra or externally or both. 4. Inflammation of the lymphatic glands of the groin, constituting sympa- thetic bubo. 5. Balanitis (fidxavos, glans), see p. 190. 6. Phymosis, or paraphymosis, may easily arise, owing to the swelled condition of the glans and prepuce. When the latter is cedematous, it pre- sents a curious semi-transparent appearance called crystalline. See Part IV. Chap. XXI. 7. Inflammation of either testicle. See Part IV. Chap. XXI. 8. Gonorrhoeal rheumatism; pain, swelling, and tenderness of the joints, especially of the knees and ankles, and fever. This generally occurs towards the decline of the complaint, and attacks young people of a delicate stru- mous habit. The same persons are also liable to rheumatic ophthalmia, or inflammation of the fibrous structures of the eye ; but this must not be con- founded with the gonorrhoeal inflammation of the conjunctiva, which is caused by the contact of the discharge. Bacot says, that the rheumatism 184 GONORRHOEA. is sometimes suddenly relieved by the appearance of patches of minute papulae or pustules. Gonorrhoea is always most severe in first cases, and in patients who are very young, or who possess irritable or scrofulous constitutions. In such cases it may be attended with extreme fever and constitutional disturbance, and may even prove dangerous to life by leading to extensive abscesses in the neighborhood of the bladder.1 But after repeated attacks, the urethra becomes, as it were, inured to the disease, and each subsequent infection is generally (although not always) attended with fewer of the symptoms of acute inflammation. In some instances the constitutional affection is extremely anomalous, and charac- terized by severe and continuous rigors. Gonorrhoea sicca.—There is one form of gonorrhoea which is occasionally met with in the male, and Mr. Acton has often met with it in the female, in which the mucous membrane is red, swollen, and tender, but free from dis- charge. In the male, there are severe scalding and pain in making water, with painful erections, and the lips of the urethra are red and swelled. This form of disease has the popular name of the dry clap. Causes.—The poison of gonorrhoea is but one amongst many other causes capable of producing inflammation and purulent discharge from the male urethra, such as—1. Local irritation of any sort, especially immoderate and protracted sexual indulgence, and the introduction of bougies. 2. Disorders of the constitution, gout, rheumatism, lithic and oxalic gravel. 3. Discharges are sometimes occasioned by the use of particular medicines, as guaiacum and cayenne pepper. Again, a man may contract a pretty severe discharge from a woman who is perfectly chaste, and has not been previously infected by a third party. Thus—(a) The menstrual fluid is capable of causing urethritis with violent scalding and chordee, and followed by swelled testicle ; and a considerable degree of irritation may be produced by the vaginal secretions, just previous to menstruation.3 (b) Similar consequences sometimes ensue if the female be affected with any discharge whatever. Diagnosis.—The diagnosis of the simple gonorrhoea, that is, of discharge not arising from sexual connection, or which a man contracts from some accidental malady in a clean, chaste woman, is well summed up by Mr. Bacot in these words :—" If a discharge come on only a few hours after connection, and if it have continued several days without inflammatory symptoms ; if the patient has been liable to some discharge after any excess of venery or of wine ; in all such cases the probability is that the patient labors under some other diseased condition of the urethra, and that although the intercourse of the sexes may have been the exciting cause, still there may be no imputation on the cleanliness of the female."3 The time at which the disease usually appears after contagion is the fourth or fifth day. The later it appears the less severe it generally is; yet in some very mild cases, the discharge comes on immediately after connection. Gonorrhoea in the Female.—It is important to consider the precise seat of the disorder. 1. There may be vulvitis, inflammation of the mucous membrane of the external parts only, that is, of the labia, nymphae, meatus urinarius, and parts adjoining, corresponding to balanitis in .the male. The discharge is profuse, often fetid, the parts much swelled, perhaps aphthous or excoriated, and there is great pain in walking and in making water. The inguinal glands may enlarge, or there may be abscess in the labia. 2. The vagina may be affected likewise. 3. The canal of the 1 For cases, vide Judd, op. cit. p. 70. 2 Judd, p. 24. 3 Bacot, op. cit. p. 101. gonorrhoea. 185 cervix uteri may be implicated, with or without abrasion of the mucous membrane. Causes.—Discharges from the female organs may be produced by many causes. 1. Thus discharges of the first sort just spoken of are by no means uncommon in girls or women of any age, and may be the result of want of cleanliness, of teething, of disordered condition of urine, or of any other form of constitutional disturbance. The surgeon should be well aware of this, as parents are apt to be very much alarmed, and to attribute such complaints to improper causes. 2. Discharge of clear viscid mucus from the vagina is not unfrequent in debilitated subjects, the parts of generation being patulous and relaxed. 3. The canal of the cervix uteri is, as Dr. Tyler Smith has shown, the seat of the true leucorrhcea; a discharge of tenacious alkaline mucus, containing abundance of round corpuscles. This is very commonly caused by mental and Dther circumstances affecting the health in general, and the generative organs in particular. Diagnosis.—Are there any certain means of distinguishing the discharges caused by gonorrhoea from those arising from other sources ? First, as to symptoms, it may be alleged that a purulent discharge occurring suddenly, with inflammatory symptoms, and excessively obstinate, affecting the vagina as well as the external parts of generation, in a woman who is not a virgin, is most probably gonorrhoeal. The non-venereal cases, so far as the author has seen, are not so obstinate, and do not involve such an extensive track. If the discharge comes solely from the external vulva, or solely from the canal of the cervix uteri, with or without excoriation or granular surface, it is probably not gonorrhoeal. But, 2dly, if it come from the vagina, the diagnosis must be chiefly a matter of inference. Discharges from the vagina are acid, and consist of abraded epithelium and pus. But no microscopic or chemical test, at present known, enables us to distinguish those arising from idiopathic causes in chaste women, from those arising from contagion. Prophylactic Treatment.—A patient who has been exposed to the chances of venereal infection would do well to wash out the front part of the urethra with a syringeful of some astringent lotion; and, if any fissures or excoriations are perceived, to touch them with lunar caustic, and apply a bit of dry lint. Curative Treatment.—The remedies for gonorrhoea are threefold : first, antiphlogistic measures, to get rid of inflammation ; secondly, certain medi- cines containing a volatile oil, which has a peculiar sanatory influence on the inflamed mucous membrane ; and, thirdly, astringents to check the secretion of the inflamed surface. Of the first stage.—If the patient apply during the very first stage, before acute symptoms have come on, the disease may almost infallibly be cut short by employing the plan recommended by Ricord. Let him inject the urethra regularly once in four hours with a solution of two grains of nitrate of silver to eight ounces of distilled water; let this be repeated twelve times, desist- ing, however, sooner, if the discharge is rendered thin and bloody, which is the ordinary effect of the nitrate. Then let an injection of sulphate of zinc be substituted, and be continued till the discharge ceases. At the same time the patient should take a mild aperient, and after it, three times daily, a dose of copaiba or cubebs. He should avoid exercise, fermented liquors, salt, spice, coffee, and stimulants of every kind ; he should take no supper, and should continue this regimen for a week or ten days after all trace of the discharge has disappeared. The penis should be wrapped in a piece of rag dipped in water. The manner of injecting is of no small consequence, as the efficacy of the lotion depends entirely on its application to the whole of the diseased surface; 186 GONORRHOEA. and, as Dr. Graves observes, the ordinary opinion that gonorrhoea is limited to the anterior extremity of the urethra is unfounded and mischievous. The patient should be provided with a glass syringe, with a long bulbous ex- tremity, and having filled it, should introduce it for about an inch with his right hand. Then, having encircled the glans penis with his left forefinger and thumb, so as to compress the urethra against the syringe, and prevent any of the fluid from escaping, he should push down the piston with his right forefinger, letting the fluid pass freely into the urethra. The syringe should now be withdrawn, but the orifice should still be compressed, and the fluid be retained for two or three minutes; after which, on removing the finger and thumb, it will be thrown out by the elasticity of the urethra. It is always worth the surgeon's while to see that the injection is properly used. Instead of using an injection, many patients who apply early before the inflammatory stage has come on, as well as patients who have had repeated attacks, may be cured by beginning the use of copaiba or cubebs in large doses at once. The cubebs should be taken in the dose of a drachm thrice daily, and the copaiba in the form of capsules. Of the second stage.—Supposing it to be a first attack in a young irritable subject, and that it has proceeded unchecked to the acute stage, the patient should be confined to the house for a few days, if his avocations permit it. Walking, and above all, horse exercise, should be prohibited. The penis and scrotum should be supported by a suspensory bandage, and be kept con- stantly wet with tepid water. The glans penis, if very irritable, should be protected by a piece of lint spread with spermaceti ointment. The diet should be moderate, to the entire exclusion of fermented liquors, and the patient should drink soda water, barley water, linseed tea, gum water, and other mucilaginous fluids. The scalding will be relieved by combinations of alkalies and sedatives (F. 174), and by a hip-bath of the temperature of 80°; but the bath should not be hot, nor even warm, otherwise it will excite the circulation and bring on erections. The bowels should be opened with a dose of calomel at night, and some castor-oil in the morning; and it is advisable to give half a grain or a grain of calomel with gr. one-eighth of tartar-emetic, and gr. x. of Dover's powder; or F. 63, &c, every night whilst there is much pain and chordee. The mercury is not necessary as a specific, but it is highly useful to check the inflammatory symptoms. As soon as the patient is free from fever, he should take copaiba or cubebs. Young, irritable people, however, with light complexions, can seldom take these medicines without suffering from sickness or diarrhoea, or sometimes even from fever and a rash ; and every combination of aromatic and opiate that can be devised will not enable the stomach to tolerate them. If the patient is very plethoric, and suffers greatly from pain and fever, and has a hard pulse and white tongue—and if there be great aching in the bladder or perineum, protracted agony after micturition, tenderness in the abdomen, pain in the back, or other signs of irritation of the urinary organs—it may be right to apply leeches to the perineum, and to admin- ister opium freely. It is decidedly not safe to use injections with young, delicate, irritable subjects during the acute stage, and most especially whilst there is any ten- derness of the glands of the groin, or any aching of the spermatic cord or testicles ; as they might easily produce swelled testicle, or great irritation of the neck of the bladder. And, as a general rule, it is best to refrain from them altogether, till the inflammatory symptoms are mitigated by the anti- phlogistic remedies before mentioned. Treatment of Complications.—Painful erections and chordee may be relieved by bathing the parts with tepid or cold water, and a combination of narcotics with antiphlogistics, F. 30, 63, &c; and if the chordee lasts GONORRHOEA. 1-8 7 long, a little mercurial ointment and extract of belladonna should be smeared on the part at bed-time. Hemorrhage may be checked by cold and pressure on the urethra. Inflammation of the mucous glands of the urethra is to be treated by poultices. The swelling may be punctured if it obstructs the flow of urine, but not otherwise. Swelling of the glands in the groin may generally be removed by rest, and, if necessary, a few leeches. Of the third stage.— As soon as the acute stage has subsided, the patient should use the injections of nitrate of silver, followed by zinc, in the same manner as was recommended for the first stage. If the discharge does not cease entirely, or if it comes back again, other injections, F. 135-139, may be tried; adapting their strength to the irritability of the part, and not permitting them to cause severe pain. But a gleet is often a very tedious complaint, and requires a judicious and long-continued course of remedies that act on the urinary organs, together with most temperate habits of living. Copaiba, either alone or combined with astringents, F. 176; steel, F. 13, 180; and cantharides, especially in combination with zinc, F. 179, are the most useful remedies. The bowels should be kept properly open, but saline purgatives should be avoided. If the patient wants to make water oftener than natural, and there is an uneasy sensation in the urethra afterwards, and the urine deposits a mucous cloud, buchu and uva ursi (F. 181) will be advisable. It is also useful to inject the urethra with cold water from an elastic bottle twice a day. If the urine is preternaturally acid, or loaded with the phosphates, or the digestive organs deranged, the case should be treated as directed in the section on urinary deposits. If the health is materially enfeebled by debauchery or malprac- tices, affusion of cold water on the genitals, cold sea-bathing, blisters to the perineum, bark and steel, good living, and perfect chastity of body and mind are the necessary remedies. If other means fail, a smooth metallic bougie may be introduced every other day, or the porte caustique of Lalle- mand may be introduced, for the purpose of slightly touching the whole of the canal with the nitrate of silver. Gonorrhoeal rheumatism must be treated on the same principles as com- mon rheumatism. The bowels should be well cleared by calomel, and then ammonia with lemon-juice, F. 58, every four or five hours, and a dose of Dover's powder at bed-time. In the chronic stage, F. 63 or 72 at bed-time; iodide of potassium, sarsaparilla, bark, volatile tincture of guaiacum, sea air tonics, and warm bathing, are the remedies. Treatment of Gonorrhoea in the Female.—During the acute stage, rest in the recumbent posture, fomentations of decoction of poppy-heads and chamomile flowers, frequent ablution, lubrication with lard or cold cream, and very frequent sponging with a weak solution of alum, a piece of lint dipped in which should be inserted between the labia, with laxatives and diaphoretics, are the measures to be adopted until heat, pain, and tenderness subside; afterwards injections of nitrate of silver and sulphate or acetate of zinc should be used, just as has been recommended for the other sex, and they should be continued for some time after all discharge has ceased. Terebinthinate medicines (copaiba, Ac.) may be given, although they do not do much good unless the discharge proceeds from the urethra or its vicinity It is supposed that these medicines produce their good effects by bein°- excreted with the urine, and so coming in contact with the diseased surface Hence it has been proposed to use injections of copaiba, and it is said that they do good in both sexes. Abscesses or other complications, if they occur, must be treated on general principles. In any obstinate dis- charge the cervix uteri should be examined through the speculum, and the interior of its canal be touched with solid nitrate of silver, if a copious 18G PRIMARY SYPHILIS. muco-purulent discharge be seen to issue from it. Steel is usually of service in chronic cases. SECTION III.—PRIMARY SYPHILITIC ULCERS. General Description.—Primary syphilitic ulcers or chancres may be caused by the application of the syphilitic virus to any surface, mucous or cutaneous, entire, wounded, or ulcerated. Their most frequent seat is the genitals; and in men they are more frequently than otherwise found on the inner surface of the prepuce, or the furrow between the prepuce and corona glandis, or the angle by the fraenum ; parts which should always be carefully searched for such ulcers. The time at which venereal sores appear is usually said to be from the third to the tenth day after infection; but it is more probable, as Ricord observes, that the syphilitic virus operates progressively from the first moment of its application, and that although no ulcer may be formed, yet that a portion of skin may have imbibed the poison, which may have produced its characteristic adhesive effect; or it may have found its way into a follicle ; so that the virus is in full operation, although no actual ulcer may be perceived till later. The average duration of a syphilitic ulcer produced by inoculation is, according to Wallace, twenty-five days. Primary syphilitic ulcers present many varieties, which may be arranged under the following heads, according to the very practical suggestions of Mr. Henry Lee—1st, the Hunterian, or indurated chancre, a slow, torpid ulcer, encircled by the adhesive inflammation ; 2d, the non-indurated, or pustulous ulcer, marked by early and free suppuration; 3d, the phagedaenic or ulcerative ; 4th, the sloughing. 1. The Hunterian, or Indurated Chancre, is generally found on the com- mon integument or on the glans penis. It may begin either as a pimple or as a patch of excoriation which heals up, leaving the centre ulcerous. Let us suppose this ulcer to have been produced by inoculation with the point of a lancet: during the first twenty-four hours the puncture reddens ; in the second and third days it swells slightly, and becomes a pimple, sur- rounded by a red areola; from the third to the fourth day, the cuticle is raised by a turbid fluid into a vesicle, which displays a black spot on its summit, consisting of the dried blood of the puncture ; from the fourth to the fifth day, the morbid secretion increases and becomes purulent, and the vesicle becomes a pustule with a depressed summit. At this period the areola, which had increased, begins to fade, but the subjacent tissues be- come infiltrated and hardened with lymph. After the sixth day, if the cuticle and the dried pus which adheres to it be removed, there is found an ulcer, resting on a hardened base; its depth equal to the whole thickness of the true skin, its edges seeming as if cleanly cut out with a punch—its sur- face covered with a grayish pultaceous matter, and its margin hard, elevated, and of a reddish-brown or violet color.1 The ulcer feels to the finger like a little cup of cartilage set in the flesh. 2. The Non-indurated, or Suppurating, may be said to have four stages. In the 1st, it is a small itching pimple, or pustule, which bursting displays— 2dly, a foul yellowish or tawny sore, attended with slight redness and swelling, and spreading circularly. It may or may not be covered at first with a dirty brown scab. In the 3d stage it throws out indolent fungous granulations (and in this stage is sometimes called the raised ulcer of the prepuce), and is usually stationary for a little time after it has ceased to ulcerate, and before it begins to heal. In the 4th stage, it slowly heals; cicatrization being pre- ceded by a narrow vascular line. If the ulcer be seated near the fraenum, it is almost sure to perforate it. 1 Ricord, op. cit. p. 89. PRIMARY SYPHILIS. 189 3. Phagedsenic chancres are extremely rapid in their progress, and highly painful; their surface yellow and dotted with red streaks ; their shape irre- gular ; their edges ragged or undermined ; and the discharge profuse, thin, and sanious. The surrounding margin of skin usually looks puffy and cede- matous, showing a low grade of vitality; but sometimes it is firm and of a vivid red. Sometimes these ulcers eat deeply into the substance of the penis; sometimes they undermine the skin extensively ; but in general they spread widely but not deeply. Sores of this last description are called serpiginous. In many cases the sore deserves to be called irritable, rather than phage- dasnic ; being acutely painful, discharging thin ichor; with a raised surface of yellowish exudation; but not spreading much, though it obstinately refuses to heal. 4. Sloughing phagedaena affecting chancres requires no observations on its symptoms distinct from those made at page 92 et seq. It must be added that chancres may be affected with simple acute inflammation leading to gangrene, from local irritation, such as horse exercise, and excess in stimu- lating liquors. When the British army was in Portugal, the men suffered severely from sloughing chancre, to which they gave the emphatic name of Black Lion ; but the disease, though so destructive to our men, was mild amongst the natives, possibly because they had become thoroughly syphilized, or inured to infection.1 Chancre in the Urethra.—Ricord has proved satisfactorily that this is the cause of the secondary syphilitic symptoms which were formerly attributed to gonorrhoea. The existence of chancre in the urethra may be suspected, if in a case of gonorrhoea the discharge is very capricious, sometimes thin, scanty, and bloody, sometimes thick and profuse; and if there is one painful indurated spot. But it can only be proved, either by the ulcer being visible at the orifice, or by inoculation with the matter. Syphilitic Ulcers in the Female require no distinct observations. They do not usually cause so much distress as in the male, but they are very slow in healing, especially if interfered with by the urine. When situated high in the vagina, they may cause no symptoms at all, except, perhaps, a mucous discharge, and can be detected only by the speculum. Constitutional Effects.—When a patient has a syphilitic sore, which has not been destroyed within five days, he is liable afterwards to those maladies which will presently be described under the term Secondary Syphilis. Yet it seems almost certain, that it is only after the Hunterian variety that such symptoms are to be dreaded, or preventive treatment require'd; and that sores of the suppurative, ulcerative, and sloughing varieties, and those attended with suppurating bubo, do not as a general rule inflict this penalty. It seems, also, that the existence of a developed Hunterian chancre, or of its cicatrix if hard and red, like the existence of the vaccine vesicle, affects the entire constitution; so that if it be cut out or destroyed, the wound will assume the same character, and require the same constitutional treatment, as if the malady had not been interfered with. It seems, also, that repeated syphilitic infection begets a kind of pro- tection against fresh attacks ; and likewise that the production of additional suppurating syphilitic sores, not only does not confer any fresh liability to secondary symptoms, but seems to diminish that which exists already. Hence it has been proposed to inoculate patients with syphilitic matter,— or to syphilize them, as it is termed—as a measure of prevention and cure, 1 For an account of this interesting point in the history of syphilis, see the late Inspector-general Fergusson, Med.-Chir. Trans, vol. iv. and Guthrie, ib. vol. viii. 190 DIAGNOSIS OF CHANCRE. just as vaccination is used against the smallpox. But the facts that have been published by the advocates of this disgusting proposition, are not sufficient to warrant the author in doing otherwise than most strongly deprecating it as a remedial measure, although inoculation may be occa- sionally justifiable as an experiment.1 SECTION IV.—AFFECTIONS THAT MAY BE MISTAKEN FOR CHANCRE. The ordinary means of distinguishing a syphilitic ulcer are, that it is seated on the genitals; that it has followed a suspicious connection ; that it is probably circular ; perhaps that it has a hardened base and elevated edges; and above all, that, if treated with simple applications merely, it is extremely difficult to heal. There is, besides, the test of inoculation, as proposed by Ricord. If some of the secretion of a real chancre, taken whilst it is extending and before it begins to heal, be inoculated into the skin of the thigh, it will most likely produce a sore of its own kind there, after the manner we have described when speaking of the Hunterian chancre. It may be right to adopt this practice in some few cases when the existence of chancre in the urethra is suspected ; or when the characters of a sore on the penis are undecided; or when there is a sore suspected to be syphilitic on the face, or any other unusual part; or when it is wished to test the pus from a bubo; but the sore produced by inoculation must be destroyed by nitric acid, as soon as its character is decided, else it may give both sur- geon and patient a great deal of trouble. Moreover, it must be recollected that although the production of a chancre by inoculation proves that the sore from which the matter was taken was a chancre, yet, that the contrary is by no means proved by the failure of inoculation. For a sore, though chancrous in its origin, will not yield an inoculable matter when it has arrived at its healing stage ; and it is often very difficult to procure a sore by inoculation from a chancre. See p. 201. Affections that may be mistaken for Chancre.—This is the most convenient place for describing the nature and treatment of various affec- tions that may be mistaken for chancre. 1. Gonorrhoea externa, or balanitis, is an inflammation of the surface of the glans and inside of the prepuce, with profuse purulent discharge, and excoriation of the cuticle. It generally affects dirty people with long pre- puce, and is caused either by the acrid secretions of the part, or by contact with unhealthy secretions in the female. Sometimes, however, it occurs to cleanly people whose health is disordered. The thick profuse discharge, the peculiar smell, the superficiality of the excoriations, and their appearance immediately after connection, distinguish this complaint from chancre ; and a little opening medicine, common soap and water, and any mild astringent lotion will suffice to cure it. Lime-water is the best lotion if there is much inflammation, and a grain of corrosive sublimate to an ounce and a half of lime-water if there is not. If the cure is not effected in two or three days, the excoriations should be touched with nitrate of silver. Sometimes balan- itis is attended with very great inflammation and fever, and with phymosis, from the great swelling of the prepuce; and the pain may be so severe and gnawing, as to make the surgeon uncertain whether there is not a phage- daenic ulcer concealed by the foreskin. The thick discharge, and the pain being general and not confined to one spot, form the chief means of diagnosis; and repeated injection of warm water and astringent lotions under the fore- skin are the remedies. 1 See Henry Lee's Pathological Obs., Lectures on Syphilis, &c, Lond. 1854. Victor de Meric's papers in Lancet, 1853-54. V ' TREATMENT OF PRIMARY SYPHILIS. 191 2. Minute aphthous-looking points, sometimes in clusters, sometimes sur- rounding the glans ; some of them healing, whilst others break out. They are totally devoid of pain; and although they may last a long time, do not lead to ulcers. They are best treated by black wash or mere lime-water, or lotions of arg. nit. or cupr. sulph. and alteratives and aperients. 3. Herpes praeputialis1 begins with extreme itching and sense of heat. The patient examining the part, finds one or two red patches, about the size of a split pea. On each patch are clustered five or six minute vesicles, which, being extremely transparent, appear of the same red color as the patch on which they are situated. In twenty-four or thirty hours the vesicles become larger, milky, and opaque; and on the third day they are confluent and almost pustular. If the eruption is seated on the inner surface of the prepuce, the vesicles commonly break on the fourth or fifth day, and form a slight ulcer with a white base and rather elevated edges. If this ulcer be irritated by caustic or otherwise, its base may become as hard as that of a chancre. If left to itself, it mostly heals in a fortnight; sooner, if situated on the external skin. The cause of this complaint is either some derange- ment of the digestive organs, or irritation within the urethra, produced by unhealthy urine. It is very liable to recur in the same individual, which, of course, if known, will greatly aid the diagnosis. Treatment—A little dry lint, or goldbeater's skin, at first, and subsequently a very weak lotion, with aperient and alterative medicines. 4. Psoriasis prasputii, painful, irritable, and bleeding cracks or fissures around the edge of the prepuce; best treated by ung. hydr. nitr. dil., and arsenic internally. SECTION V.—TREATMENT OF PRIMARY SYPHILIS. The indications for the treatment of primary syphilis, are—1st, to destroy the poisonous ulcer, and heal the breach of surface as soon as possible. 2d, to prevent the occurrence of secondary symptoms. Treatment—If a patient applies so soon as he perceives the chancre, it will be advisable to destroy it by nitric acid, then give an aperient, enjoin rest and low diet, and wrap the penis in rag dipped in warm water. Even if the sore has lasted more than a week it may still be expedient to destroy it; but this will not give the same security against secondary symptoms, as in the former case. But if the chancre presents a well-marked indurated base, or if the penis is swelled and inflamed, or the patient feverish, or if there is any swelling or tenderness in the groin, this cannot be done. When this is the case, the local applications should consist of some mild liquid capable of chemically decomposing the poisonous secretions of the sore, such as black wash, F. 125. If there is very much irritation, the penis should be enveloped in a poultice of boiled chamomile flowers, and the patient be kept in bed. If there is much induration, Ricord recommends an ointment of calomel. Afterwards, during the indolent and granulating stages, the sore may be treated with any astringent lotion, and be touched occasionally with nitrate of silver or sulphate of copper. , ,. . , .a In former days, mercury administered to salivation was deemed the specific for syphilis; and it was believed not only that it had peculiar virtues in counteracting the syphilitic poison, but also that without it every case of syphilis would infallibly go on from bad to worse. The modern doctrine, however, is, that every case of syphilis may he treated without mercury; that the' too profuse administration of it may render the disease infinitely i Bateman on Cutaneous Diseases, 5th ed. p. 238 ; Burgess's Cazenave, p. 88. 192 TREATMENT OF PRIMARY SYPHILIS. worse ; that there are many cases which do not admit of it at all; but that in the right cases the moderate and judicious use of mercury removes the existing symptoms, and renders the patient far less liable to a relapse. The cases in which mercury is not required or not admissible are these :— when the primary sore has been destroyed or healed within the first week ; when a chancre is inflamed, irritable, phagedaenic, or sloughing; when there is a bubo, suppurating, or about to suppurate ; when the patient is feverish; when he has been already broken down by repeated attacks of syphilis and by mercury ; when he is known to be very easily salivated; or when mercury readily produces sore throat, loss of flesh, night-sweats, or the erethismus to be presently described. If the patient is scrofulous or consumptive, the surgeon must use his judgment; but neither syphilis nor mercury seem, ac- cording to Dr. Cotton, to be special causes of phthisis; and we need not abstain from the moderate use of that remedy when the consumptive tend- ency is but slight. If, then, there are none of these contraindications, and if the sore be in- durated, the surgeon should give mercury; not because absolutely necessary to a cure, but because it has been proven by experience to hasten the cure of the primary, and to lessen the chance of secondary symptoms. Then the object is to induce a gentle mercurial action, and to maintain it long enough. And there are three modes of effecting this: fumigation, friction, and internal administration. Fumigation has been employed for a very long time as a mode of apply- ing mercurial vapor to a diseased part, and of causing it to be absorbed by the skin, so as to impregnate the whole system. For the most part, however, it was a difficult and very uncertain operation, till Mr. Langston Parker1 revived and improved it by combining the vapor of water with that of mer- cury ; but the greatest improvement is that effected by Mr. Henry Lee, who has adopted calomel as the preparation to be employed, instead of the sul- phuret or oxide which had been used previously, and which required to be used in very much larger quantity, and could not be depended on from their liability to undergo decomposition. Instead of one or more drachms of oxide or sulphuret, Mr. Lee prescribes ten grains of calomel for each fumi- gation. Of course rather more or rather less may be used at discretion. If the patient can afford it, he may buy at an instrument-maker's an apparatus consisting of a lamp so arranged as to evaporate both the calomel and some water, with an India-rubber cloak to confine the vapor. A poor man must content himself with a heated brick or tile, which may be put into a chamber- pot under a cane-bottomed chair, on which he will sit in puris naturalibus, having a blanket around his neck, enveloping the chair and himself, and retaining the vapors. The heat of the lamp or brick should be such as to evaporate the dose of calomel evenly during the ten or fifteen minutes which should be spent in the operation; not to dissipate it too soon. The fumigation should be repeated every night at bed-time, till very slight sponginess of the gums is produced, which should be maintained by regulat- ing the quantity of calomel, till (if the case goes on well) the sore has healed, and hardness of cicatrix has nearly vanished. Generally speaking, however, three or four weeks is long enough. See Erethismus, p. 194. If the in- ternal administration is preferred, five grains of blue pill should be given every night and morning, and if no effect on the mouth is produced by the sixth day, the dose at night should be doubled. The strong mercurial ointment is not so likely to disorder the bowels as the blue pill, but it is more troublesome, and is now almost an obsolete 1 H. Lee, Med.-Chir. Trans, vol. xxxix. ; Langston Parker, Modern Treatment of Syphilitic Disease, Am. ed., Phila. 1854. ILL EFFECTS OF MERCURY. 193 remedy. The dose is from 3ss—3j; to be rubbed in daily upon the inside of the thighs or arms till it disappears. The morning is the best time for doing it, as the skin is then softer. It should be rubbed on different limbs successively, the patient wearing the same drawers both by night and day. If the skin becomes irritated, it should be well washed and bathed. If the patient is too weak to rub in the ointment himself, it must be performed by a servant whose hands should be protected by a pig's bladder, well softened in oil and tied round his wrist. Meanwhile the patient should live regularly, but not too low. He should avoid all excess of food or wine, and everything likely to disorder the bowels ; his clothing should be warm, so as to keep the skin perspirable ; and, above all, he should most sedulously avoid fatigue, cold, wet, and night air. The ill effects of Mercury depend, first, on its tendency to localize itself, or to seek peculiar outlets for elimination ; and, secondly, on its tend- ency to destroy or impoverish the blood constituents. To the former category belong : 1. Irritation of the bowels, with dysen- teric symptoms, straining and tenesmus. To be treated by opium with chalk mixture ; hip-bath, and opiate enema, F. 101; omitting the mercury for a few days, and combining it afterwards with opium; and using double pre- caution against cold and damp. 2. Sore throat—Redness of the whole fauces, and ulceration of the tonsils with fever. In this case the mercury must be discontinued for the present. 3. Violent salivation.—This may be caused by a too liberal use of the remedy, or by a sudden check to the cutaneous secretion by cold and damp, or by loss of blood, or anything that suddenly lowers the system. It is, however, very common to meet with persons who are salivated by very small quantities; and every practitioner should make a point of ascertaining this before he prescribes mercury for any new patient. There is good reason for believing that a great susceptibility of salivation and tendency to Bright's disease of the kidney often go together. The symptoms of severe saliva- tion are, swelling and inflammation of the salivary glands, cheeks, tongue, and fauces, with a flow of peculiarly fetid saliva, and superficial sloughing of the surface of the gums and of the inside of the cheeks. The best local applications for this state are, gargles of brandy and water, of the solution of chloride of lime, of tannin, or of hydrochloric acid (F. 107 et seq.). The bowels should be kept open by aperients; and, as soon as fever has abated, the patient should have a good diet, and the iodide of potassium with bark may be given. The experiments of M. Melsens, showing the fact that mercury and other metallic substances may long continue in the body in combination with the tissues, and that they may be dissolved out and eliminated through the kidneys by means of the iodide of potassium, furnish a good explanation of the modus operandi of this medicine, in all cases in which mercury has been administered to excess.1 Change of air, and espe- cially removal from the venereal wards of an hospital, are indispensable.2 [By far the best treatment of mercurial stomatitis is the internal adminis- tration of chlorate of potash. From one to two drachms should be admin- istered daily, given in divided doses and largely diluted, as this salt is not very soluble. For the effects of this medicine see Ricord's Lecons sur la Chancre, p. 336, or the edition of Hunter on the venereal before cited, page 502.] ' See Dr. W. Budd's Translation of the Essay of M. Melsens, in the Brit, and For. Med.-Chir. Rev. Jan. 1853. ...,,■ 2 Dr. Macleod relates two cases of coma following the sudden cessation ot salivation; one fatal; the other cured by reproducing it. Lond. Med. and Phys. Jour. vol. lvi. p. 231. 13 194 treatment of syphilis. 4. Eczema mercuriale (Eczema rubrum, Erythema mercuriale, hy- drargyria) consists of patches of redness and inflammation, which appear first on the groins, axillae, and flexures of the limbs, and then spread over the trunk. These patches are covered with minute vesicles, which soon burst, discharging a thin acrimonious fluid, and leaving the surface exco- riated, and exceedingly painful and tender. The discharge often becomes profuse and fetid, and the affected parts much swollen and fissured. It generally lasts for ten days, but may remain for many weeks.1—Treatment. Warm bathing ; fomentations of decoction of poppies, chamomiles, or bran ; aperients, diaphoretics, and opiates, during the early stages ; subsequently, bark or sarsaparilla, and the mineral acids. Dr. Colles has described an- other and less severe form of eruption, which resembles the itch, except that the intervals between the fingers are free from it. The treatment is the same. 5. Erethismus mercurialis consists in an impoverished state of blood, and want of nourishment of the heart and brain. The symptoms are great depression; anxiety about the praecordia, dyspnoea, frequent sighing, weak and tumultuous action of the heart;—frequent sense of suffocation, dis- turbed sleep, and faintness upon any exertion, which faintness may prove fatal. In a case which the writer lately treated, calomel fumigation had been continued for eleven weeks, in order to get rid of an indurated cicatrix, and to prevent secondary symptoms; spite of which, the cicatrix continued indurated, and psoriasis had appeared when the writer saw the patient, a fortnight after the discontinuance of the mercury. The symptoms were anaemia, intense debility, sleeplessness, night-sweats, copious urine, great nervousness, palpitations on the slightest exertion, and entire impotence. This case was treated as below, and is mentioned to show that the calomel fumigation is capable of doing as much mischief as mercury in any other form, and that it is unwise to push mercury as a preventive of future symp- toms. If used judiciously it will relieve such manifestations of syphilis as exist, but cannot be always expected to eradicate the diathesis at once. Treatment—Removal to a fresh atmosphere; stimulants; tonics; and nourishment; especially decoction of bark with nitric acid ; followed by small doses of iodide of potassium.3 The non-mercurial treatment of primary syphilis consists simply in ob- serving the rules calculated to produce the highest state of health; in treating symptoms ; in relieving debility by bark, cod-liver oil, and other tonics ; and pain and irritability by opium; and in administering, if the surgeon thinks fit, the iodide of potassium, with compound decoction of sarsaparilla, which latter remedy is believed not only to restore the flesh and strength, but also to assist in eliminating the syphilitic poison. The gangrenous chancre, from excessive inflammation (when occurring in healthy subjects, with firm pulse), requires to be treated by rest, fomenta- tions, purgatives, and opiates ; in some cases by venesection. The poppy fomentation is the best application at first, and the balsam of Peru, or nitric- acid lotion subsequently, to assist in throwing off the sloughs. The ulcer which remains is usually healthy, and is very seldom followed by secondary symptoms ; therefore there is no need of mercury unless the sore begin to ulcerate (there being nothing in the general health to account for it), or unless secondary symptoms appear. But it far more frequently happens that sloughing and phagedaena are the results of broken-down health, from intemperance, or some other 1 One variety, hydrargyria maligna, now almost unknown, is attended with typhoid- like fever. Eight out of fourteen cases died. Alley on Hydrargyria, Lond. 1810. 2 Vide Dr. Bateman's case, Med.-Chir. Trans, vol. ix.; Colles' Lectures on Surgery, vol. ii. 342. BUBO. 195 source of exhaustion. For such cases the treatment has been before de- scribed. Opium largely; beef-tea, wine, good living, and tonics; opiate lotion to the sore. In some cases the local application of the mercurial vapor will check an obstinate phagedaena, or serpiginous tendency. Vide p. 92 et seq. If phymosis is present, and there is a discharge from under the con- stricted prepuce, the case may either be one of mere balanitis, or there may be a chancre under the prepuce. If there be an ulcer, it may be detected by local hardness and tenderness. Whilst there is any inflam- mation, fomentations and water-dressing must be applied, and a mild astringent lotion, F. 117, should be injected frequently between the pre- puce and the glans. The prepuce should be slit up, if the tumefaction is so great that it threatens to slough; but not otherwise. If phymosis be caused by small ulcers at the edge of the prepuce (which sometimes occur during the healing of venereal sores), they should be touched with arg. nit. or cupri sulph., or ung. hydr. nitrat As soon as the fraenum has been perforated by an ulcer, it should be completely divided with scissors. Chancre in the urethra must be treated by astringent injections ; and by mercury, if not contraindicated by any of the circumstances above mentioned. SECTION VI.—BUBO. Definition.—Bubo signifies an inflamed lymphatic vessel or gland in the groin, leading from a venereal ulcer. Causes.—It must be borne in mind—1. That any source of irritation, such as gonorrhoea, or even protracted venereal indulgence, will in certain constitutions cause swelling and suppuration of the glands of the groin, without the presence or slightest suspicion of chancre. 2. A bubo accom- panying a true venereal ulcer may be created, not by the ulcer alone, but by some added source of irritation, as caustic unluckily applied to an ulcer. 3. Bubo may be caused by the transmission along the lymphatics of the specifically poisonous secretions of a chancre ; and here, Mr. Lee observes, that for the most part a bubo arising from a Hunterian chancre will not sup- purate, and that one arising from a suppurating chancre will; that in the former case there is an almost certainty, in the latter great improbability of secondary symptoms. Varieties.—1. Bubo of the Penis consists of an inflamed lymphatic vessel on the penis, which may be felt like a quill under the skin, and may create abscess in any part of its course. 2. Acute bubo at the groin gene- rally affects only one gland, and pursues the course of an ordinary acute abscess. The cellular tissue between the gland and the skin is the common seat of suppuration, but there may also be a small abscess in the centre of the gland, arising, no doubt, from the absorption and transmission of poi- sonous matter, and the pus of this latter is alone capable of producing a chancre by inoculation. 3. The bubo which accompanies the Hunterian chancre consists generally of one gland, enlarged, inflamed, and adherent, but gradually dispersing without suppuration. [The lymphatic glands, in connection with a Hunterian or true infecting chancre, are always affected, but in place of finding one gland, enlarged, inflamed, and adherent, as Mr. Druitt says, we have always found a series, a chain of hard, movable, indolent tumors, very seldom so large as a small almond.] 4. Bubo of any kind in persons weak or scrofulous, or especially if worn out by the improper ad- ministration of mercury, will lead to slow destructive suppuration. The skin is long before it inflames, but when it does so, a large track of it becomes of a dusky-bluish tint; the matter spreads widely ; and at last large portions 196 BUBO. of the skin perish by ulceration, leaving an extensive sore that may be months in healing. Diagnosis.—If a bubo at the groin affect one gland only, and that above Poupart's ligament, it is most probably caused by chancre on the penis, pro- vided there be, or have been, one. But if many glands are swelled, and they are below the level of Poupart's ligament, the swelling is probably caused by some irritation about the foot. But the only sure diagnosis of a syphi- litic bubo is, that if the matter taken from it be inoculated, it will produce a chancre ;—or that the sore produced by opening the bubo presents the elevated edges and copper-colored margin of a chancre. As, however, every bubo is attended with suppuration of the surrounding cellular tissue, the surgeon should recollect that some of the matter taken when it is first opened may not cause chancre by inoculation. [The bubo accompanying an infecting chancre very seldom suppurates, and when it does the pus formed is never inoculable. The bubo accompa- nying a simple chancre furnishes inoculable pus, unless, as occasionally happens, the swelling of the lymphatic gland is simply inflammatory or sympathetic] It has been disputed whether the syphilitic virus may be taken up by the lymphatics and produce a bubo in the groin, without having first caused a chancre. Such supposed cases are called bubon d'emblee by the French. But though it is very certain that the inguinal glands are apt to inflame and suppurate, if a person of bad constitution indulges in immoderate sexual intercourse (especially if at the same time his health is lowered by fatigue, or irregular living), still there is little proof that such buboes are syphilitic, unless preceded by chancre. Yet it must be borne in mind that they may be produced by a chancre or patch of induration so small as to have escaped the patient's notice. Treatment.—1. The acute bubo must be treated as an acute abscess. The first indication is to produce resolution ;—by rest, aperient and saline remedies, low diet, leeches, and fomentations. [The student should be warned of the risk of applying leeches in the neighborhood of a chancre ; each bite may readily be inoculated and become itself a chancre.] The applications to the chancres must be soothing, and mercury, if being admi- nistered, should be at once given up. As soon as the tenderness is relieved, pressure by means of a compress and bandage, or by placing a weight on the part as the patient lies in bed, is useful. Even if matter does form and does not seem inclined to come to the surface, the iodine paint, cold lotions, aperients, tonics and pressure, will sometimes cause it to be absorbed. But if it increases, and the skin becomes inflamed and shining, a puncture should be made, and the case be treated as any other acute abscess. If the acute stage of inflammation has passed off, and other circumstances render mer- cury advisable, it may be resumed ; but it should not be given during acute suppurating bubo. 2. In treating the scrofulous bubo, the general health must be amended by every possible means; tonics, sarsaparilla, change of air, and especially a sea-voyage ; and cold lotions when demanded by an aggravation of heat and pain. If these measures fail, and matter forms, it must be let out by one or more punctures. Or if the skin is extensively undermined, bluish, and thin, the process of cure will be hastened by an application of the potassa fusa. In the same way, in treating the sore formed by opening a bubo, the first thing is to get rid of the loose red skin. This may be done (as soon as the part is becoming indolent and swelling is abated) by cutting it away with scissors, or by the potassa fusa. A solution of nitrate of silver is the best dressing afterwards. SECONDARY SYPHILIS. 197 Sometimes there remain one or two indolent enlarged glands projecting in the midst of the sore, denuded of skin, and incapable of forming healthy granulations. These may be destroyed by caustic in the following way :— An ounce of bread crumbs, two drachms of corrosive sublimate, and one drachm of red oxide of lead, mixed into a paste with a little water, may be made into conical troches of the shape of bread-seals ; and one of these may be inserted into a puncture in the diseased gland, which it will speedily cause to slough. Sinuses, if they are not soon healed by stimulating injections, may be slit up ; and if the ulcer become inflamed or irritable, or if it be attacked by sloughing or phagedaena, the treatment must be adopted that has already been directed for similar ulcers in other parts.1 SECTION VII.—SECONDARY SYPHILIS. The symptoms of secondary, or constitutional syphilis, generally occur about six weeks after the primary symptoms ; sometimes a fortnight, some- times not for months. Before their appearance, the patient possibly be- comes thin and wan ; he looks dispirited ; his eyes are heavy; and he com- plains of want of appetite and sleep, and of rheumatic pains. The symptoms are usually first manifested upon the skin and mucous membrane of the throat, and then upon the bones. We shall first describe these several local affections, and then the treatment of secondary syphilis generally; but syphilitic affections of the eye and testis, which generally accompany those of the throat, will be treated of in the chapters that are particularly devoted to those organs. Syphilitic Eruptions vary in degree from the slightest discoloration to the most inveterate ulcers. 1. In the mildest form, the skin is mottled and stained in irregular patches of a brownish-red color; which are caused by a slight swelling and vascular injection. A greater degree of the same de- rangement will produce syphilitic psoriasis, in which the skin is raised in copper-colored blotches, covered with scales of hypertrophied cuticle. Or there may be an eruption of papulae or pimples, varying in size from a pin's head to a pea. These eruptions are succeeded merely by scabs or exfolia- tions of the cuticle. Or there may be a copper-colored mottling of the skin around the abundant pimples of acne on the back, breast,, and shoulders. 2. Scaly Eruption (Lepra syphilitica) is an aggravated variety of the preceding. It begins with an eruption of copper-colored blotches, which become covered with scales of enlarged cuticle ; these are succeeded by scabs, and, when they fall off, by shallow ulcers with copper-colored edges. 3. Vesicular Eruption (Rupia). Large flattened bullae, filled with serum, which gradually become purulent, and finally dry into scabs, under which the Fig. 55. This cut exhibits the crusts of rupia ; from a cast in the King's College Museum. 1 [For the treatment of bubo, see the edition of Ricord's Hunter on the Venereal above referred to, p. 387.] 198 SECONDARY SYPHILIS. skin is ulcerated. The ulcers spread under the scabs, and the latter become remarkably thick from successive additions, so as to resemble oyster, or limpet shells. 4. Pustular Eruption (Ecthyma). Large prominent pustules, with a copper-colored base, leading to ulcers. 5. Tubercular Eruption. Broad, red, copper-colored tubercles, forming most frequently at the alae of the nose, or on the cheeks. They gradually suppurate, and are succeeded by deep irregular ulcers, terminating in puck- ered cicatrices, and more properly belong to the class of tertiary symptoms, in which mercury is almost inadmissible. This form of disease is most un- favorable, and usually appears at a considerable distance of time from the primary symptoms, in persons whose constitution is originally weak, or has been shattered by privation, dissipation, or frequent unavailing courses of mercury. A patch of this kind of unhealthy inflammation is apt to form on the tongue, and after a time an abscess breaks, disclosing a ragged excava- tion,, filled with orange-colored sloughs, and exuding a copious fetid discharge. If it occurs on the palate, a probe will detect bare exfoliated bone ; which rapidly perishes and leaves a hideous chasm. Mucous Tubercles (Tubercule Muqueuxr Pustule Plate Condyloma) con- stitute a peculiar eruption of the skin,, and rank among secondary symptoms, although there is good ground for believing that they are themselves conta- gious, and that their secretions are capable of producing the like eruption in healthy persons. They consist of raised patches of skin, with a red and moist surface like that of mucous membrane, exuding a thin acrid and ill- smelling discharge. The most frequent situation is the neighborhood of the genitals, or any other place where two surfaces of skin are in contact. They seem to consist of patches of psoriasis, modified by the moisture of the situation. The remedies are regular washing with soap and water ; and the use of a dilute lotion of chloride of soda or of zinc, F. 127, after which the part should be sprinkled with dry calomel. Syphilitic Sore. Throat.—1. The mildest variety is a superficial excoria- tion of the mucous membrane of the tonsils or some other part of the mouth or fauces, corresponding to psoriasis on the skin. The parts affected are swollen and sore, usually red and glazed, and stripped of the natural epithe- lium ; this state may exist in a mere patch, or may extend all over the tongue, and inside of the lips. When attended with patches of thickened copper- colored and vascular skin, and redness of the conjunctiva, and soreness of the nostrils and ears, it has a very characteristic appearance. 2. The excavated ulcer looks as if a piece had been scooped out of the tonsil. Its surface is foul and yellow, its edges raised, and ragged, and swelled. There is remarkably little inconvenience from it, and very little constitutional affection,, unless it be attended with eruption likewise. The patient has a peculiar guttural way of speaking, and often complains of pain in the ears. 3. The sloughing ulcer begins as a small aphthous spot, which rapidly ulcerates, and is attended with great pain and fever. The surface of the ulcer is covered with an ashy slough, and the surrounding mucous membrane is dark, livid, and swollen. The lingual artery may be opened by the spread of the ulceration, and the patient may die of hemorrhage, unless the com- mon carotid is tied. Syphilitic Ulcerations of the nose and palate commence with ulcerations of the mucous membrane, similar to those of the throat, which may denude the periosteum, and then produce exfoliation of the bones, with profuse fetid dis- charge and odious deformity. Ulceration of the nose generally begins with a sense of heat, and dryness, and snuffling. Syphilitic ulceration of the larynx is mostly caused by an extension of TREATMENT OF SECONDARY SYPHILIS. 199 ulceration from the palate. It is characterized by tenderness, great huski- ness of voice (which frequently degenerates into a mere whisper), suffocative cough, and expectoration of bloody purulent matter; there is great loss of flesh and strength, and life is often terminated by suffocation. Syphilitic Disease of Bone most frequently attacks the tibia, ulna, os frontis, clavicle, and other superficial bones. It commences with tenderness of the affected bone, and severe pain, which begins in the evening, FiS- ,r)6- and lasts almost all night, but ceases in the daytime. The pain is shortly accompanied with ob- long swellings, called nodes, arising from infiltration of the periosteum with lymph and serum. These swellings are rather tender; they communicate a doughy feeling, or obscure sense of fluctuation to the fingers, and the skin over them is at first pale and movable. If the disease is arrested at this stage, it causes merely a superficial deposit of rough porous bone, from the organization of the lymph effused ; or else a consolidation of the bone itself through the deposition of fresh osseous matter into its can- celli. If the disease proceed one step further, a quantity of glairy serum is effused between the peri- osteum and bone, producing an exquisitely-painful fluctuating tu- mor. If it advance still further, the bone becomes carious; matter forms between it and the periosteum; extensive exfoliations ensue ; the patient suffers severely from the pain and discharge ; and if the disease be seated on the head (in which situation it is called corona veneris), death may ensue from irritation of the dura mater, or protrusion of the brain through apertures in the skull. Such aggravated cases are fortunately, however, now very rare ; although common enough when mercury was supposed to be the only means of stopping the ravages of the disease. Diagnosis.—There is often some difficulty thrown into the surgeon's way by the denial of patients that they have ever had any primary symptoms. And this denial may be truthful enough, for a sore so small, or a bubo so slight, may have existed, that they escaped notice. If, however, the patient has a copper-colored eruption, a sore throat, falling off of the hair, enlarge- ment of the glands around the occiput, rheumatism in the joints, or peri- osteal nodes on the superficial bones, and a general faded unhealthy look, and these disorders are of recent date, and cannot be attributed to any causes connected with diet or residence, the probability is that they are syphilitic. . Treatment.__In the first place, if a venereal eruption and sore throat are ushered in with pain in the chest and febrile symptoms, it will be neces- sary to give aperients, and saline medicines, and confine the patient to the house. The warm bath will also be highly useful. When the febrile state has vanished, if the patient has never taken a course of mercury,__or if he has been subjected to an imperfect course of it for the This cut shows the ravages of syphilitic caries. From the King's College Museum. 200 TREATMENT OF SECONDARY SYPHILIS. primary symptoms,—and his constitution is sound, he may take mercury after the manner directed in the fifth section. If, under its use, the strength and general appearance are improved, so much the better; but if the patient gets thinner, weaker, and haggard, and suffers from chills or feverishness, or if his ulcers become irritable and phagedaenic, it must be given up. The corrosive sublimate in very small doses, F. 86, with bark or sarsaparilla, is useful in many protracted cases. The iodide of potassium is the remedy next in efficacy to mercury, and should be administered when the former is deemed unnecessary or inexpe- dient. The salts of ammonia, F. 197, are worth a trial. Sarsaparilla may almost always be used with advantage. It may be combined with corrosive sublimate or the iodide of potassium, or may be administered after a course of these remedies, to restore the flesh and strength. The mineral acids, especially the nitric ; sedatives, especially hyoscyamus and conium, F. 34 ; tonics, F. 1, 2, 3, 4, 5, will be all of ser- vice in protracted cases. In these the surgeon will find it necessary to change and vary his remedies repeatedly. The main object should be to improve the general look and condition of the patient; to treat symptoms j never to push a remedy, if it does manifest harm, under the vague idea that it is specific; and never to attempt to produce sudden benefit by large doses of mercury, or other violent remedies which may weaken or impair the constitution. Local Treatment.—For syphilitic eruptions, the warm, vapor, and sulphur baths will be often expedient. Obstinate patches of lepra or pimples may sometimes have their removal hastened by ung. hydr. nitratis diluted, or the ung. hydr. precipitati albi, or the ung picis. Itching eruptions may often be relieved by a weak lotion of corrosive sublimate. Ulcers must be treated according to their condition, whether inflamed, irritable, or indolent. In general, weak mercurial applications, such as black wash, or weak red pre- cipitate ointment answer best. For the common excoriated sore throat, any soothing detergent gargle will do.—F. 107, 108. When there are ulcers, it is advisable to use gargles of corrosive sublimate (F. 112) ; and when the ulcers are indolent they may be touched with the linimentum eeruginis. Mercurial fumigation may be used to the part affected. When a foul ulcer is seated on the velum, or roof of the mouth, or pharynx, or alae nasi, an attempt may be made to check its ravages, by destroying its surface and edges with acid nitrate of mercury. Ulceration of the larynx is occasionally benefited by similar fumigation, but mercury so as to affect the mouth is almost always injurious ; as it is in other cases of rapid ulceration. Sarsaparilla and sedatives, blisters to the throat, and occasional leechings, swabbing with solution of arg. nit., and the operation of tracheotomy, if the breathing becomes much embarrassed, are the necessary measures. The pain of nodes is often relieved by blisters, and so are rheumatic pains of venereal origin. Acute inflammation of the periosteum or pericranium is best treated by iodide of potassium, in doses of three grains every four hours, and Dover's powder; the use of mercury requires the greatest caution, and is only admissible if the patient has a sound constitution, and has never taken a course of it. It is peculiarly noxious when there is caries of the bones of the nose. When nodes are very tense and full of fluid, it may be necessary to puncture them, but it is better to adopt Mr. W. Fergusson's plan of subcutaneous incision, instead of direct puncture. If during secondary syphilis, the nose becomes tender or painful, the greatest benefit will be derived from the application of one or two leeches twice or three times a week to the inside of the affected nostril. At the same time the patient TREATMENT OF SECONDARY SYPHILIS. 201 should take plenty of sarsaparilla, with iodide of potassium, and should have the benefit of country air, and a nutritious diet. By these means, any fur- ther mischief will sometimes be averted. If, however, ulceration does occur, it is of the utmost consequence to remove any loose or carious portions of bone as soon as possible. Syphilis of Children.—When a man labors under constitutional syphilis it is probable that he may communicate it to his wife [if she become pregnant by him, through the medium of the foetus]; but, at all events, if the wife has it, she may communicate it to the foetus in utero. The consequence is some- times that the infant dies about the fourth or fifth month, and the woman miscarries repeatedly. Sometimes the child is born weakly and shrivelled, with hoarse cry, snuffling respiration, discharge from the nostrils, copper- colored blotches or ulcers, especially about the anus and pudenda, and aphthae in the mouth. Sometimes, again, it is born healthy, but these symptoms appear a month afterwards. Lastly, a child may be affected with primary syphilis during its birth. The parents in these cases should have a course of mercury, and be treated in other respects for secondary syphilis. Moreover, if a woman has been repeatedly delivered of dead children from the fifth to the seventh month, and if there is reasonable suspicion of a lurking syphilitic taint, even though there be no overt symptoms, a mild mercurial course (p. 192) is advisable. And for the children, the best plan is to rub ten grains of mercurial ointment daily into the axillae or soles of the feet, every night till the symptoms dis- appear. The prognosis is always favorable ; and although the symptoms are apt to recur once or twice, they are in general easily removed by a short repetition of the remedy. It seems to be extremely probable that a syphilitic infant may produce sores on the nipple of its wet-nurse, and constitutional syphilis afterwards. The sores are of the nature of mucous tubercles (p. 198), and they are most probably contagious, and capable of producing secondary symptoms. The treatment necessary is that which we have just referred to. For further particulars on this very curious question, we must refer to the before-quoted work of Dr. Egan.1 1 See also Diday on Infantile Syphilis, translated and published by the New Syden- ham Society. Many opinions regarding syphilis will doubtless be modified by new researches. For instance, Mr. H. Lee (Lancet, Jan. 25, 1859) holds that the true adhesive Hunterian chancre is most difficult to produce by inoculation on the same patient; that its secretion is not pus, but a thin serum mixed with epithelial debris ; that it may be made to suppurate by irritating applications, and that then its secretion, if inoculated, produces, not ulcers nor pustules, but little patches of adhesive inflam- mation, with a desquamating surface. PAET IY. INJURIES AND SURGICAL DISEASES OF VARIOUS TISSUES, ORGANS, AND REGIONS. * ________ CHAPTER I. DISEASES OF THE AREOLAR TISSUE. Of the diseases of the areolar tissue, the greater number have been already sufficiently described, when treating of the elementary processes of disease, and effects of injuries. We have nothing to add to our account of inflam- mation ; abscess, acute or chronic ; diffused or erysipelatous inflammation ; oedema, ecchymosis, and scrofulous ulcer. Of the inflation with air we shall speak under the head of emphysema ; and of the injection of irritant liquids under the head of extravasation of urine. This tissue is the favorite seat of a great variety of tumors, especially the fatty, painful subcutaneous, fibro- plastic and allied species, encysted, and cancerous ; for the diagnosis and treatment of which we refer to the chapter on Tumors. Cancer in this tissue, whether superficial or deep, is rare as a primary affection, and is usually of the soft variety; but no doubt many of the cases heretofore reported as cancerous have been fibro-plastic. CHAPTER II. SURGICAL DISEASES OF THE SKIN. I. Hypertrophy of the entire skin, which increases in breadth and length so as to project in pendulous flaps or ridges, is sometimes seen, and is some- times congenital. If inconvenient, the knife is the remedy. II. Warts, or Vegetations, are diseases consisting in an hypertrophy of the papillae and cuticle. (1.) The commonest variety is the wart which frequently grows on the hand or face of children, and which consists of lengthened papillae, each containing a vascular loop, and clothed with dry, hard cuticle. If necessary to interfere, warts may be snipped off, or tied, or be touched with some of the caustics to be presently mentioned; but they often return obstinately, in spite of treatment, and disappear of themselves when let alone. (2.) A second variety consists of hypertrophied papillae, clothed with thin cuticle, especially apt to come on the inside of the thighs, perineum, about the anus, within the prepuce, and in similar situations on and near the genitals of either sex, especially the female. Some are highly vascular, and easily bleed ; some are pale and indolent; some broad and flat; some tall and stalked ; all discharge a thin sour ichor; and are caused by the irritation of the discharges of gonorrhoea or of syphilis, combined with that (202) TUMORS OF THE SKIN. 203 of the natural perspiration of uncleanly persons. They may grow on the site of a healed chancre. These warts are commonly called venereal warts, because they are doubtless caused by the irritation of venereal dis- FiS- &7. charges; they sometimes also are contagious, and may produce sim- ilar warts in healthy persons. But they do not of themselves give rise to secondary syphilitic symptoms, nor do they require mercury. Treatment—If daily washing with soap and water, and with chloride of zinc lotion, F. 127, does not suffice, the most effica- cious plan is to cut off all the morbid growths with the knife or curved scissors; and apply an astringent lotion during the cica- trizing state. If they grow again, they may be touched with nitrate of silver, or some escharotic, such as one drachm of muriatic acid with three drachms of muriated tincture of iron; liquor plumbi diacetatis ; creasote, or the acid nitrate of mercury. (3.) A third variety is the wart which comes on the face or some other part of the skin of elderly persons, and, after a time, becomes the seat of epithelioma. With this may be classed the chimney- sweeper's wart of the scrotum, the warty growths which are the first stage of so-called cancer, epithelial cancer, or cancroid (or properly speak- ing, epithelioma), of the lip and penis, and the warty tumor of cicatrices, described by Caesar Hawkins, which begins as a simple wart on the site of an old scar, increases, ulcerates, throws out huge fungous masses; contami- nates the glands, and causes death by the pain and exhaustion of foul ulce- ration.1 See Epithelioma, p. 119. III. Corns are growths of thick cuticle, not merely lying upon the true skin like callosities, but penetrating into it. They are produced when the skin, situated over some projecting point of bone, is irritated by pressure or friction. Their usual seat is on the joints of the toes, and tight boots or shoes are their usual cause. They are divided into two kinds, the hard and the soft. The hard is situated on the surface of the foot, where the cuticle can become dry and hard ; the soft between the toes, where the cuticle is soft and spongy. We must observe, however, that what are called soft corns between the toes, are not always corns, but excessively irritable fungous warts, and consist of a growth from the cutis vera, not of a mere thickening of the cuticle. Treatment__The points to be attended to are, to have the boots or shoes properly adapted to the shape and size of the feet;—to wash the feet every ' Ca>sar Hawkins, Med.-Chir. Trans, vol. xix.; R. W. Smith, Dublin Quarterly Journ. Med. Sc, May, 1850; Hannover, Epithelioma, &c. Venereal warts. From Ashton. 204 TUMORS OF THE SKIN. night, and to rub the corns every morning with a little Naples soap, or some other kind of soap just moistened. If very painful they may be poulticed at night, and kept moist by day with glycerine, so that they may be kept soft and pliable, not hard and dry. If these measures be adopted, and the part relieved from pressure, the corn will soon peel off. But some feet are so misshapen originally, or the toes are so crowded to- gether by wearing small, low, pointed shoes, that it is impossible to contrive any shoes that will not press and create corns somewhere. In some of these cases the application of a plaster of thick soft leather, having a hole punched in it to receive the corn and relieve it from pressure, is a very useful device. If the corn is on the sole of the foot, a piece of felt, or small fold of flannel may be arranged so as to relieve it from pressure. For the soft corns be- tween the toes, and for very irritable corns, the nitrate of silver is the best application. When a corn inflames, and matter forms beneath it, the pain is most excruciating, and only to be relieved by paring it down and letting out the fluid.1 IV. Horny Tumors are formed by an inspissation of the matter of the sebaceous follicles, and by laminated growths of epithelium from their in- terior. They are easily removed by two oval incisions.8 V. Wens are encysted tumors, most common on the head, face, and shoulders, consisting of obstructed sebaceous glands (whose orifice may often be found in the form of a small black spot or crust), or else of erra- tically-developed cutaneous cysts. The matter contained is a collection of epidermic scales with hairs, oil-globules, and crystals of cholesterine, and has received the name atheroma or steatoma, from its resemblance to gruel or suet. Distension, suppuration, ulceration, and fungous granulation of the interior of the cyst sometimes occur. If an aperture is visible, and the tumor is not very large, it may be gently opened by a probe or director, and the contents be pressed out. Otherwise, it may be extirpated entirely by running a scalpel through it, seizing the cut edge of the cyst, and gently tearing it out with a touch or two from the knife. But two cautions are necessary. One is, not to tamper with or irritate such tumors ; and another, not to excise them when the patient is out of health, or when they are inflamed. VI. Cheloid Tumor.—This consists essentially in an hypertrophy of the tissue of the true skin, intermixed with fibro-plastic matter. It presents itself in the form of one or more projecting tumors, or of thickened reddish patches, in the substance of the skin. The most frequent situation is the chest; but such tumors are partial to the site of cicatrices (especially in people of color), and are often multiple. Occasionally superficial ulcers occur,- but in most cases this disease leads to no ill consequence. It is ex- tremely liable to return after extirpation. Iodine and arsenic should be cautiously tried, F. 94, 97.3 VII. Molluscum.—A malady consisting in the development of numerous tumors on any part of the body where hair grows ; varying in size from that of a small shot to that of an orange ; hard and painless ; either imbedded, or prominent and stalked ; sometimes exuding a milky fluid from a minute aperture; consisting according to Dr. L. Beale, of an alteration of the hair follicles, and hypertrophy of the areolar tissue. Probably the chloride of arsenic, if resorted to early, might cause diminution of the tumors (F. 97). But if one or more becomes very inconvenient, it may be cut out.* 1 Brodie, Lecture on Corns. Med. Gaz. vol. xvii. p. 775 ; Key on Bunion, Guy's Hosp. Rep. vol. i. p. 416. 2 Vide Erasmus Wilson, Med.-Chir. Trans, vol. xxvii. 3 Warren on Tumors, p. 40; Burgess's Translation of Cazenave, p. 305. Mayo's Pathology, p. 23 tional causes that gave rise to neuralgia, may also occasion every other symptom that can be produced by functional nervous disorder ; such as rigid and permanent spasm (as in wry neck), or twitching and convulsion of muscles; difficulty of swallowing and performing evacuations, owing to spasms of the oesophagus, of the sphincter ani, or of the perineal muscles; sneezing, dumbness, stammering, thirst, and affections of the sight and hear- ing. The treatment must be conducted on the same principles. 324 CONCUSSION OF THE BRAIN. CHAPTER X. INJURIES OF THE HEAD. SECTION I.—WOUNDS OF THE SCALP. Wounds and contusions of the 'scalp, be they ever so slight, are not to be neglected. For they may be followed by erysipelas, or by inflammation and suppuration under the occipito-frontalis, or within the cranium, or by suppuration of the veins of the diploe, and general pyaemia, that may easily prove fatal. Wounds should be accurately and quickly closed ; but first of all, care should be taken to wash away all foreign bodies and clots with clean water, and a bit of clean old linen, or a clean sponge. The writer will say, once for all, that sponges that have been used to wipe up foul dis- charges should never be used for recent wounds, particularly of the scalp. If used at all, they should first be thoroughly purified by immersion in weak hydrochloric acid. No part of the scalp, however torn or bruised, should be cut away. Cases are known in which almost the whole scalp has been stripped from the bone, and yet has been laid in its place, and the patient has perfectly recovered. It is wise not to use stitches if it can be avoided. Neither are they usually necessary; for the wounds may be controlled by plasters and bandages. If used, they need not go through the whole thick- ness of the scalp. It is a good plan to seal up the wound with collodion, or Friars' Balsam on lint; so as to coagulate the blood outwardly, and lessen the risk of suppuration. The patient should be confined to the bed, or to the house, and be purged, and put upon regular but not low diet. Hemorrhage from small vessels is usually controlled by closing the wound and using pressure. If a large vessel be wounded, it should be tied. Some- times a blow on the head, which has not pierced the'skin, causes an exten- sive and increasing extravasation of blood under the scalp, rendering it evident that an artery has been divided by a blow. The exact situation of the injured vessel should, if possible, be ascertained, and pressure be applied there with a small pad of lint and bandage. If suppuration threaten, which will be indicated by sallowness, chills, and dry tongue, with some amount of swelling, and if purgation does not re- move these symptoms, adhesions may be separated at any suspicious spot; or a moderate incision down to the bone be made at any part where mischief is likely to occur. Incisions are the sine qua non in suppuration under the scalp. If there is mere serous effusion in this situation, it may, if necessary, be let out by one or more punctures with a lancet. If blood is extravasated without a wound, absorption is to be promoted by moderate purgation and cold lotions; and no incision is to be made, unless positively necessary. SECTION II.—CONCUSSION OR CONTUSION OF THE BRAIN. Definition.—Concussion (commonly called stunning) signifies sudden in- terruption of the functions of the brain, caused by a blow, or other mechanical injury to the head. Symptoms.—There are two degrees of it. 1. In ordinary cases, the patient lies for a time motionless, unconscious, and insensible ; if roused and ques- CONCUSSION OF THE BRAIN. 325 tioned, he answers hastily, and again relapses into insensibility ; after a time he moves his limbs as if in uneasy sleep, and vomits, and frequently recovers his senses instantly afterwards ; remaining, however, giddy, confused, and sleepy for some hours. 2. In the more severe degree the patient is pro- foundly insensible, the surface pale and cold, the features ghastly, the pulse feeble and intermittent, or perhaps insensible, and the breathing slow, or performed only by a feeble sigh, drawn at intervals. Vomiting is an important symptom. It is not present in very slight cases, nor in very severe ones ; and its occurrence is mostly an indication of ap- proaching recovery. Consequences.—1. In cases not attended with severe lesion, the patient suffers from some degree of headache and feverishness for a few days, which may be easily aggravated into a fatal inflammation of the brain. 2. If the concussion be very severe, it may be followed by death ; and there is no doubt but that it is attended with more or less of contusion, ecchymosis, rupture, and extravasation of blood in small specks, or in larger masses ; and that in the cases formerly described, in which persons were said to have died of concussion purely, without anatomical lesion, there was some injury of the spine or disease of the heart to account for death. And the word concussion really means contusion.1 The degree of danger in any case may be estimated by the degree in which the spinal and ganglionic systems appear to be implicated. If, therefore, the pulse and respiration continue feeble for many hours ; if the eyelids do not move when irritated, and the legs are not drawn up when the soles of the feet are tickled, the prognosis will be serious. 3. Concussion is occasionally succeeded by a peculiar state of insensibility, which may last some days. The patient lies as if in a tranquil sleep ; his pulse is regular ; but on the slightest exertion it rises to 130 or 140, and the carotids beat vehemently; when roused he answers questions, but immediately relapses into unconsciousness. Some patients in this state resemble som- nambulists ; they may get out of bed, bolt the door, shave, or make water, but still are insensible to what passes around. 4. It may leave a very infirm state of the health and intellect; impairment of the memory, or of the senses, especially of smell and hearing ; and a constant tendency to inflammation, and to extravagant actions after drink or any other excitement. Pathology.__The early symptoms, it will be seen, are partly those of im- paired cerebral function, partly those of collapse, or syncope. Vide p. 33. It is commonly said that concussion may prove fatal without any injury that can be discovered by dissection; but Dr. Bright pointed out, many years a<>-o, that the brain may be studded with minute ecchymoses, the size of pin's heads. The difference of injuries, however, inflicted slowly and gently, from those inflicted suddenly and with violence, is remarkable. As Mayo long ago observed, great part of the brain of an animal may be gently and quietly sliced away with little or no effect; but if ever so small a portion be suddenly crushed, the heart stops directly.9 Treatment—The indications are : 1, to recover the patient from msensi- 1 See Mr. Prescott Hewett's Lectures, Med. Times and Gaz. 1858. 2 "The English dragoon sword is so blunt, that the strongest man cannot drive it through the head-dress of the Sikh or Afghan ; nevertheless the enemy is most often beaten from his horse, and frequently killed by the violence of the shock. Sot so, however with the trenchant blade of the Sikh ; this weapon, wielded by a strong man, will cut 'through any head-piece, and bury itself perhaps in the brain ; and yet you find no symptoms of concussion or compression. In the former example the soldier is effectually disabled, often killed outright; in the latter, although the individual is mortallv wounded, he mav be able to continue the fight, and even to kill his antagonist, before he falls himself dead or dying from his horse.''-Cole's Field Practice in India, p. 45. See also a very able paper in the B. and 1. Quarterly, Jan. 1853, by Dr. R. C. Williams. 32 G COMPRESSION FROM EXTRAVASATED BLOOD. bility and collapse; 2, to prevent inflammation; 3, to restore any faculties that may remain impaired. 1. In order to fulfil the first indication, friction of the surface with the hand, and the application of warmth to the feet, may be resorted to, if the depression is very great, and the pulse very low; but it is better in most cases to leave the patient to recover by himself, than to be officious in administering stimulants, as they would increase the effusion of blood, sup- posing the brain to be lacerated. Mr. Guthrie's sentiments on this point are very decisive. " It is useless to open the patient's veins," he observes, " for they cannot bleed until he begins to recover, and then the loss of blood would probably kill him. It is as improper to put strong drinks into his mouth, for he cannot swallow ; and if he should be so far recovered as to make the attempt, they might probably enter the larynx and destroy him. If he be made to inhale strong stimulating salts, they will probably give rise to inflammation of the inside of his nose and throat, to his subsequent great distress."1 Professor Miller has well observed, that during the insensibility from shocks the patient should be examined to ascertain what other injuries, if any, he has sustained. Broken bones, dislocations, and wounds should then be set to rights. 2. After reaction has taken place, the bowels should be freely acted on, and perfect rest and low diet should be observed. If the pulse becomes hard and frequent, and if the patient complains of pain or tightness in the head, or becomes flushed, or delirious, or stupid and comatose, if vomiting come on again, or heat of head and white tongue, blood should be taken from the arm, or by leeches or cupping from the head, the purgatives should be repeated as often as may be necessary, with saline and antimonial draughts in the intervals; and the head should be shaved and kept wet with evaporating lotions. As a general rule, after any severe blow on the head, the patient should observe a cautious antiphlogistic regimen for a month or six weeks—carefully keeping himself free from all fatigue, intem- perance, and excitement. If violent delirium or convulsions come on after an injury to the head which has been treated by copious venesection, and if they are not relieved by further depletion, or if that seems inexpedient, they would probably yield to acetate of morphia. 3. In order to remove headache, deafness, giddiness, squinting, loss of memory, tinnitus aurium, and other remote consequences of concussion, a course of mild alterative mercurials, repeated blisters, or an issue or seton, the shower-bath, change of air, and a most regular diet, are the remedies. SECTION III.—COMPRESSION FROM EXTRAVASATED BLOOD. Symptoms.—The symptoms of compression of the brain are those of apo- plexy. They are, insensibility; palsy (sometimes general, sometimes con- fined to one side); dilated and insensible pupil; slow, laboring pulse ; skin often hot and perspiring ; retention of the urine, through palsy of the blad- der ; involuntary discharge of feces through palsy of the sphincter ani; and stertorous breathing, owing to palsy of the velum pendulum palati. Sometimes, however, the pupils are contracted, and sometimes one is con- tracted and the other dilated. That side of the body is paralyzed which is opposite to the injury ; and the paralysis, like the insensibility, may vary immensely in degree. There may be every degree from mere numbness and weakness to complete loss of power ; and every degree of interruption to the mental functions, from slight 1 Guthrie, G. J., on injuries of the Head affecting the Brain, Lond. 1S42, p. 11. COMPRESSION FROM EXTRAVASATED BLOOD. 327 drowsiness, or slowness, to utter unconsciousness. Convulsions and muscu- lar twitchings or rigidity indicate generally irritation or laceration of the brain or its membranes. Causes.—Compression (surgically considered) may be produced by three causes. 1. By extravasation of blood. 2. By fracture of the skull with depression. 3. By suppuration within its cavity. The symptoms of compression from extravasated blood generally show themselves in the following manner:—The patient receives a blow, and becomes stunned and insensible from the concussion, with extremely feeble pulse and cold skin. After a while he recovers his senses ; but again in an hour or two he becomes sleepy, confused, and insensible ; with slow stertor- ous breathing, slow pulse, and dilated pupils. The symptoms closely cor- respond with those of one form of apoplexy, called the ingravescent; in which the patient suddenly feels an acute pain in the head, caused by the bursting of a bloodvessel, and becomes sick and faint—in fact, suffers from concussion. Then he recovers his senses; but shortly afterwards, as the extravasation from the ruptured vessel increases, becomes quite comatose.1 On the other hand, if a large quantity of blood is extravasated rapidly, the symptoms of compression may immediately succeed the insensibility of concussion, without any interval of consciousness. The blood may be situated, 1, between the dura-mater and skull; and if in large quantity, it proceeds most likely from laceration of a branch of the middle meningeal artery. It may, however, proceed from one of the sinuses, particularly the lateral. It is the common consequence of fracture, by which the vessels running in the grooves of the bone are torn through. 2, between the membranes. Here we may refer to p. 51, for a notice of the fact, first clearly pointed out by Mr. Prescott Hewett, that injuries are often accom- panied with extravasation within the cavity of the arachnoid ; and that the blood may coagulate, forming a thin layer, which adheres and becomes vas- cular like a false membrane. 3, in the substance of the brain. The diagnosis between the symptoms of concussion and those of com- pression is a sort of pons asinorum and bugbear to young students, who are often led to expect sharply-drawn distinctions which are seldom found in practice. Moreover, it is often confused by ideas that the injury in concussion is immaterial; whereas, as we have before said, the real con- dition of a concussed brain is one of contusion and ecchymosis, which may produce symptoms of their own. The leading points of distinction are obvious enough. 1st. The symptoms of concussion always follow the accident immediately; those of compression from effusion of blood may come on after an interval. " The first stunning or deprivation of sense," says Pott, " may be from either ; no man can tell from which ; but when these first symptoms have been re- moved, or have spontaneously disappeared, if such patient is again oppressed with drowsiness or stupidity, it then becomes most probable that the first complaints were from concussion, and that the latter are from extravasation." 2dly. In concussion the pulse is feeble, and the skin pale; and the greater the insensibility the feebler will the pulse be. In compression, on the con- trary, when reaction is^ thoroughly established, the pulse will be slow and full, and the skin hot and perspiring. 3dly. Stertorous breathing and mus- cular palsy are rare in mere concussion, common in compression. 4thly. The pupil in concussion is variable ; sometimes contracted, sometimes dilated, and not always insensible to light; in compression, it is almost always dilated and insensible. Treatment__The head should be shaved and examined, and if there is no 1 Copland, Diet., Art. Apoplexy. 3 2 S FRACTURE OF THE SKULL. sign of fracture or injury, the case must be treated as one of apoplexy; the indications being to avert inflammation, and procure absorption of the blood by cold applications to the head, a large dose of calomel, and purgatives in repeated doses. If, in spite of the above measures, the insensibility con- tinues, and the lungs become clogged with mucus, and the breath escapes from the corner of the mouth with a peculiar whiff during expiration, which are very perilous symptoms, the last resource—and under these circum- stances, it must be confessed, a very desperate one, and one which modern surgeons become daily more unwilling to resort to,—is trephining. The trephine should be rather large, because the blood is almost always found coagulated. Perhaps the inner table may be found extensively fractured, with only a mere fissure of the outer table. An exploratory incision may be first of all made at the seat of injury; or, if that be unknown, over the parietal bone on the side, opposite to the paralysis, if any. When a piece of bone has been removed, the dura-mater, in its normal state is found to be level, and of a reddish-silvery color, and it rises and falls synchronously with the motions of respiration; but if there is fluid underneath, it bulges up tightly into the aperture made by the trephine, and its motions are very indistinct or entirely lost. In this latter case a puncture should be made to let the fluid escape ; and numerous instances are on record in which, after the surgeon has punctured the distended dura-mater, and some ounces of blood have escaped, the patient has recovered his conscious- ness immediately.1 Lastly, to quote from the valuable practical remarks of Mr. P. Hewett, supposing a man to fall—from a ladder, for instance—in a fit of apoplexy, care must be taken not to ascribe to the fall the effects of the disease which preceded it. SECTION IV.—FRACTURE OF THE SKULL. Fractures of the skull are caused by great violence, such as blows or falls on the head, and gunshot wounds. If the blow be caused by a large blunt object, or by a fall on the head, it will most likely result in a widely extended fissure, running perhaps across the vault or base of the skull, and tearing arteries, sinuses, or nerves in its way; fracture of the base, for example, is common when the patient falls on his head from a height, so that the weight of the whole body tells upon the base of the skull through the spinal column. If the blow be caused by a sharp instru- ment, as a hammer, or pickaxe, or brick- bat, it will probably cause a starred de- pression confined to the seat of injury. The Symptoms and consequences of fracture of the skull depend on the con- Fracture of the skuii. ditions which accompany it; especially, 1. On the amount of concussion or of internal hemorrhage. 2. On the forcing in of portions of bone so as to compress the brain. 3. On the complication with scalp wound. 4. On the situation. 5. On the inflammation excited subsequently. 1. Simple Fracture with Depression may be ascertained by a careful examination of the shaved scalp, when, if it exist, there will be felt a de- 1 Guthrie, op. cit. pp. 39, 125 ; Brodie, Med.-Chir. Trans, vol. xiv. FRACTURE OF THE SKULL. 329 pression at one part, with a corresponding edge or projecting ridge near it. Sometimes a coagulum of blood under the scalp conveys the feeling of a sharp elevated ridge of bone : it may be known, however, by its yielding to firm pressure with the finger, and by observing that no part of the bone is below its natural level. Sometimes, too, an irregular conformation of the sutures and Wormian bones may be mistaken for fracture. Moreover, a mere driving in of the outer wall of the frontal sinuses is not necessarily attended with injury to the brain. Treatment—In a case of simple depressed fracture, if there are no symp- toms of compression, and if the patient is conscious and rational, he should be bled, purged, and kept under the strictest antiphlogistic regimen ; and then, perhaps, recovery may be completed without the slightest appearance of compression, and inflammation be averted. Even if there be slight symp- toms of compression, the same plan is to be adopted. In children, whose bones are soft and thin, great indentations and depres- sion may be produced without fracture. They are to be treated antiphlo- gistically; and if the bowels are kept well open, they may not cause any bad symptom whatever, and the bone may rise in time to its proper level. 2. If the fracture be compound, in like manner it is better not to trephine, unless there are urgent symptoms. If comminuted, and if splinters are sticking into the brain or its membranes the bone must be elevated. If possible, it should be done with the elevator alone. But if one piece of bone is wedged in under another, a small aperture should be made with the tre- phine, °or Hey's saw, in order to make room for employing the elevator. If any pieces of bone are perfectly loose and detached, they must be re- moved ; but not if they have a pretty good adhesion to the pericranium or dura-mater. 3. Fracture of the Inner Table.—This part may be splintered exten- sively by some injuries which do no great damage to the outer table; especially by sabre-cuts descending perpendicularly; musket-shots, and blows with pokers and similar weapons. When there is reason to suspect this, a most careful examina- tion should be made with the probe, and, if discovered, the trephine should be em- ployed to raise or remove any splinters that may compress or irritate the surface of the brain. 4. Fractures of the Base of the skull may run in various directions, but most frequently through the petrous, squa- mous, basi-sphenoid, and ali-sphenoid bones. The diagnosis will be founded—1. Fracture of the inner table of the skull, On the nature of the injury; for the patient sl Mary's Museum. has probably pitched on his head, and has a wound or bruise on the vertex, but no fracture there. 2. There will most probably be copious venous bleeding from one ear ; the blood coming from the diploe of the bone, being permitted to well out through the tympanum by laceration of the membrana tympani. In this case, if the mouth and nostrils be closed, air will perhaps also bubble out through the external audi- tory meatus in expiration. 3. After bleeding has ceased, a most significant symptom is the draining away through the ear of the cerebrospinal fluid from beneath the arachnoid. It is a clear fluid, hardly coagulable by heat, and containing much less albumen and saline matter than serum does. This indicates that the fracture passes through the internal auditory meatus, and has ruptured the tube of the arachnoid, which accompanies the auditory and 330 WOUNDS OF THE BRAIN. facial nerves into that meatus, and so allows the escape of the cerebro-spiual fluid. Immense quantities of it may be discharged. 4. Various symptoms may be noticed, indicating damage to the nerves that escape by the base of the skull. Thus extreme deafness points to the auditory ; paralysis of the muscles of the face, inability to close the eye tightly, and a dragging of the mouth to the opposite side, point to the facial nerve ; loss of sensibility in either half of the tongue, to the third division of the fifth ; loss of motion, to the ninth ; inability of swallowing, and slow or stertorous breathing, to the eighth; and thus the implication of these nerves shows the course of the fracture to be through their several foramina. 5. Bleeding from the nose or mouth, and great ecchymosis within the orbit, not a mere speck of blood beneath the conjunctiva, but a complete ecchymosis coming from be- hind, will also show the direction of fracture. In some cases traumatic aneurism of the orbit has followed, and has been relieved by ligature of the common carotid. In this and in other fractures of the skull the symptoms depend on the amount of injury to the brain, and so does the prognosis. Stupor, dilated pupils, with rapid pulse, hot skin, dry tongue, and delirium, are unfavorable symptoms; yet fracture of the base has been shown not to be so necessarily fatal as was once supposed ; and if there is no primary injury to the brain, if the patient is thoroughly purged and kept on low diet and in the most absolute repose, so as to arrest inflammation, he may recover.1 SECTION V.--WOUNDS OF THE BRAIN, AND HERNIA CEREBRI. I. Wounds of the Dura-mater add very considerably to the danger of compound fractures of the skull, both from the risk that inflammation may spread over the surface of the arachnoid, and from the greater chance of hernia cerebri. Hence this membrane should never be punctured in search of fluid, without due consideration. II. Wounds of the Sinuses are of no great consequence, provided the blood does not accumulate within the skull; hemorrhage from them is easily restrained by pressure. III. Wounds of the Brain, whether incised or lacerated, are not attended with special and recognizable symptoms besides those which arise from the concussion, compression, or inflammation that may accidentally be present. Instances are numerous in which portions of the brain have been lost, without any ill consequences at the time or afterwards. But yet Sir B. Brodie has observed in some cases a greater degree of mental confusion than usually attends concussion, and, in others, spasmodic twitchings of the muscles. If foreign bodies are embedded in the brain, the danger will be materially augmented. Sir B. Brodie says, that no foreign body, whether a portion of the skull or not, is to be removed, if the removal will add in the least to the irritation or injury; but the practice of most surgeons is to remove them without delay, but with as little disturbance as possible. The treatment of these cases consists in the preventing of inflammation, and in causing the wound to cicatrize without the formation of hernia cerebri. IV. Hernia Cerebri.—When a portion of the skull has been removed, the brain is liable to protrude through the aperture in the form of a rounded 1 See Guthrie, op. cit.; Sharp on Injuries of the Head, Lond. 1841; MM. Laugier, Robert, and Chassaignac, in Ranking's Abstract, vols. ii. and iii.; Mr. Hilton's excellent Clinical Lectures, Lancet, 1853, vol. i.; and Prescott Hewett's Lectures, Med. Times. 1855 and 1858. [See an excellent paper by Thomas Bryant, in Guy's Hospital Reports, third series, vol. v., and the Ainer. Jouru. of Med. Sci., January, lb60, p. 183.] TRAUMATIC inflammation OF TnE BRAIN. 331 tumor, styled hernia or fungus cerebri. Mr Guthrie describes two varie- ties of it. In the first, which occurs within two days, the tumor is composed of coagulated blood, and is caused by hemorrhage into the brain near its surface. It is accompanied with delirium and phrenitis, and is generally fatal. The best treatment is, to shave it off level with the surface, so as to permit a free discharge of blood. The other kind of tumor consists of brain itself, infiltrated with lymph. If the dura-mater is still entire, the tumor causes it to slough by its constant pressure, and then protrudes through the aperture in the skull. As it increases in size, it suffers constriction from the aperture through which it passes, and sloughs ; but is speedily succeeded by a fresh growth of brain and of fungous granulation, which undergoes the same processes, till the patient dies of the irritation. Treatment—In order to prevent this tumor, a well-regulated pressure, just sufficient to afford a natural support, should be made upon the brain by means of compresses of soft lint oiled, in all cases when the skull is per- forated. If the fungus has already protruded, the best application is liq. calcis, with which the lint may be wetted. If this fail, and the degree of pressure requisite to prevent increase cause symptoms of cerebral oppres- sion, the part should be shaved off level with the scalp, and any further growth be prevented by the liq. calcis and lint, and pressure, as before. SECTION VI.—TRAUMATIC INFLAMMATION OF THE BRAIN. General Description.—Inflammation of the brain and its membranes rarely makes its appearance till a week after an injury, frequently not till three weeks, or even later. Its symptoms and progress are very various ; sometimes sudden, violent, and soon terminating in destructive suppuration ; sometimes slow, insidious, and unsuspected, till suddenly manifested by fatal coma or palsy. Symptoms.—First stage.—The patient complains of tightness and pain in the head, aggravated by heat, motion, and anything that causes excitement of mind or body, together with a disagreeable sense of languor or weakness, confusion of ideas, quick pulse, disturbed sleep, nausea, and want of appe- tite, and alternate flushing and paleness. Second stage.—The symptoms having lasted a day or two, there comes on a violent rigor, followed by burning heat of the skin ; the pulse is hard and frequent; the carotid and temporal arteries pulsate vehemently; the headache becomes most intolera- ble and throbbing, the pupils are contracted ; light is unsupportable to the eyes, and sound to the ears; the tongue is dry, the bowels obstinately cos- tive,' and the stomach rejects everything with frequent retching. Besides these symptoms, violent delirium or convulsions come on at intervals, or perhaps coma. If they are unrelieved, the third stage soon follows. The pulse loses its force, and becomes either slow and oppressed, or excessively rapid ; and squinting, low delirium, convulsions, or palsy, soon usher in death. Rigors, followed by squinting, dilated pupil, stertorous breathing, coma, and palsy, are indications of suppuration. Certain changes on the outside of the head also accompany the mischief that is going on within. Supposing the injury which is the cause of the inflammation to have been accompanied with a wound, which up to the occurrence of the inflammation has been going on well—to use the words of Pott " the sore loses its florid complexion and granulated surface, and be- comes pale, flabby, glassy, and painful; instead of good matter, a thin gleet is discharged from it; the lint with which it is dressed sticks to all parts of it • and the pericranium, instead of adhering firmly to the bone, separates all'round from it to some distance from its edges." The bone, moreover, may become white, dry, and bloodless. , If there be no wound, the scalp will 332 TRAUMATIC INFLAMMATION OF THE BRAIN. present a puffy, circumscribed, indolent tumor at the seat of injury, on incising which the pericranium is found detached. If the dura-mater is exposed, it at first appears of " a dull, sloughy cast, and smeared over with something glutinous," and subsequently is covered with matter. Pathology.—So far we have described the classical or heroic form of acute encephalitis. But many cases will be met with in which the order of symptoms is very irregular. Thus, in the first place, severe and continuous vomiting may be the earliest symptom, without any complaint of the head ; or a sudden attack of convulsions, or of furious delirium ; or a sudden palsy, owing probably to insidious mischief which betrays itself when too late ; or pains in the head of an intermitting character ; or severe shiverings, termi- nating in a hot and sweating fit;—and many of these symptoms may occur without any fixed or regular signs of inflammation being betrayed by the pulse. Again, injuries of the skull are liable to be followed by pyaemia, with abscess in the lungs, liver, or joints, and the other signs of that affection. This may occur from mere bruises which have injured the diploe, without fracture of either table, and without wound. Sleeplessness, wild intermit- ting delirium, and sudden suppression of a flux of cerebro-spinal fluid from the ear, after fracture of the base of the skull, especially if accompanied by hot skin, quick pulse, and rigors, are very suspicious symptoms. Morbid Anatomy.—The morbid appearances usually found are suppura- tion in the diploe ; clots in the sinuses; exudation of yellowish or greenish lymph on the free surfaces of the dura-mater and arachnoid, covering per- haps extensive tracts, and perhaps partially or entirely converted into pus; similar exudation beneath the arachnoid; serous effusion into the ventricles; softening, or abscess of the central part of the brain or cerebellum. Prognosis will be unfavorable if the malady is not promptly relieved by depletion, or if it has advanced to its second stage. Treatment.—The prevention of inflammation after injury depends chiefly on the most perfect quiet of mind and body, which may be insured by Dover's powder or opium ; by free purging ; a moderately low diet; and the appli- cation of cold to the head. The earliest symptoms are to be combated by free bleeding and leeching, with cold to the shaved head, and purgatives with antimony. If exudation seems to be pouring out, as indicated by the persistence of the symptoms, in spite of depletion, the remedies are mercury given so as to affect the system—for instance, two grains of calomel every six hours ; blisters to the head or nape of the neck ; mustard cataplasms to the feet; terebinthinate or stimulant enemata; and trephining, if suppura- tion is indicated by symptoms of compression (and especially by palsy of the opposite side of the body), or by the above-mentioned state of the wound. The «trephine should be large, and if the matter be seated between the dura mater and skull, it may afford relief. But so capricious are the symptoms of injury and disease of the brain, so difficult the diagnosis, so impossible is it to be always sure of the precise seat of mischief,. and so inherently dan- gerous are these injuries necessarily, that the trephine may not lay bare the real mischief, or even, if it does, may give no relief. Abscess in the brain, or softening, may be very remote consequences of injury, not occurring perhaps for years. Their symptoms are very obscure and insidious. Occasional headache ; general loss of health and strength ; impairment of the memory or other mental faculties; quick pulse, and furred tongue; disorder of the eyes or ears; sense of constriction, or of coldness in the scalp, or of creeping in the limbs, with numbness, are the most fre- quent. But these are succeeded by sudden convulsions, or palsy, or coma, from which the patient soon dies, although he may perhaps recover for a time. Treatment.—Blisters, issues, or setons ; mercurial alteratives; purgatives; TREPHINING and paracentesis. 333 shower-baths ; the most regular diet, and avoidance of every kind of excite- ment of mind or body, are the remedies in case mischief is expected. After the occurrence of palsy, or other decided symptoms, blisters; leeches, if the pulse is strong enough, and there is pain or heat in the head; purgatives and enemata. But if the patient is low and feeble, he must be supported by mild nutriment and stimulants, especially ammonia. In the first place, the [Fi-. 183. SECTION VII.--TREPHINING AND PARACENTESIS. I. Trephining.—The apparatus requisite for this operation comprises a large and small trephine, a straight and curved Hey's saw, and an elevator —besides a good scalpel, and the other instruments which every surgeon is supposed to have in his pocket. There are four cases which may require this operation. 1. Fracture of the skull with depression of bone. 2. Extravasation of blood under the skull. 3. Suppuration of the dura mater. And, lastly, occasional cases of epilepsy arising from the irritation of a diseased spot of the skull. For the first and last cases, the trephine should be quite small, so as not to sacrifice more bone than is absolutely necessary. Supposing it to be a case of depressed fracture. bone, if not already laid bare by a scalp wound, must be exposed by an incision in the shape of a V, or H, or T. Then, perhaps, some loose fragments may be picked out, or a pro- jecting point may be cut off with a Hey's saw, or with bone forceps, that will enable the sur- geon to raise the depressed portion. But if this cannot be done, a circular piece, consist- ing of the edge of the depressed bone, and of the adjoining bone under which it has been wedged, must be removed. The pericranium being shaved off from the part which is to be perforated, the surgeon applies the trephine, and works it with an alternate pronation and supination of the wrist, and when it has made a circular groove deep enough to work in steadily, he takes care to withdraw the centre pin. He saws on steadily and cautiously pausing frequently and examining the groove with a probe, to ascertain whether it has reached the dura mater, and when it has, he introduces the elevator to raise the circular piece of bone. He must be particularly careful to fix the centre pin, and the greater part of the circum- ference of the instrument, on firm bone—and by no means to press heavily, whilst sawing, on any piece that is loose or yielding. The saw will be known to have reached the diploe by the escape of blood with the bone-dust; but it must be recollected that the diploe exists neither in children nor in the aged When the piece of bone is removed, the surgeon must gently insinu- ate the point of the elevator under that which is driven in, and using his fiuo-er or the edge of the firm bone as a fulcrum, must carefully raise it to its°pr'oper level. Then all loose fragments having been removed, and the wound sponged clean, the scalp must be carefully laid down, and the patient be put to bed. The trephine should not be applied in the course of the sutures nor over the lower part of the frontal or occipital bones, if it can be avoided ; but, if necessary, there is no great objection. II Paracentesis Capitis, or puncture of the head, is an operation that Application of the trephine.] 334 DISEASES AND DEFORMITIES. has been resorted to in hopeless cases of hydrocephalus in children. It con- sists in introducing a very fine trocar or grooved needle perpendicularly to the surface, through the anterior fontanel, as far as possible from the longi- tudinal sinus. When two or three ounces of fluid have escaped, the puncture should be carefully closed, and moderate support be applied to the head by bandages. If the child becomes faint, it must be kept in the recumbent posture, and have a few drops of sal volatile. The operation may be repeated at intervals of two or three weeks.1 SECTION VIII.—TUMORS. I. Tumors of the Scalp are most frequently cutaneous cysts, see pp. 118, 202, 221; or vascular tumors. II. Tumors of the Bones are apt to be of most ivory-like density. If near the orbit, so as to interfere with the eye, or if very disfiguring, they may be removed. III. Tumors within the Cranium, that concern the surgeon, are usually fibro-plastic, or soft cancer, arising in the bone or membrane, and perforating the skull. Other enlargements, such as aneurisms, or hydatids, will produce similar symptoms at first. The earliest symptom is generally intense, long- continued, and frequently returning headache. Then there may follow the signs of compression, in the form of gradually-increasing mental imbecility, and palsy of the limbs. Sometimes the patient is cut off with a sudden attack of hemiplegia. But if he survives long enough, the growth makes its way outwardly, perforates the skull, and appears as a soft lobular tumor. Attentive examination may perhaps detect two kinds of pulsation in it; one synchronous with the arterial pulse, the other with the rise and fall of the brain in respiration. The tumor cannot be moved laterally ; but in its earlier stages may perhaps be returned into the skull, giving rise, when returned, to symptoms of compression of the brain which subside when it is permitted to protrude again.—See p. 115. The treatment must be palliative ; leechings, purgatives, and moderate diet. Any interference with the knife is almost sure to be fatal.* CHAPTER XI. DISEASES AND INJURIES OF THE SPINE. SECTION I.—DISEASES AND DEFORMITIES. I. Lateral Curvature from debility of the bones, ligaments, and muscles, is exceedingly common in this country in young females from about the age of ten to sixteen. The first thing that attracts attention is a projection, or, as the vulgar say, a growing out of one scapula, or of one side of the bosom, or an elevation of one shoulder, most commonly the right. On examination, the spine is found to be curved like an italic y, and somewhat twisted on its long axis. The right shoulder and the right side of the chest are unnaturally high and rounded, whilst the opposite is depressed and concave. In the same way the left hip projects, whilst the loins on the right side are curved inwards. 1 See Dr. Watson's Lectures in the Med. Gaz. for March, 1841. 2 See Lebert, su*- les Mai. Cancereuses, &c. DISEASES OF THE SPINE. 335 [Fig. 184. Lateral curvature of the spine.] Causes.—This affection is readily caused by occupations or postures that tax one side of the body more than the other; especially the habit of standing at ease on the right leg, with the left knee a little bent; a common habit with all persons who stand long. By this means the left side of the pelvis is thrown up, and the right shoulder raised. Awk- ward one-sided postures in sitting whilst writing, or at needle-work, are also causes. We may add, that there are some circumstances which may possibly cause distortion, even in the healthiest adult; such as one leg being shorter than the other, or walking with a wooden leg. Why one-sided postures should cause distortion must be evident, when it is con- sidered that the intervertebral substance is com- pressible, to such an extent, that an adult man of middle stature loses about an inch of his height after having been in the erect posture during the day, and does not regain it till after some hours of rest. " Since the united thickness of the interverte- bral substance in an adult man is about 3.875 inches," we see that they lose nearly one-fourth by compres- sion, which they do not recover till after some hours of rest. But if the weight of the body falls unequally on the spine day after day, it must be evident that they will become compressed on one side more than on the other; and that if their elasticity be impaired, and the muscles and ligaments be weak, and the bones soft, as they are in young persons who have not a sufficiency of fresh air, wholesome food, and active exercise, this lateral distortion will become permanent.1 Curvature from Rickets.—There is another form of curvature from de- bility, which chiefly affects young children of the lower orders, and arises from rickets. It is readily distinguished by the general rickety aspect of the patient (vide p. 214), and by the distortion of the limbs that is also present, as well as by the circumstance that the spine is not simply curved laterally, as described above, but is often curved directly forwards ; the seat of this curvature being the upper part of the back; or perhaps it may be curved backwards. Treatment.—The first and most essential measure is to strengthen the bones and muscles, by means of good diet, sea air, steel, cod-liver oil, or phosphate of lime, F. 201; the shower-bath ; sluicing the back with cold salt and water in the morning; a hard mattress instead of a soft feather- bed ; early rising, and abstinence from books. 2. Whilst the back is weak, it ought never to be subjected to the dead-weight of the body.3 The pa- tient should take as much out-door, foot, or horse exercise as her strength will allow; but when not moving, she ought to be lying down on the floor, or on any convenient hard couch, and not sitting or standing up- right. 3. A gentle course of gymnastic exercises, calculated to bring the left arm into play, may be useful. 4. Mechanical support may be required in severe cases; and the best way of applying it seems to be by a circular well-padded iron girdle, to be buckled round the pelvis, to which is attached 1 Bishop, Lancet, 1846, vol. i. p. 215. 2 Jackson, the pugilist, used to say that he knew an infallible plan for making any child crooked; viz., Let it bolt its victuals and stand on one leg. Mayo's Philosophy of Living. 33G ANGULAR CURVATURE. a crutch, by which the axilla of the depressed side can be supported and gradually raised, whilst a broad hand passes over the convex side of the chest, and forces it back into its proper position. Fig. 185. The author has devised a chair, with sup- ports for the shoulders, so that they can be kept at the same level, and in the same ver- tical plane ; whilst it allows of free motion of the body backwards and forwards.1 [One of the very best ways of straightening the vertebral column in these cases of lateral curvature, when there is no disease of the bone, is to force the patient to pull the spine in the contrary direction by his own muscles. As Mr. Druitt says, the distortion may oc- cur even in the healthiest adults by one leg being shorter than the other, the reason of which, as it is very easy to see, must be this, that to maintain the centre of gravity canes of the vertebra. of the body in a proper position the spine must be curved toward the longer leg. In cases of lateral curvature of the spine, therefore, increase the length of that leg which is on the side of the body opposite to the direction of the curve, so that to avoid being tilted over when standing on his feet, the patient must straighten the spine. This can readily be effected by increas- ing the thickness of the sole of the shoe worn on that side, by inserting into it a piece of cork. This, simple plan was first recommended by M. Nelaton, and we have used it ourselves with perfect success.] II. Angular Curvature (Pott's Curvature) is produced by softening and absorption, or caries of the bodies of the vertebrae—a disease which generally affects scrofulous children or adults. It usually begins with symp- toms that indicate irritation of the spinal cord, such as weakness, coldness, and numbness of the legs, and incapability of making exertion; and these symptoms are followed by twitchings and spasms of the legs, and afterwards by palsy. The bowels are costive ; and there is difficulty sometimes of pass- ing, sometimes of retaining, the urine, which is generally pale and alkales- cent. Children rarely complain of much pain or tenderness in the back; but if the patient is an adult, there is generally a heavy dull aching pain, aggra- vated by motion, together with great tenderness on pressure ; and a peculiar dead sickening sensation like that of a carious tooth, if a smart blow be struck on the diseased part with the knuckles. Great distress is sometimes caused if the patient seats himself quickly (or bumps down into a chair, as the vulgar say), so as to shake the spinal column ; and this will sometimes elicit a complaint from children, who give no other sign of pain or tender- ness. If the disease is situated in the dorsal vertebrae, it will moreover be accompanied with tightness of the chest, and difficulty of breathing ; and if in the cervical, one or both arms may be palsied, and there will be a diffi- culty of supporting the head, which the patient steadies with his hands whenever he moves about. As the disease advances, the trunk becomes curved forwards, and the spinous processes of the diseased vertebrae project backwards; so as to cause great deformity. Perhaps abscesses, of the chronic scrofulous sort, form, and if so the patient will exhibit great con- stitutional derangement and hectic. Consequences.—1. In favorable cases, the diseased bones collapse and are anchylosed, as after ulceration of the cartilages of joints; abscesses, if 1 It is made by Spratt, of Brook-street, Hanover-square. DISEASES OF THE SPINE. 337 they form, are healed, or their matter is absorbed ; and the patient recovers in two or three years, with more or less deformity, which is of course incura- ble. 2. In some fatal cases the patient dies suddenly from two or three of the diseased vertebrae giving way, and crushing the spinal cord ; or from dislocation of the odontoid process, owing to ulceration of its ligament; or from the bursting of abscesses into the spinal cord ; or from their bursting into the pleura or peritoneum ; but more frequently death is caused by slow irritation and exhaustion, consequent on the formation and bursting of psoas or lumbar abscesses. Diagnosis.—This affection must not be confounded with hysteria. It may readily be distinguished from the distortion which arises from debility by noticing that the curvature is abrupt and angular, whereas in the latter affec- tion it is gradual and rounded, and implicates nearly the whole spine. Treatment.—1. Rest in the horizontal posture is absolutely necessary. But the patient must not be taught to lie on his back, nor must any means be used with a view of straightening the spine, as they would merely impede the natural process of recovery, by preventing the remains of the diseased vertebrae from falling together. A bandage containing strips of whalebone, and reaching from the head to the hips, is of use in keeping the. trunk at per- fect rest, 2. Issues may be made and kept open with caustic on each side of the spinous process of the diseased vertebrae, if there is any irritation of the spinal cord. In scrofulous cases they do no good. Leeches may relieve occasional accessions of pain or tenderness. 3. At the same time, the con- stitution must be thoroughly supported by good diet, and by cod-liver oil, sarsaparilla, phosphate of lime, F. 201, or bark with lime-water, and steel, and other tonics and alteratives, as directed for scrofula. 4. Efficient me- chanical support during convalescence is necessary. III. Lumbar and Psoas Abscess.—These are abscesses arising commonly from that diseased condition of the spine which has just been described, although abscesses may occur in the same situation from constitutional de- bility and other causes, without spinal disease. When the connections of the various muscles and fasciae to the spine are considered, the variety of courses which these abscesses take is very intelligible. Sometimes they point in the back (constituting lumbar abscess, if low down); sometimes the matter makes its way between the abdominal muscles, and may point at any part of the abdominal parietes; sometimes it enters the sheath of the psoas muscle, passes downwards in its sheath, causes absorption of that muscle, and points below Poupart's ligament, forming a tumor which diminishes or disappears when the patient lies down, and receives an impulse on couching. This is called psoas abscess. In some few cases it does not extend" below Poupart's ligament, but can be felt through the abdominal parietes as an oblong tumor in the situation of the psoas muscle ; in other cases it extends downwards into the thigh, on either side, or in front of the femoral vessels. Sometimes it reaches so low as the knee ; sometimes passes backwards to the nates; sometimes through the pelvis and sacro-sciatic notch to the nates ; and sometimes it has discharged itself through the bladder or rectum.1 In all cases of doubtful diagnosis the evidence of dis- ease of the vertebrae, and of rigidity of the psoas muscle, or of inability to ' See Stanley, op. cit. p. 331. Mr. Stanley points out the diagnosis between the psoas abscess and the iliac abscess ; which latter is a collection of matter in the cellular tissue between the peritoneum and the fascia iliaca, or between that fascia and the iliacus muscle. It generally arises from cold, strains, or falls, or from general debility ; sometimes from spinal disease, but it is not so regularly connected with the last cau*e as psoas ab-cess is. It generally attacks adults, and often women after parturition. It usually points above Poupart's ligament, near the anterior superior spine of the ilium ; and the difficulty of extending the thigh, so constant in psoas abscess, is absent. 22 338 SPINA BIFIDA. hop on the leg of the diseased side, or to extend it fairly on the pelvis should be looked for. The diagnosis is further alluded to in the chapters on Aneu- rism and Hernia. Treatment.—The first indications are, to procure absorption of the matter, to keep up the health, and to remedy the spinal disease. If the tumor en- larges, and threatens to burst in spite of these measures, it must be treated in the manner directed for large chronic abscess. IV. Acute or Subacute Inflammation of the spinal cord may be caused by blows, by twists, or other injuries, and may occur during acute rheumatism ; moreover, it not unfrequently attacks persons who are greatly exposed to cold and wet, such as laborers and prostitutes. It is not uncom- mon in hot climates in the form of peculiar diseases, called barbiers and beriberi. Fever, violent pain in the back, and complete paraplegia, with loss of power over the rectum and bladder, are the symptoms. The treat- ment must consist of bleeding or cupping ; calomel to affect the mouth, and subsequently blisters and warm baths. In subacute and chronic cases the iodide of potassium; with colchicum or alkalies if indicated by the state of the urine ; or the bichloride of mercury with tincture of bark, F. 87. V. Spina Bifida, or hydrorachitis, is an affection in which the spinous processes and laminae of some of the vertebrae are cleft or deficient. The spinal membranes, deprived of their ordinary support, yield to the pressure of the fluid which they contain (which also is secreted in unusual quantity), and bulge out, forming a fluctuating tumor in the middle line of the back. Pathology.—This affection evidently has its origin in the earliest stage of foetal existence, and depends on an arrest of development of the neural arches of the vertebrae, and generally of the lumbar and sacral. It is found, on dissection, that not merely the spinal membranes are distended, but that the nerves or the cord itself may have very important connections with the sac. "If the tumor," to use Mr. Prescott Hewett's words, "corresponds to the two or three upper lumbar vertebrae only, the cord itself rarely deviates from its course, and the posterior spinal nerves are generally the only branches which have any connection with the sac. But if the tumor occupies partly the lumbar and partly the sacral region, then generally the cord itself and its nerves will be found intimately connected with the sac. M. Cruveilhier believes from his dissections that this connection is constant." This is well illustrated by the sketch (Fig. 186) of a preparation in the St. George's Hospital Museum, made by Mr. Hewett, who kindly obtained permission for the author to have the drawing made. The patient was five months old, and died under Mr. Tatum's care. The cavity of the tumor is seen to be intersected by the cord, and by the nerves emanating from it. The cord and its nerves passing out of the spinal canal at the upper part of the opening, run across the cavity of the tumor to its posterior wall, where they are firmly fixed, the nerves being here flattened and spread out upon a fine membrane. From the sac, the anterior branches of the first four sacral nerves return in distinct bundles, forming large loops, to the anterior sacral foramina, through which they pass as usual to form the sacral plexuses. The fluid had evidently been effused between the visceral arachnoid and pia mater; and the walls of the sac were formed by the visceral and parietal arachnoid and by the skin, all of which were much thickened, and firmly united to each other. In cases like this, in which the cord and its nerves pass through the cavity of the tumor, it is probable that the fluid was originally effused in the sub- arachnoid cellular tissue, after partial adhesions had formed between the cord with its nerves, and the two layers of arachnoid covering its posterior sur- face. But in some cases the cord and its nerves are found spread out upon the posterior wall of the sac, without passing through its cavity ; and in diseases of the spine. 339 these most probably the fluid was effused into the subarachnoid cellular tissue, after extensive adhesions had united the cord and its nerves to the Fig. 186. Fig. 187. Spina bifida, dissection of. Tumor found in spina bifida. two layers of arachnoid covering its posterior surface. Whereas, if the fluid be effused into the cavity of the arachnoid, before any adhesions form between the two layers of that membrane, no nerves will, in Mr. Hewett's opinion, be connected with the sac. Terminations.—The tumor formed by a spina bifida, may vary in size from that of a turkey's egg to that of an adult head ; and its integuments may be thick and covered with a dense cuticle, or may be thin and transparent. In some cases the tumor bursts during the act of birth ; in most others, after the patient has lived some months or years, it becomes enormously distended, and ulcerates, the patient speedily dying of the irritation. In one case, of a young woman, aged 27, which came under the author's observation some time a«-o, and which was afterwards under the care of Mr. Walsh, the tumor relieved itself, when distended, by the exudation of a watery fluid through a minute aperture. In some few cases the patient lives to the ordi- nary span of life, without being much troubled with the deformity. There is, further, a great variety in the amount of inconvenience attending it. Sometimes it is combined with congenital hydrocephalus; sometimes with club-foot; sometimes with more or less palsy of the legs, or incontinence of urine (which symptoms are easily accounted for by the wasted and com- pressed condition in which the cord and its nerves are often found), whilst in other cases there are none of these inconveniences, unless the tumor is compressed or inflamed. Treatment__We have been thus minute in describing the real nature of this disease, in order to deter the surgeon from hazardous attempts at curing what must almost inevitably be an incurable malady. We read of cases in which the tumor has been cut off, and the edges united by twisted suture ; or in which it has been included in a ligature and tightly tied ; but these plans will not be readily adopted by any one who would rather not open the spinal membranes, or injure the cauda equina. The operation of puncture, too is generally followed by speedily fatal results. Therefore, we think the 340 INJURIES OF THE SPINE. surgeon's wisest plan is, merely to apply moderate support by means of a hollow truss, or some such contrivance, so as to counteract that tendency to effusion which there always is when the natural support of any part of the body is taken away.1 If the swelling increase very fast, and the surgeon is inclined to try the effect of a puncture, he should at all events strictly observe the following'rules laid down by Mr. P. Hewett. 1st. " The tumor should never be punctured along the mesial line, espe- cially in the sacral region ; for it is generally at this point that the cord and its nerves are connected with the sac. The puncture is to be made at one side of the sac, and at its lowest part, so as to diminish the risk of wound- ing any of the nervous branches. 2d. " The instrument ought to be a needle or a small trocar; for, if a lancet is used, there will be a greater risk of wounding some important part contained in the cavity of the tumor."3 After puncture, very great attention should be paid to proper support by bandages. VII. Cancer of the Spinal Column. When severe and continued pain in some part of the spine, and more or less derangement of the nervous functions, and perhaps some perceptible tumor, occur in a patient affected with cancer, the probability is, that some of the morbid growth is deposited in or near the vertebrae.3 SECTION II.--INJURIES OF THE SPINE. I. Concussion.—Violent blows or bendings of the spine are liable to pro- duce very serious injury to the spinal cord. Sometimes they cause an im- mediate paralysis of the parts below the seat of the injury, which gradually passes off, and thus resembles the effects of concussion of the brain; some- times they are followed by inflammation, which requires prompt antiphlo- gistic measures, in order to avert permanent paraplegia or death. II. Extravasation of Blood.—A severe blow on the back sometimes causes an extravasation of blood into the spinal canal, which, as it increases, causes compression of the cord, and paraplegia. III. Dislocation and Fracture.—Dislocation of the spine is rare, ex- cept in the cervical region, but it occasionally does occur even in the lumbar [Fig. 188. Fig. 189. Fracture of the vertebra.] Interior of the spinal canal in fracture of the vertebra. 1 See a successful case treated by Sir A. Cooper in this way, Med.-Chir. Trans, vol. ii. 2 See cases of spina bifida, with remarks by Prescott Hewett, Lond. Med. tiaz. 1844. 3 Caesar Hawkins, Med.-Chir. Trans, vol. xxiv. INJURIES OF THE SPINE. 341 and dorsal without any accompanying fracture. [According to Mr. Bryant, dislocation of the spinal vertebrae is not so exceedingly rare an accident as is generally taught. In the paper above referred to, under the head of injuries of the head, are recorded twenty-four cases ; six of these were cases of pure dislocation, three were cases of fracture, and the remaining fifteen were cases of fracture and dislocation combined. It should be added, moreover, that in dislocation of the vertebrae, as a rule, the upper vertebra is the one thrown forward.] When fracture occurs, it generally passes transversely across the body and arch of the vertebrae. The ill consequences of these accidents will, of course, be proportioned to the amount of injury inflicted on the spinal cord; and if that escapes compression, the consequences may not be serious. Thus it may happen that one or more spinous processes may be broken off; or that the cervical vertebrae may be twisted round ; and the last dorsal and first lumbar vertebrae have been displaced backwards, the patient recovering with permanent deformity, but nothing worse.1 But it more frequently happens in fracture and dislocation of the vertebrae, that the spinal cord is compressed or lacerated, and the parts below the seat of injury deprived of their nervous influence ; and in these cases the symp- toms vary, according to the level of the injury. If the injury affect one of the lumbar or lower dorsal vertebras, the legs and lower part of the trunk are palsied and insensible, the penis is erect, the feces are discharged involuntarily, owing to palsy of the sphincter ani; but the urine cannot be voided voluntarily, owing to palsy of the muscular coat of the bladder. Immediately after the injury, the secretion of urine is diminished, but in a few days it becomes copious, ammoniacal, and offensive, and the mucous coat of the bladder inflames, and secretes a quantity of viscid adhesive mucus. The bowels are distended with wind, and obstinately costive ; in protracted cases the evacuations become black, treacly, and ex- tremely offensive. The temperature of the palsied parts at first rises—in one case so high as 1110 F.—but afterwards sinks to the natural level, or below it. In some few cases, in which the spinal cord is not entirely com- pressed or lacerated, the patient may retain some degree of sensation or motion, or may suffer from painful spasms of the legs ; but in general the loss of feeling and motion is complete. If the fracture or dislocation be high in the back, or at the lower part of the neck, there will, in addition to the above symptoms, be palsy of one or both arms, and great difficulty of breathing, especially of expiration, be- cause the intercostal and abdominal muscles are palsied, and the diaphragm has no antagonist. If the injury be above the origin of the phrenic nerve (fourth or fifth cervical), the diaphragm will be palsied, and death instantaneous. The most frequent example of this is the dislocation of the odontoid process, which is sometimes caused by ulceration of its transverse ligament, some- times by blows on the back of the head, or by lifting a child up by the head. IV. Softening is a frequent consequence of concussion or laceration of the spinal cord. The affected part becomes pulpy and diffluent, without, however, any traces of inflammation. V Acute Inflammation of the spinal cord is a very rare consequence of injuries, except penetrating wounds, which generally prove speedily fatal in consequence. It is known by rigors, delirium, twitchings, and numbness of the limbs ; difficult and quick breathing ; tympanites of belly ; followed by paralysis of legs, possibly of arms; perhaps general convulsions and coma. Suppuration has been found along the whole of the spinal canal, i Guerin, L'Experience, Dec. 3, 1840; Shaw, Med. Gaz. vol. xvii. p. 936. 342 INFLAMMATION of the eye. and the pus has been known to make its way along the sheaths of the nerves, so as to form considerable collections amongst the muscles.1 Prognosis.—If a fracture is situated high up, so as to affect the respira- tion, the patient rarely survives more than a day or two. If it is situated in the lower part of the back, or loins, he may live two or three weeks, or a month ; and, in some rare cases, recovery has even occurred, of course with permanent paraplegia. The manner in which death occurs after these in- juries is from general exhaustion and debility. The appetite and digestion fail; a weakening diarrhoea comes on, and then the nates slough, and the patient soon sinks. The prognosis is very uncertain after severe blows; sometimes the patient lives and recovers the use of his limbs even after com- plete paraplegia ; sometimes life is saved but with permanent paraplegia; sometimes, on the other hand, the patient having appeared to recover from the ill effects of the injury, most unexpectedly becomes paralytic, and dies from slow disorganization of the cord. Treatment—1. If there be any displacement, an attempt may be made to reduce it by extension. In partial dislocations of the neck, however, the attempt should be very cautious indeed, since, although it has succeeded (in the case of M. Guerin for instance), it has also been known to produce instant death. 2. The patient must be kept at perfect rest in the horizontal posture, and the greatest care must be taken to prevent or delay gangrene of the nates, by arranging pillows or India-rubber water-cushions. 3. The urine must be drawn off by the catheter, and the bowels be kept open by clysters and purgatives, to which Sir B. Brodie recommends ammonia to be added. Tonics and the muriatic acid may be given to support the strength, and obviate the derangement of the urine. The tympanitic state of the belly may be relieved by rubbing it with the compound camphor liniment. 4. Cupping may occasionally be employed if there are inflammatory symp- toms, and the pulse is firm. But in the majority of cases, if fracture has occurred, and the cord is. injured, loss of blood is contraindicated by the pulse, and would hasten a fatal issue. 5. If the patient recover with his life, any remaining weakness or palsy may perhaps be attempted to be removed by the cautious use of blisters or issues, friction, warm bathing, and the internal use of nux vomica ; but they will very rarely do any good.'J CHAPTER XII. INJURIES AND DISEASES OF THE EYE. SECTION I.--INFLAMMATION OF THE EYE GENERALLY. 1. The Eye is a very complex organ, containing very many different structures of great delicacy and minuteness. The effect of disease on each of these points and structures requires to be considered separately ; yet the student should be aware that he may not find in actual practice that the various diseases ending in itis, such as choroiditis, or sclerotitis, have such nicely-defined differences as are often assigned to them in books. For instance, it is a most arbitrary assumption that the choroid can be inflamed 1 See case of latent fracture of spine, proving fatal by suppuration within the verte- bral canal, by Mr. Simon, Pathological Trans, vol. vi. Dr. Bristowe, ib. 2 Vide Cooper on Dislocations, and Brodie on Injuries of the Spinal Cord, in Med. Chir. Trans, vol. xxi. [Hamilton, op. cit. pp. 147, 502.] INFLAMMATION OF THE EYE. 343 apart from the retina, or the retina apart from the choroid ; still more to talk of congestion of the one, and inflammation of the other. No doubt there are many instances of isolated affections even amongst the most minute textures, as we shall show presently. But the first grand distinction the student must draw, is between inflammation of the conjunctiva, popularly, but falsely called ophthalmia; and inflammation of the eyeball. The con- junctiva, including that which covers the cornea, is a mucous membrane, subject to inflammation with mucous or purulent discharge, smarting or scalding pain, and more or less sensitiveness to light. This may be caused by various derangements of health ; by long application with bright light; by atmospheric influence ; or by the application of irritants, of which gonor- rhoeal pus is the most intense. It may lead to opacity and ulceration of the cornea, but be quite unattended with disease of the interior of the eye, and is greatly under the control of local astringent applications. In very severe cases, however, the deep-seated parts are apt to be implicated in the vascu- lar action, although they may escape ultimately from the ravages of disease. II. Inflammation of the Eyeball, on the contrary, is attended with quite a different set of symptoms ;—those, in fact, which, as Dr. Jacob ob- serves, are commonly ascribed to iritis; as if the iris were the only tissue concerned, whereas, in reality, in iritis, all the inner structures of the eye are more or less involved. The symptoms are, a bright pink arterial tint of the sclerotic ; the iris altered in color, first from increased vascularity, next from effusion ; the pupil irregular, its contractile and expansive power diminished; dimness of vision ; no great intolerance of light; pain, not scalding, but aching, or neuralgic, and of various degrees of intensity. Loss of transpa- rency in the cornea, especially of the posterior elastic lamina, adhesions of the iris to the crystalline capsule ; opacity of the lens and its capsule ; soft- ening of the inflamed cornea or sclerotic, so that they bulge under the pres- sure of the liquid within, fluidity of the vitreous humor, complete paralysis, or permanent bulging of the iris ; loss of healthy structure of the retina, and various changes in the choroid, and effusion between it and the retina, are among the consequences of protracted subacute or chronic inflammation. Of the acute inflammation, attended with tensive agonizing pain, swelling of the eyelids, chemosis, flashes of light, and hot scalding tears, the consequence may be not merely effusion of lymph, with loss of transparency of the cornea and lens, but suppuration within the eyeball, indicated by shiverings, most acute pain, and a yellow distended cornea ; which in such a case sloughs, if not slit open by the surgeon. Causes.—Inflammation of the eyeball may be, 1, traumatic, that is, caused by injuries ; 2, idiopathic, or caused by various morbid states of the blood. 1. The first, or traumatic form, may be caused by various injuries, espe- ' cially blows and wounds ; but the liability to it, and the severity of it will be greatly increased by intemperance, or any other circumstance which deranges the general health. The symptoms will be those which we have already enumerated, in various degrees of severity, attended with furred tongue, quick pulse, headache, and fever. The treatment embraces 'all the points treated of in the chapter on the Treatment of Inflammation in gene- ral First, the causes—foreign bodies, chemical irritants, and the like— must be removed if possible. Secondly, soothing measures must be adopted to allay disturbed sensation;—perfect rest of the eye, and.in all instances, especially if there be a wound of the eyeball, the eyelids should be closed by a narrow strip or two of court plaster; opium, to allay pain and to insure repose of body and mind ; application to the injured part either of a bit of soft, dry, old cambric, or of a fold of rag dipped in cold water and frequently renewed ; or of linen dipped in warm water, or in a warm decoction of pop- pies, whichever the patient finds most soothing ; for if the one does not suit, 344 INJURIES OF THE EYE. the other must be tried. Thirdly, eliminatives; such as a good dose of calo- mel and colocynth with rhubarb and carbonate of potass, so as to drain the blood of cacoplastic matters. These complete the preventive measures. But if, notwithstanding, inflammation does come on, then, fourthly, the a (flux of blood must be checked. If the patient, according to the signs detailed at p. 60, is able to bear it, venesection may be performed. If not, from eight to twelve leeches may be applied to the temple, or cupping. The fourtli indi- cation will also be assisted by the use of saline purges, and saline draughts with small doses of tartar emetic. Fifthly, should the preceding measures not check the disease, or should bloodletting be considered inapplicable, mer- cury should be given gently, as directed for iritis, so as to control the effu- sion, or cause it to be absorbed. Lastly, the diet should be proportioned to the patient's strength, but not too low. The eyes should be protected from light; yet without sacrificing good ventilation and coolness. As the disease is disappearing, bark will often be of material service. 2. Of the various idiopathic inflammations of the eyeball, we will mention (a) that most foudroy'ant attack, which sometimes occurs in pyaemia; in which the eye is filled with unhealthy lymph, and destroyed with a rapidity that admits of scarcely any remedy. See Pyaemia, (b) Inflammation of the eyeball as a consequence of contamination of the blood from the poison of syphilis, is described under the head of syphilitic iritis ; (c) that caused by rheumatism, common or gonorrhoeal, is described under the heads of sclerotitis, and of rheumatic iritis, (d) Scrofulous affections are spoken of under the head of scrofulous iritis, and corneitis ; and in the diagnosis of cancer, Sect. 18. Strumous ophthalmia, commonly so called, is a disease of the conjunctiva, so far as it is a local disease at all. Lastly, one eye may be affected sympathetically by disorganization of its fellow; a thing to be averted by removing the cornea and evacuating the morbid products, or extirpating the eye after the manner of Bonnet.1 SECTION II.—INJURIES. I. Wounds of the eyelids or eyebrows should be most carefully adjusted by means of sutures, introduced with a very fine needle, which should pass through the cartilage, if divided. The glover's needle, figured at p. 138, is the best. The greatest care should be taken to prevent irregular cicatriza- tion, with the distortion, and inversion or eversion, that may be the result of it. A linen rag wetted with cold water should then be laid on the part,— inflammation should be counteracted, and the patient be kept at rest till the wounds are healed. Wounds of the forehead, but more especially of the eyebrow, and of the margin of the orbit, even though the globe of the eye has not been struck, are occasionally followed by loss of vision, owing to concussion of the retina, or effusion of blood in the eye. II. Blows on the eye are generally followed by a disreputable-looking ecchymosis, which is inconvenient enough. But sometimes a blow on the naked eyeball, even when so slight as to leave no trace of injury, or a severe blow on the temple, causes concussion of the retina, or some other deep- seated injury to the eye, dimness or total loss of sight; which, when neglected, may lead to permanent blindness. For the prevention and treatment of ill-consequences, refer to the section on Inflammation of the Eyeball generally. Blood effused into the chambers is generally absorbed in the course of a 1 See a series of cases by Haynes Walton, illustrating thi* point, Med. Times, Feb. lsth, 1S")4 ; and similar cases by Mr. R. Taylor, ibid. Oct. 2Mh. 1s.">4. The author most strongly recommends the perusal of a Treatise on Inflammations of the Eyeball, by Arthur Ja- cob, M. D., &c, Dublin, 184!). INJURIES OF THE EYE. 345 fortnight, if inflammation be kept down. If coagulated firmly, it will take much longer, even months. Rupture of the eye may be caused by a violent blow, or explosion. Whether the contents of the globe are lost, entirely or partially, extreme quietude and care should be taken to save any remnant of sight, and to avert dangerous inflammation. Dislocation of the crystalline lens is another possible result of a severe blow. If driven into the anterior chamber, and if the patient is young, and if it gives no trouble, it may be left to nature, especially if there be reason to think that the capsule does not surround it. If, however, it becomes irritating, or if the patient is above forty, it should be removed. If dis- located into the posterior chamber, it will almost certainly produce disor- ganization of the eye, if not removed by extraction; and it may be well to bring it into the anterior chamber by means of a needle, before the removal. III. Foreign Bodies.—When a patient complains of a foreign body in the eye, the surgeon should first examine the cornea; then the inside of the lower eyelid and lower part of the globe, by everting the lid, and telling the patient to look up. If nothing is discovered Fig. 190. there, the patient should turn the eye downwards, so as to expose the upper part of the globe, and the surgeon should turn the upper eyelid inside out, which may easily be done by taking the eyelashes between the finger and thumb, and turning the lid upwards over a probe. If any substance stick in the cornea, so that it cannot be removed by a probe, or silver tooth- pick, or fine forceps, the point of a cataract needle or lancet should be carefully passed under it so as to lift it out. A still more effective instrument is a sort of delicate scoop or gouge, introduced by Haynes Walton ; for foreign bodies, when sharp and angular, and particles of hot iron often become so im- bedded in the cornea that they must be scooped out. Perfect rest to the eye should be enjoined, and every other means be taken to obviate inflammation. To remove particles of lime or mortar, the lids should be everted, and the eye be well syringed or sponged with weak vinegar and water, or with oil, or with pure water, if neither be at hand. For injuries with acids or alkalies, ablution or syringing with water is the readiest remedy. m0™ng foreign We may observe that whenever there is an inflammation of the particles from conjunctiva, with a fair probability that it may have been the cornea. caused by the intrusion of a foreign body, the strictest and most accurate search should be made; because an eye might be lost, or the patient subjected to weeks of illness, and of ineffectual treatment, if it were allowed to remain. Whenever a foreign substance has passed within the anterior chamber, if it can be seen and readily seized, it is better to extract it at once, if the surgeon possess the requisite skill and instruments, which are those required for the extraction of cataract. Mr. Bowman finds a drop of castor-oil the most soothing application in those very painful cases, in which the epithelium has been scratched or roughly stripped off from the surface of the cornea.1 IV. Prolapse of the Iris, in consequence of penetrating wounds of the cornea, may be attempted to be reduced by closing the eye, and very gently rubbing the lid against the cornea, so as to press on the prolapsed portion, and afterwards by exposing it to a strong light, so as to cause the pupil to contract. Or a solution of atropia, F. 198, may be applied to the conjunctiva, 1 Bowman, Lectures on the Parts concerned in the Operations on the Eye, Lond. 1849, p. 120. 346 DISEASES OF THE EYELIDS. and this, whether a portion of the pupillary margin be or be not prolapsed. In either case, if dilatation can be effected, there maybe a favorable issue. Mr. 11. Walton relates an instance in which reduction was effected by means of a probe. Dr. Mackenzie thinks that if the little bag of iris were emptied of its aqueous humor, it would often return immediately to its place, and suggests an attempt to empty it by pressure. Unless the reduction can be attempted immediately after the prolapsus, all chance of returning it is lost, because it soon becomes strangulated. When the prolapsed part cannot be returned, some surgeons have advised that it be snipped off, lest it irritate the eye ; but in doing so there is likelihood of producing further protrusion. In some rare accidents, when a large part or nearly the whole of the iris hangs out, it may be prudent to remove a part; but, generally, the safer plan is to let it remain ; all that is not required to plug up the opening will very soon be removed spontaneously. The protruded part, says Mr. Walton, rapidly cicatrizes over, with a partly opaque, and partly transparent cicatrix. Any application (such as the lunar caustic formerly recommended) interferes with the natural process. SECTION III.—DISEASES OF THE EYELIDS. I. Hordeolum, or sty, is a small painful boil at the edge of the eyelid, having most probably its seat in a ciliary follicle. Treatment—Poultices or fomentations; subsequently ung. hydr. nitrat. dilut., to remove any remaining hardness. Aperients, and afterwards tonics and alteratives, are always necessary, as the complaint always arises in debili- tated constitutions. II. Ophthalmia Tarsi is an inflammation of the palpebral conjunctiva and the edge of the eyelids, with disordered secretion of the Meibomian glands—so that the eyelids stick together, and become encrusted with dried mucus during sleep. It may be acute—attended with great pain and sore- ness,—but in general it is chronic and obstinate, and attended with itching. It commonly occurs to weakly persons with disordered digestive organs. It may lead to ulceration of the eyelids, disease of the hair follicles, and loss of the lashes ; sometimes to thickening and subsequent inversion of the edge of the lids. Treatment.—In the first place, the health, which is always out of order, must be remedied by aperients, alteratives, tonics, change of air, bathing, and whatever other measures may be suitable for each particular case. Whilst there are much heat and swelling, the eyes should be bathed with an anodyne collyrium, F. 142, and the edges of the lids be smeared with lard at bed-time to prevent them from sticking together. But so soon as the bowels have been well cleared, an astringent collyrium, F. 140, may be used during the day, and the diluted unguentum hydrargyri nitratis be applied in very small quantity, with a small camel's-hair brush, to the edges of the lids at bed-time, F. 168. The lashes should be plucked out if there is any ulcera- tion about their roots. Mr. Walton generally cuts them off even in the early stage of the affection, as this facilitates cure by enabling the applica- tions to be more effectually made. III. Syphilitic Ulcers of the eyelids, if primary, will be known by their sudden appearance and rapid progress in a patient otherwise healthy, and by their not having been preceded by a wart or tubercle, like cancerous or epithelial ulcers, and by their yielding to treatment. Secondary ulcers will be known by their coppery color, and the general cachectic look of the patient, and presence of secondary symptoms in other parts. Treatment.—The treatment of syphilis generally. IV. Trichiasis signifies a growing inwards of the eyelashes. Some- times the lashes which turn in, seem to constitute a second or distinct row, DISEASES OF THE EYELIDS. 347 and the term distichiasis has been applied to this state. Mr. H. Walton has shown, however, that the appearance of this supposed independent row is a deception, and depends on the isolated position of the innermost lashes when inverted. Causes.—It seems to depend on some changes in the fibro- cellular tissue in which the cilia follicles lie, produced by irritation. The disease is exceedingly common amongst the lower orders, especially the Irish. Treatment—If plucking the lashes proves ineffectual, an operation must be resorted to ; and three are enumerated by Mr. Walton. One consists in the excision of a portion of skin from the lid, so as to give a sufficient outward tendency to the whole lid, to keep the inverted lashes away from the globe. An incision is made through the skin of the lid close and parallel to the lashes. A second incision is made to meet the extremities of the first, and to include an elliptical portion of skin between them, which is next dissected out, and the edges brought together by sutures. The other operation con- sists in the extirpation of the roots and bulbs of the offending lashes. An incision is first made along the edge of the lid through the skin, correspond- ing to the lashes that are to be removed. Two other short cuts are then made at each end at right angles, so as to form a small flap, which is to be lifted, and the bulbs of the hairs most carefully dissected off the cartilage. The skin is then to be laid down, and retained by a stitch. The third is a last resource, and must be done only as an extreme measure, and when there is so much thickening of the lid edge, and so much irregularity of the lashes, that neither of the others will suffice. It is to dissect away the hair follicles from the entire tarsal border. V. Entropion has been attributed to a variety of causes, among which may be mentioned contraction of the ciliary margin of the lid, thickening of the conjunctiva at the line of reflection from the lid to the globe, contraction of the entire tarsal cartilage, and redundancy of the skin of the lids. Mr. Wilde has endeavored to show that it is due to contraction of the conjunc- tiva lining the lid. Mr. Haynes Walton attributes its immediate cause to the unnatural action of that portion of the orbicularis palpebrarum muscle, which covers the edges of the tarsal cartilage, and which he states to be thicker, and more marked, than any other portion of the muscle that is on the cartilage. Mr. Wilde shows that the operations usually undertaken for the removal of entropion, such as the division of the tarsal cartilage perpendicularly at each angle, and suspending the lid after Crampton's method, under the idea of the contraction either of its edge or body ; or the removal of any portion of the conjunctiva; or the cutting off the so-called redundant skin—do not answer; and recommends the plan of cutting off the cilia, leaving, however, the cartilage entire. Among the other proofs that Mr. Walton adduces, of the power of the ciliary portion of the orbicularis muscle to act in the manner he describes, is the fact, that a colleague of his can invert his lids by the influence of the will alone. He proposes, therefore, the removal of the ciliary portion of the muscle so as to destroy the inverting power, and the removal of a por- tion of the skin of the lid to overcome whatever contraction the tarsus may have acquired. Simple division of the lid by a central slit has been recom- mended, and is adopted by some surgeons; and Mr. Walton says that this operation, by destroying the perverted action of the orbicularis, may in some instances answer, i. e., where the tarsus has not acquired any permanent curve, but in the great majority it will not, it being necessary in addition to remove a bit of the skin of the lid also. An incision is made along the edge of the tarsus, and close to its cuti- cular margin, from one angle of the lid to the other; and a second nearly parallel to it, about three lines distant, and joining it at its extremities; the 348 DISEASES OF THE EYELIDS. [Fig. 191. y Operation for entropion.] [Fig. 194. knife being carried down to the cartilage, through both skin and muscle. Then one corner of this flap being raised by forceps, it is dissected clean off the cartilage, and the edges of the wound brought together by sutures.1 VI. Ectropion, or eversion of the eyelid, may be caused, 1. By a thickening of the conjunctiva, owing to long-continued inflam- mation. The weak ung. hydr. nitric, oxyd., or lotion of arg. nit. (gr. ii ad %i), may be tried first, in order to bring the conjunctiva into a healthy state ; but if they do not succeed, a portion of the thickened conjunctiva must be re- moved by a careful dissection along the edge of the lid ; so that the parts may be braced up by the contraction that ensues : and it may be necessary besides to cut out a triangular slip from the tarsus. In the aged, the eyelid falls down from paralysis, and the exposed conjunctiva becomes thickened. 2. It may be caused by a cicatrix on the cheek,—that resulting from a burn, for instance. But by far the most common cause is the cioatri- 1 Vide Wilde on Entropion and Tri- chiasis, Dublin Journ. Med. Sc, March, 1844 ; Haynes Walton, Operative Oph- thalmic Surgery, Lond. 1853, p. 157. [Skey's Operative Surgery (Pbila. 1851), p. 591.] Fig. 192. Fig. 193. Fig. 192 represents an ectropion caused t>y a cicatrix ; Fig. 193, the successful results of the operation poken of in the text. DISEASES OF THE EYELIDS. 349 zation resulting from the healing of abscesses at the edge of the orbit. Various operations have been suggested and practised for its removal, one of which consists of the removal of the cicatrix, and the subsequent trans- plantation of a portion of skin from the temple or the cheek, after the manner described in the observation on lost noses. It is a simpler and better plan to transpose the skin, as Mr. Walton calls it,—that is, to sepa- rate it freely to a considerable extent around, draw it to the position required, and retain it by sutures. It may also be necessary to remove a wedge- shaped portion of the tarsal cartilage. Vii. Lagophthalmos (hare eye) signifies an inability to close the palpe- bral Sometimes it arises from the contraction of cicatrices, and requires the same treatment as ectropion, when arising from the same cause. But it sometimes depends upon inaction of the orbicularis muscle, through palsy of the portio-dura ; so that the levator palpebral being unopposed, keeps the eye open. This may be caused by exposure to cold—on the outside of a coach, for instance : in which case it is attended with numbness of the cheek, and generally subsides in a few days with aperients, nursing, and per- haps a blister behind the ear. But it may be caused by a tumor in the course of the nerve ; by disease of the part of the temporal bone through which it passes ; or by congestion within the head, like the following disease :— VIII. Ptosis signifies a falling of the upper eyelid from palsy of the third nerve. Sometimes it is attended with headache, giddiness, and other signs of congestion in the head, which should be treated by bleeding, pur- gatives, and blisters. Sometimes it arises from debility, and may be removed by tonics. Sometimes it is an accompaniment of that form of amaurosis which arises from organic cerebral disease ; and is attended with dimness of sight, a sluggish dilated pupil, and more or less strabismus; the eye being turned outwards and downwards because the external rectus and superior oblique are the only muscles unparalyzed. If it occurs without any assign- able cause, and persists, notwithstanding the employment of every measure calculated to improve the health, a portion of skin must be taken out from the eyelid, so that the lid may be brought under the influence or action of the occipito-frontalis muscle, and be elevated by it. This must not be done, however, if, as Mr. Walton remarks, double vision should be caused by the eye being thus brought into use. This author says further, that the portion of skin to be removed must be taken near the eyebrow, else the lid may be everted, and should be dissected neatly out with a scalpel, so that there may be no scar. [Ptosis signifies falling of the upper eyelid from any cause whatever. In addition to that of palsy of the third nerve, which of course acts by pro- ducing paralysis of the levator palpebral, the only cause pointed out by Mr. Druitt, should, be added congenital absence and wounds of that muscle, hy- pertrophy of the cellular tissue of the upper lid, and also disappearance of the cellular adipose tissue and elongation of the skin, as is witnessed in aged persons. The treatment of the case will of course consist in removing the cause ; if the lid be too long it will be made shorter, if too heavy it will be made lighter, and if the muscle be feeble, the surgeon will endeavor to in- crease its force.] IX. Ancyloblepharon.—Union of the edges of the lids, when complete and congenital (which is very rare), may be removed by an incision ; when partial and consisting of a junction of the lids near one angle, which is sometimes caused by cicatrizing ulcers, it is incurable. X. Symblepharon signifies a union of the lid to the globe, following some accident that has caused ulceration of both—the introduction of lime, for instance. It is irremediable, if the adhering surfaces are extensive. Very slight adhesions (fraena) may be divided; but the raw surfaces are too 35 0 DISEASES OF THE LACHRYMAL APPARATUS. apt to adhere again. To prevent this, Mr. Walton divides the band verti- cally through its entire thickness, and brings the edges of each side severally together by sutures. XI. Tumors of the lids may be of many varieties. Warts, enlarged cutaneous follicles, and vascular tumors, or naevi, are to be treated the same here as elsewhere. Cysts of hydatids (p. 168) may grow beneath the loose fold of conjunctiva which passes from the inside of the eyelid to the surface of the eyeball. If that fold be divided longitudinally, the hydatid will escape, or may be extracted by a hook or forceps. There is one small tumor found here, and called, par excellence, the tarsal tumor, the true nature of which the writer has examined, in concert with Mr. H. Walton. It consists of one of the acini of the Meibomian follicles, filled by thick sebaceous mat- ter. If it projects on the inner surface of the lid, it is readily recognized as a small darkish speck, which may ulcerate and discharge its contents. If it chance to project on the outer surface of the so-called tarsal cartilage (for it must be observed that the Meibomian follicles are not, as is usually said, on the inner surface of the cartilage, but are contained within its very substance), then the obstructed follicle, having no means of emptying itself, forms a small tumor, which increases by the addition of fibro-plastic matter to its exterior. Such tumors may be felt under the skin and orbicularis, attached to the outer surface of the tarsal cartilage. On everting the lid, a slight depression is noticed within. A sufficiently free puncture should be made from within the lid, the cyst broken up with a probe, and the sebaceous and epithelial contents be evacuated. [The instrument invented by Desmarres will be found very useful in re- moving tumors from the eyelid as it has the double advantage of fixing the lid and of preventing the flow of blood which often interferes greatly with the operation. It consists of a forceps, one blade of which ends in an oval- Fig. 195. Desmarres' instrument for removing tumors of the eyelids. shaped flat plate, and the other in a ring ; a screw is adjusted to the instru- ment, by which the ring can be made to press down upon the plate. In using the instrument, the flat plate is introduced under the eyelid, or as much of it as is deemed necessary, the skin being carefully stretched, and then by means of the screw the ring is made to exercise sufficient compres- sion around the tumor to prevent the blood from reaching the parts into which the incisions are to be made.] XII. Pediculi.—These loathsome insects sometimes lodge about the roots of the eyelashes, and produce an obstinate itching. They are easily killed by any mercurial preparation; but the surgeon ought to be aware of their existence, as they might be mistaken for crusts of dried mucus. SECTION IV.—DISEASES OF THE LACHRYMAL APPARATUS. I. The Lachrymal Gland is occasionally subject to acute and chronic inflammation—the symptoms and treatment of which will be obvious. II. Xerophthalmia signifies a dryness of the eye from deficiency of the tears, or rather of the mucous secretion of the conjunctiva. It may be pal- OBSTRUCTION of the nasal duct. 351 liated by the occasional application of glycerine, or of a tepid lotion of in- fusion of quince-seed, by means of an eye-cup. Mr. Taylor has succeeded in two instances in restoring useful vision by keeping the cornea constantly moist with glycerine.1 III. Epiphora signifies a redundancy or over-secretion of tears, so that they run over the cheeks. It should be distinguished from the stillicidium lachrymarum, or overflow of tears, in consequence of an obstruction in the channels that convey them to the nose. It may depend on general irritability of the eye, and is not unfrequent in scrofulous children. When arising from this cause it should be treated by aperients and alteratives, with tonics and antacids (F. 38, 10, 11, 20, 76, 77). An emetic may be given if the stomach is foul. The same local applications may be used as are prescribed for scro- fulous ophthalmia. Search should be made for foreign bodies or inverted eyelashes. IV. Closure of the Puncta Lachrymalia may be congenital, in which case it is quite incurable, or it may be a consequence of inflammation of the lachrymal sac and its appendages. Of course it produces a stillicidium lach- rymarum. When a consequence of inflammation, it is only temporary, and passes off as soon as the inflammation subsides, to which the treatment should be directed. Actual closure of both puncta, except from the cicatrization of a wound, scarcely ever takes place, and the loss of only one does not matter much if there be no accompanying inflammatory affection, and the eyelids are not displaced. The treatment to be adopted when both are obliterated, and the canaliculi are not destroyed, is, according to Mr. Bowmau,3 to cut across one of them close to the obstruction, and then slit up the canal on a probe. When an orifice cannot be so formed, he recommends opening the sac below the tendo oculi, and slitting up the canal near the obstruction on a probe run into it from the sac. For this to be successful, the obstruction should be sufficiently far from the sac to allow of the canal being slit up in the interval through the conjunctiva. When this cannot be effected, there should be made an opening between the sac and the inner corner of the eye, and a fistulous aperture be established by the presence of a foreign body. To ascertain whether there is actual stoppage in the passage, Anel's gold probes may be used. Bowman has also shown that every divergence of the lower punctum from slight eversion of the eyelid, the result of chronic inflam- mation of the conjunctiva, or disease of the skin of the lid, may produce stillicidium. To remedy this condition, he slits up the canal from the punc- tum, till the incision reaches that part of the mucous surface on which the tear's collect or against which they rest. V. Obstruction of the Nasal Duct is most probably a consequence of thickening of the mucous membrane that lines it, and is, according to Mr. Walton, a scrofulous affection not uncommon in delicate young persons. The patient complains of weakness of one eye, which is perpetually watering ; and of dryness of the corresponding nostril. The lachrymal sac distended with tears forms a small tumor by the side of the nose, from which tears and mucus can be squeezed upwards through the puncta, or downwards into the nose, if the obstruction be not quite complete. A case is related of com- plete obliteration of the bony canal of the nasal duct by bony deposit, in which a permanent opening was established from the eye to the nose,3 Mr. • See his excellent paper on this disease in the Edin. Med. and Surg. Journ., No. 198, new series. 2 Med Chir. Trans, vol. xxxiv. 3 H Walton Med. Times, May 1846. A case is related in Forbes's Rev. xii. 641, of congenital absence of the nasal duct, in which M. lierard succeeded in establishing a communication with the nose. fistula laciirymalis. Fie;. 196. Abscess of the lachrymal sac, after ecaiiatina. Walton has lately met with a similar case in the person of a medical man. Obstruction mostly leads to VI. Chronic Inflammation of the Lachrymal Sac—tenderness of the sac, perhaps redness of the superjacent skin ; irritability and constant tendency to inflammation of the conjunctiva, with mucous or purulent discharge. There is often great variation in the symptoms in J^ f the same case, especially at different seasons of the year ; for there may be great suffering in winter, and scarcely any inconvenience in summer. VII. Acute Inflammation of the sac is known by great redness, swelling, pain, and tenderness, at the side of the nose, implicat- ing the eye, and attended with fever and headache. If it be not soon relieved the sac will suppurate and burst. VIII. Fistula Laciirymalis signifies an ugly fistulous aperture at the inner corner of the eye, communicating with the lachrymal sac. It is the ordinary consequence of the three preceding affections, if unrelieved, and may be said to have five stages. First, it begins with obstruction of the nasal duct; the most prominent symptom of which is a perpetual watering of the eye. Secondly, this is followed by inflammation ; which, thirdly, gives rise to abscess; and this, fourthly, by its bursting, causes the fistulous aperture from which the name of the affection is derived ; whilst, fifthly, in old neglected cases, the lachrymal or superior maxillary bone may become carious; but this is not very common. The fistulous aperture is generally crowded with fungous granulations, and the skin around is red and thick- ened, from the perpetual irritation of the tears that escape from it. Some- times there is considerable loss of skin. Treatment.—Acute inflammation of the sac must be treated by leeches, purgatives, and cold lotions or poultices. If the pain increase in severity, and become throbbing, the sac should be opened in the manner to be pre- sently described. Chronic inflammation of the sac should be treated by an occasional leech ; by steaming the nose so as to soothe and bring the whole track of mucous membrane into a healthier state, and by the strictest attention to the general health, and especially to the functions of the skin and of the digestive organs. When the sac becomes distended, the patient should endeavor to press its contents down into the nose ; and he should also frequently draw in his breath strongly whilst his mouth and nostrils are closed, so as to draw the tears down the duct by the pressure of the atmosphere. The secretions of the eyelids should be corrected with citrine ointment (F. 168), and a few drops of some astringent collyrium (F. 140) should be put twice a day into the inner angle of the eye, so as to be absorbed by the puncta, and carried into the sac. By these means the thickening of the duct may perhaps be removed, or, at all events, the patient may go on pretty comfortably. Treatment by the style.—But if the retention of the tears in the sac causes a constant irritability of the eye, or if there is a fistulous orifice between the sac and the cheek, measures should be adopted to restore the obstructed duct. If there is no aperture, the sac should be opened just below the tendo oculi, which, in a healthy condition, may be found by gently drawing the eyelids outwards, when it is seen as a small rounded cord, passing inwards from the inner canthus of the eye. But this guide is fistula lachrymalis. 353 scarcely available when there is swelling and inflammation at the corner of the eye ; then the operator must trust to his knowledge of anatomy, and to his surgical tact. Mr. AValton says that the correct place for the puncture corresponds to a spot a little below, and in- Fig. 197. ternal to, the lower punctum. The escape of tears and mucus shows when the sac is opened. Then a style should be intro- duced, i. e., a, silver or a silver-gilt probe, about an inch or an inch and a quarter long, with a head like a nail, with blunt edges, which lies on the cheek, where it passes unnoticed like a black patch.1 It should be pushed downwards, but a little backwards and inwards through the duct into the nose. It will be known to have reached the nose by the escape of a little blood. The constant presence of this instrument causes the duct to dilate, so that the tears flow by its side. It should be occasionally cleaned, and then be replaced ; and it causes so much comfort, and the duct is so likely to close, if it be left styieforiach- off (in neglected cases in which the mucous membrane has rymai fistula. been destroyed), that it generally is worn for life. In less severe cases it may effect a cure after being worn a few months. When the parts about the corner of the eye become healthier, the head of the style may be reduced in size. The above is the plan of treatment which the author has generally seen adopted ; and the results have been on the whole satisfactory; but it follows of necessity that in so common a complaint many other plans of treatment are followed by different surgeons. Short pieces of catgut bougie, or silver tubes, are sometimes employed instead of the style. Some- times attempts are made to restore the nasal duct to its proper calibre by introducing instruments from below; either a common silver probe, with its blunt end bent at a right angle, or else a steel probe made for the purpose; whichever is employed, should be passed along the inferior meatus of the nostril till its point is under the anterior extremity of the inferior turbinated bone, and then by manipulation it may pass into the duct; yet with the greatest care, this proceeding may inflict injury, and sometimes cause violent hemorrhage. Bowman has suggested a plan of slitting up the canaliculus, and passing probes of different sizes through the enlarged aperture into the obstructed duct, thus catheterizing, as it were, the channel. IX. The Lachrymal Gland is very rarely the seat of disease, and the author is not aware of any accurate dissections or microscopical exami- nations : moreover, it is pretty certain that other tumors in the outer part of the orbit have been mistaken for enlargements of this gland ; and that a healthy gland has been occasionally removed unintentionally with such a tumor. Pain, preternatural flow of tears, and a lobulated tumor under the outer part of the roof of the orbit, are the symptoms; careful extirpation the remedy. See Section xviii. Sometimes this gland is extirpated, in order to get rid of the flow of tears, in cases in which the eye has been lost, and the puncta closed by burns or other injuries, so that the tears are inces* santly dribbling on the cheek. An incision must be made for this purpose along the edge of the orbit, through skin, orbicularis, and fascia, when the gland will be exposed, and both portions of it must be removed ; for it must be recollected that it has two lobes, and that if either of these is left, the purpose of the operator is defeated 1 Mr. Walton covers the head of the style with a drop of black sealing-wax, meltea on smoothly : this is better than black paint, though it will require renewal occasionally. He finds that a style with a round head, a little bent at the upper end, sits better, and irritates less ; for when the head of it is merely bevelled off, the lower part of its cir- cumference still rests on the skin and ulcerates it. 23 354 DISEASES OF THE CONJUNCTIVA. SECTION V.--DISEASES OF THE CONJUNCTIVA. I. Common Acute Ophthalmia consists of inflammation of the con- junctiva. Symptoms.—Smarting, heat, stiffness, and dryness of the eye, with a feeling as if dust had got into it; the conjunctiva of a bright scarlet redness; the redness superficial, so that the enlarged vessels can be moved by pulling the eyelids ; slight intolerance of light and flow of tears on exposure of the eye, and more or less headache and fever. Causes.—Slight local irritation, disorder of the digestive organs, or cold and damp. II. Catarrhal Ophthalmia is a variety of this inflammation caused by cold and damp, and attended with a thin purulent discharge, which in severe cases becomes thick, and doubtless contagious. Treatment.—A dose of calomel followed by black draught, and preceded by an emetic if the stomach is very foul; the eye to be frequently bathed with poppy decoction, or the weaker forms of F. 140, lukewarm or cold, according to the patient's choice ; the edges of the eyelids to be smeared at night with fresh lard, and with weak ung. hydr. nit. ox. after the first day or two ; a green shade to be worn over both eyes, whilst there is much intole- rance of light; but the patient not to be confined to the house too long, unless the case is very severe, or the weather bad. In the catarrhal variety, a large drop of solution of arg. nit. (gr. i. ad ^i.) may be put into the eye twice or thrice a day. If there is much pain, leeches may be applied to the temples; and if the patient is plethoric, and there is much headache and fever, bleeding and calomel in repeated doses may be required. But it is a great mistake to treat common inflammation of the conjunctiva, when it occurs in delicate subjects, by lowering measures. After the bowels are cleared, a good diet, and exposure to moderate light and cool air, and an astringent lotion, will do more good than black draughts, leeches, and green shades. III. Chronic Inflammation of the Conjunctiva may be a sequel of the acute; or may be caused by some local irritation, such as inverted eye- lashes ; or by some derangement of the health. Treatment—1. All local sources of irritation should be removed. 2. The general health should be amended, in the same manner as directed for chronic inflammation generally. (Vide p. 63.) 3. The distended capil- laries must be unloaded by occasional leechings, and be excited to contract by stimulants and astringents, such as the various collyria in F. 140, &c, which should be used with an eye-cup ; or the vinum opii (which Mr. Walton dilutes with an equal quantity of water), and of which a few drops may be put into the eye daily. The edges of the eyelids should be smeared every night with weak ung. hydr. nit. ; and blisters should be applied behind the ears, if the case is obstinate. IV. Purulent Ophthalmia, or purulent conjunctivitis, is a very violent form of inflammation of the conjunctiva, and is attended with a thick puru- lent discharge, which supervenes in from twenty-four to forty-eight hours after the commencement of the disease. There are three varieties of it:— 1, the purulent ophthalmia of children; 2, the common purulent ophthal- mia of adults; and 3, the gonorrhoeal ophthalmia. The Purulent Ophthalmia of Children, or ophthalmia neonatorum, always begins to appear a few days after birth; generally on the third day. Symptoms.—At first the edges of the lids appear red, and glued together; their internal surface is red and villous, and the eye is kept closed. Then the conjunctiva of the globe becomes intensely scarlet and much swelled, often so much so as to cause eversion of the lids; it secretes a thick purulent discharge, and the child is very restless and feverish. If neglected, this PURULENT OPHTHALMIA. 355 disease may occasion opacity or ulceration, or perhaps sloughing of the cornea; but it generally yields to early and proper treatment. Yet some- times the interior of the eye is very much damaged, and the retina is left very feeble. Causes.—In most instances in which the author has seen this disease, the mother has complained of some amount of discharge during her pregnancy. In some well-marked cases the husband has also had gleet; therefore it is not unfair to infer that this ophthalmia is caused by the contact of vaginal secretion during birth. Possibly irritation of the eyes from neglect of clean- liness may be a cause in other cases. Treatment—This disease, if submitted to early treatment, is easily cured by great attention to cleanliness, and by incessantly washing away the dis- charge with some mild astringent lotion. Either of the weak collyria (F. 117) will answer; and a large drop of a solution of one grain of nitrate of silver to an ounce of distilled water may likewise be put between the lids once a day with a camel's-hair pencil. The practice pursued at the Cen- tral London Ophthalmic Hospital, is to wipe away from the eye with a soft rag and warm water as much discharge as possible, then to apply with a syringe a lotion of four grains of alum to an ounce of water; after that, the edges of the lids are smeared with lard to prevent them from sticking together, and these proceedings are repeated every half-hour. Neither blis- tering nor leeching is resorted to. When the discharge is on the wane, the lids may be smeared at night with weak citrine ointment. The eye should be opened with very great delicacy by resting the fingers on the edges of the orbit, and then drawing open the lids in such a way as to avoid any pressure on the eyeball; because if the cornea is beginning to suppurate, it might easily be burst, and the lens be squeezed out. The bowels should be cleared with a grain of calomel or gray powder, followed by a little castor-oil or rhubarb. If the disease has been neglected, and there is great tumefaction, a leech may be applied to the temple, and half a grain of calomel be given every eight hours, for three or four doses. If the insides of the lids become thickened, a condition called granular conjunctiva, which never happens unless too strong a lotion has been used, the proper plan is to leave the in- jured eye alone, and to lay a few threads of cotton, spread with blistering plaster between the external ear and the head, so as to create a discharge. If the cornea ulcerate or slough, or if the discharge be obstinate, tonics are required (quin. sulph. gr. ss.—vel ext. cinchon. gr. iii. ex lacte), and the astringent collyria should be persevered with. V. Purulent Ophthalmia in Adults (Contagious or Egyptian Oph- thalmia). Symptoms.—The disease begins with stiffness, itching, and watering of the eye, with a sense of dust in it, and slight swelling of the lids, which stick together during sleep ; and on examination of their internal surface, the palpebral conjunctiva is found to be intensely red, thick, and villous, like a foetal stomach injected. As the disease advances, the con- junctiva covering the globe becomes also intensely red, swollen, and villous, and discharges a copious secretion of pus. The swelling of the ocular con- junctiva is called chemosis. It is produced by effusion of serum and lymph into the cellular tissue which connects the conjunctiva to the sclerotic; and it elevates the conjunctiva into a kind of roll around the margin of the cor- nea, which sometimes overlaps it entirely. These symptoms are accompanied with severe burning pain, extending to the cheek and temple, and great headache, fever, and prostration; the palpebrae also are swollen, tense, and shining, so that the patient cannot open the eye. Consequences.—This affection may lead to ulceration or sloughing of the cornea; and very commonly to some impairment of vision, from extension of inflammation to the internal parts of the globe. ( 35 6 GONORRHOEAE OPHTHALMIA. Causes.—It may be produced by severe local irritation, as the introduc- tion of lime, for instance, or a blow. It is endemic in Egypt, owing to the glaring sunshine and the particles of sand with which the air is loaded. It may also be produced by the close damp atmosphere, saturated with animal vapour that results from crowding many persons together in a confined space; and from the neglect of cleanliness and ventilation ; hence, its prevalence amongst the military in barracks; in schools ; and on board ship—especially amongst the wretched inmates of slave-ships. But when once produced, by any cause whatever, it is most probably both contagious and infectious ; that is, capable of being propagated both by contact with the purulent secretion, and by exposure to its vapor, if many persons affected with the disease are crowded together. VI. Gonorrheal Ophthalmia is the most violent form, of purulent con- junctivitis. The symptoms are essentially the same as those of the last species; but the disease seems to begin in the ocular rather than in the palpebral conjunctiva, the chemosis is greater, lymph being generally effused into the subconjunctival areolar tissue, the discharge thicker and more abundant, the constitutional disturbance more severe, and the cornea much more apt to slough. It is sometimes said that one eye only is usually affected; not both, as in the Egyptian variety; but both eyes are often affected, al- though usually at an interval of a few days, and that which is attacked last generally suffers the least. Cause.—This disease arises without doubt from the application of gonor- rhoeal matter from the urethra to the eye. Prognosis.—This is very unfavorable. The sight of the affected eye will either be lost, or excessively impaired, unless treatment be very early and efficacious. Diagnosis.—If a patient applies with violent conjunctivitis, and there is a suspicion that he has a clap and has infected his eye, the surgeon should insist on an examination of the penis, however strongly the patient may deny the fact of his having any disease. Consequences.—The most frequent and detrimental is sloughing of the cornea. The sloughing generally occurs quite suddenly ; the cornea may be clear in the morning—cloudy and flaccid in the evening—and by the next morning it may have burst; and this change may supervene at any time from the second day of the disease till the last. After this has occurred, the swelling of the lids subsides, the discharge diminishes and becomes thinner, and the pain greatly abates. If the slough is very small, the iris may pro- trude, and close the aperture, imperfect sight remaining—but generally the greater part of the cornea perishes; a fibrous deposit takes place on the iris, and becoming distended produces staphyloma; and all useful sight is lost. Treatment.—There are three sets of measures which may be adopted in this very hazardous disease ; viz., antiphlogistic remedies, scarifications, and astringents. Experience has shown that it is not possible to check this disease entirely by antiphlogistic measures, such as bleeding, purgatives, calomel, and anti- mony, ke. ; and that although they ought to be used in proportion to the violence of the fever with which the local disease is attended, yet that they cannot be trusted to entirely. If the patient applies, at the very commencement, the use of an alum or a nitrate of silver lotion several times a day, indeed every hour, and fomen- tations of poppy, together with low diet, antimony, and confinement to bed, may suffice to check the disease. But if the disease has reached its height, and there is great fever and headache, with full bounding pulse, it will be right to bleed freely, to purge, scrofulous ophthalmia. 357 and to administer nauseating doses of antimony, and Dover's powder, at bed-time, to allay pain. The patient must be kept in bed, in a darkened room, with the head elevated, and on low diet. But if these measures, com- bined with the local applications to be mentioned presently, do not arrest the disease and the chemosis is evidently extending round the cornea, and the cornea is becoming hazy, incisions, at equal distances, should be made completely through the swollen conjunctiva, beginning at the margin of the cornea, and radiating towards the circumference of the eye.1 " A small curved bistoury must be introduced just where the chemosed conjunctiva overlaps the cornea, and the point be carried through the entire thickness of the swelling to the palpebral sinus, taking care not to injure the sclerotic coat, then the hand should be depressed, and the bistoury made to cut its way out. The incisions may be advantageously employed more than once in the same case, and are useful even when the conjunctiva is not extensively chemosed ;"3 but an eye may perish in spite of them, as of all other means. The patient, if unruly, should be narcotized by chloroform ; if not, he should sit on a low chair, and the operator stand behind him, and raise the upper lid with a retractor, whilst an assistant depresses the lower. They should be fomented with warm water, that they may bleed. If there comes on, as frequently happens, an exacerbation of pain towards evening, it may be pre- vented by applying a few leeches in the afternoon, or by putting blisters behind the ears. The eyes should be frequently but gently washed out, by means of a piece of fine sponge, or syringe, with warm water or poppy decoction, containing three grains of alum to an ounce, in order to get rid of the purulent secre- tion ; and once or twice daily, a few drops of a freshly-made clear solution of one grain of nitrate of silver in an ounce of distilled water should be dropped into the eye by means of a camel's-hair pencil. As soon as the chemosis begins to lessen, the weaker preparations of F. 140 may be used. The diet also should be improved, and the edges of the lids should be smeared at night with weak ung. hydr. nit. ox. If the strength becomes impaired, or if the cornea has given way, tonics, especially bark, F. 1, 4, should be ad- ministered, which, with repeated blisters, and a continuance of the astringent applications, are the measures for removing the relics of the disease. VII. Scrofulous Ophthalmia (phlyctenular ophthalmia) generally attacks children under eight years of age, but is not uncommon in adults. Symptoms.—The characteristic feature of this disease is the extreme intolerance of light; quite out of proportion to any local visible disease. The lids are kept spasmodically closed, and the head turned obstinately away from the light; yet there is no general vascularity of the conjunctiva, but a little line of vascularity running towards the cornea, and terminating at one or more phlyctenules, or small opaque pimples (or sometimes pustules) at the margin of the cornea. This, like other scrofulous diseases, is extremely obstinate, and liable to recur frequently. Treatment.—The first and chief point is to look after the general health, and especially to use moderate but effectual purgation, till the bowels are emptied, and their secretions rendered healthy. Three or four doses of 1 This practice was revived by Mr. Tyrrell (vide Med.-Chir. Trans, vol. xxi. part ii., and Tyrrell on the Eye, vol. i. p. 73). It is mentioned by Astruc in the following terms: — "It was thought proper some time ago to try the same remedy in the eye tending to a mortification, as is made use of in other parts of the body when they are threatened with the same disease; viz., scarify the swelled conjunctiva thick and deep, so that the globe of the eye, and especially the cornea, might be less compressed by it; for that sudden destruction of the eye seemed to be chiefly owing to its being too tightly em- braced by the swelled conjunctiva."—Astruc on the Venereal Disease, translated from the Latin, Lond. 1754. 2 Haynes Walton, Operative Ophthalmic Surgery, p. 271. 35 s scrofulous ophthalmia. calomel at bed-time, on alternate nights, with rhubarb and soda, or rhubarl) and polychrest salt, F. 37, in the morning, will generally relieve the intole- rance of light quickly; and when the tongue is cleaning, and feverishness has subsided, recourse must be had to tonics, cod-liver oil, and to the other general remedies directed for scrofula. Quinine is particularly recommended by Mackenzie, and a combination of quinine with sulphate of iron (F. 16, &c.) by Mr. Walton. Pure air is essential. Secondly. Various applica- tions are recommended to relieve the distressing intolerance of light, such as cold lotions applied to the outside of the eye, and to the forehead and temples; or water to which a little vinegar or spirit, or nitric aether, has been added ; or the white of egg curdled with alum, or warm poultices, or dec. papav. vel anthemid., or exposing the eye to the vapor of warm water, or to the vapor of laudanum or sp. cam ph., which may be put into a teacup and be held in warm water; but belladonna, F. 149, applied round the eye is the most efficacious, and small doses of extract of conium internally. Both eyes should be protected by a shade. Thirdly, in the advanced stage of the disease, benefit may be derived from dropping in a few drops of dilute vin. opii or lotion of nitrate of silver (gr. i. ad |i.) once a day, and especially from the application of dilute citrine ointment to the edges of the lids at bed-time. [A direct current of galvanism or chemical electricity, localized to the supra-orbital branch of the fifth pair of nerves, is said to be a most efficient remedy in the photophobia of strumous ophthalmia. See the paper of Dr. Addinell Hewson on this subject, in the Amer. Journ. Med. Sci. for Janu- ary, I860.] VIII. Granular Conjunctiva signifies a thick, rough, fleshy state of that membrane (especially of that part of it which lines the eyelids), and is a frequent consequence of severe and long-continued ophthalmia, or probably of treatment by applications of too irritating a kind. It causes great pain and disturbance to the motions of the eye, and, if it continues, will render the cornea opaque by its friction. Treatment.—The directions generally given are, that the thickened part should be scarified; that, after one or two days, it should be touched with lunar caustic or sulphate of copper, that the scarification and caustic should be repeated alternately at intervals of two or three days, and that if these measures prove fruitless, the thinnest possible layer of the granular surface should be shaved off with a fine knife or scissors. But it is a sounder plan of treatment to use counter-irritation on the outside of the eyelids, and im- provement of the general health by tonics and change of air ; and to discard any local application that causes pain or uneasiness, especially if this state of conjunctiva follows an attack of inflammation that has been freely treated by caustic. When the malady is idiopathic, the system is, according to Mr. Walton, much below par, and requires tonics. It is the complaint of the poor Irish. IX. Pterygium is a peculiar alteration of the conjunctiva,—a triangular portion of which, with the apex towards the cornea, becomes thickened, elevated, red, and fleshy. It may spread over the cornea and obstruct vision; but it does not cause much inconvenience besides, and is not essen- tially an inflammatory affection, although it sometimes follows protracted ophthalmia. It is most common in warm climates, such as Calabria: the examples seen in London are chiefly in persons who have returned from the West Indies. The author would suggest the affinity of this growth to the cheloid tumor of the skin. Treatment.—If the disease is increasing, excision should be performed. The growth should be seized close to the cornea with tenaculum forceps, should be cut quite across, and be dissected off, towards the internal DISEASES OF THE CORNER. 359 canthus. But yet, as Mr. Walton directs, that portion which covers the cornea should not be meddled with, because after the operation that will pro- bably waste ; neither should the semilunar fold and caruncle be extirpated. X. Tumors, such as warts, polypi, fibro-plastic, and even enchondroma- tous growths, may spring from any part of the conjunctiva, whether near the cornea or not. Early excision by curved scissors is the remedy. SECTION VI.—DISEASES OF THE CORNEA. I. Acute Inflammation of the Cornea, or acute corneitis, is gener- ally a consequence of neglected injury. The part becomes red and opaque, the sclerotic around highly vascular; and ulceration of the cornea, or sup- puration between its layers, or abscess of the anterior chamber, may ensue. Local bleeding, mercury with antimony (F. 63), and fomentation, are the remedies. Stimulating applications are prejudicial. Turpentine in the dose of one drachm three times a day, in an emulsion with carbonate of soda and mucilage (F. 74), has been recommended. II. Scrofulous Corneitis most frequently occurs between the ages of eight and eighteen. Symptoms.—The cornea opaque, rough, and red, and unusually promi- nent ; the surrounding sclerotic also red ; pain and intolerance of light are generally trivial; there is some tendency to inflammation of the iris and retina; the pulse is frequent, and the skin dry. Treatment—For the acute, purgatives and fomentations. For the chro- nic, quinine perseveringly administered ; blisters repeatedly applied to the nape of the neck, and behind the ears; and the general tonic treatment directed for scrofula. The vin. opii, and ung. hydr. nit. ox. to the eyelids are almost the only local applications admissible. III. Opacity of the cornea may be divided into two kinds. 1st. The opacity which results from the Adhesive Inflammation, and effusion of fibrine between its layers, or between it and the conjunctiva, which is a very common consequence of inflammation of the cornea, and of scrofulous ulcers during the healing stage ; and 2dly, the opacity, or leucoma, which is produced by a loss of substance and its resulting cicatrix—that which follows a pustule of the smallpox, for example. The former kind is in most cases curable ; the latter generally not so. When an opacity of the former kind is slight and diffused, it is called nebula; when denser and of a firmer aspect, albugo. Sometimes the lymph forming an albugo becomes vascular, and one or more vessels run to it from the circumference of the eye, and the cornea becomes red and fleshy; this state of things is called pannus. Treatment.—1. All sorts of irritation about the eye or lids, and most especially inverted lids, or inverted hairs, or granular conjunctiva, must be removed, and any existing degree of inflammation be counteracted by proper measures. Then, 2, absorption of the lymph may be promoted by counter- irritants, such as blisters or tartar-emetic ointment behind the ears; by measures calculated to improve the health ; and by the application of stimu- lants to the eye. The ordinary applications are, caustic lotion (gr. i. ad gj.), or hydr. bichlor. gr. i.—ad aq. %]. ; vin. opii; or, ung. hydr. nit. ox. Which- ever is selected should not excite long-continued pain or active inflamma- tion. Gooch used to cure opacity of the cornea, even of long standing, and, in fact, other forms of chronic inflammation of the eye, by the administration of corrosive sublimate, in doses that would now be considered hazardous. He gave gr. 4; twice a day ; and in a few days' time increased the dose to gr. £, and° then to gr. i. It caused feverishness, purging, slight sweating, and headache. 360 diseases of the cornea. IV. Leucoma signifies an opaque cicatrix of the cornea. If recent, it may become much better spontaneously, or may be partially removed by the measures just indicated. If of long standing, it is irremediable, and some- times becomes the seat of calcareous degeneration, a small particle of earthy matter being found in it, which may require removal because of its friction against the eyelids. Should both eyes be affected with leucoma, and should the opacity be exactly in front of the pupil, and so large that vision is lost, it will be right, provided that dilatation of the pupils by atropine does not improve sight, to make an artificial opening in the iris opposite some part of the cornea that is transparent. Mr. Bowman has described a case of warty opacity, caused by the develop- ment of vascular papillae, covered with hypertrophied epithelium; and re- lieved by shaving off the morbid growth to the level of the healthy cornea.1 Superficial Opacities.—" There are some varieties," says Mr. Bowman, " which appear to be on or near the very surface of the cornea, and which it is probable may occupy the anterior elastic lamina. The very opaque chalky-looking films which often follow the application of quicklime or new mortar to the eye, seem to be of this kind, and so, also, do those which have been supposed by some to be stainings of the surface of the corneal tissue by a deposit of the lead lotion in common use. Occasionally we have a superficial excoriation of the cornea—one can hardly call it an ulcer—which the epithelium limits with abrupt edges, thus favoring the accumulation, on the depressed surface, of the frothy mucus or sud which the movements of the lid furnish. " The opacity thus produced is often very opaque, and unless you were aware of its cause, might seem more serious than it really is. A lens, or the point of a needle, will inform you of its real nature. " There is another form of opacity, which I believe to have its seat in the anterior elastic lamina, although it is vain to endeavor to prove it, except by a section of the parts. It has a silvery lustre, and a very fine texture of interweaving striae, and it creeps very gradually from near the border, over the surface of the cornea, towards the centre. The epithelial surface retains its smoothness and lustre, and the opacity does not appear to have much depth. Other varieties of opacity, very chronic in their course, and evi- dently not inflammatory, are liable to form, as I believe, in the same fissue. They may be of a brown tint, with an indefinite margin, and may affect both corneae at the same time." Superficial opacity, caused by a thin film of earthy matter, has been suc- cessfully removed by operation by Mr. Bowman,2 Mr. Dixon, and Mr. Haynes Walton. If the acetate of lead is used as a collyrium when there is any abrasion of the conjunctiva or cornea, a white precipitate is formed, which is liable to become fixed in the cicatrix as a dense white spot. The film may, how- ever, sometimes be removed by a needle. The nitrate of silver, if applied too long, is apt to turn the conjunctiva of a deep olive hue. V. Onyx signifies a suppuration between the layers of the cornea, and is an occasional result of acute ophthalmia, especially of the catarrho-rheu- matic. It derives its name from its re semblance ^in shape to the white spot at the root of the finger-nail. It mostly disappears with proper antiphlo- gistic treatment. If it extend very fast it may be necessary to puncture the external layers of the cornea to relieve the great pain, but the sight will be lost. VI. Ulcers of the cornea may be results of the phlyctenules of scrofu- lous ophthalmia, or they may arise from mechanical injury, or from any form 1 Op. cit. pp. 39, 122. 2 Op. cit. pp. 37, 117. DISEASES OF THE CORNEA. 361 of conjunctival inflammation. They may likewise commence as mere abra- sions, or >as little nebulous spots, independently of any other affection. When a consequence of the scrofulous phlyctenulae, they are generally deep, and tend to perforate the cornea, and leave an opaque cicatrix; when arising from other causes, FiS- 198- they are often superficial, and heal with a semi- transparent cicatrix, which gradually becomes clear. " These ulcers may," as Mr. Tyrrell observes, "exist in three states. First, that which we may term healthy, when the surface and circumference exhibit a degree of haziness or opacity of a whitish or gray aspect, which is owing to the effusion of adhesive matter on the surface, and in the surround- This figure exhibits the heal- ing texture, which is essential to the healing of the ^s stage of an ulcer of the part." In this state the case merely requires to be J^^X^-i watched, to prevent injurious increase of action. the° author has to thank Mr. "Secondly, an ulcer may be inflamed, when its partridge. hazy circumference will be observed to be highly vascular. Leeches and counter-irritation, with soothing applications, are the remedies. But an ulcer is not necessarily inflamed because it has red vessels going to it; these bring material necessary for its repair, and are not morbid. " Thirdly, an ulcer may be indolent, clear, and transparent, looking as if a little bit had been cut out of the cornea ; without any vascularity or effu- sion of lymph. This state requires slightly-stimulating applications." Again, ulcers may form on a surface that is already rendered opaque and nebulous by scrofulous inflammation. However, in any case, counter-irrita- tion, and measures to improve the health, together with weak caustic lotion or vin. opii used twice a day, are the chief remedies. The surgeon should remember the tendency of the cornea to slough fijom insufficient and non- azotized food, as proved by the experiments of Magendie. The pupil should be dilated with belladonna, if the ulcer is near to the centre of the cornea. When an ulcer is very irritable, keeping up constant pain and intolerance of light, in spite of soothing applications, the best plan is to touch its sur- face with a finely-pointed pencil of nitrate of silver, so as to produce an insensible film on the surface : this is to be repeated at intervals of three or four days. . VII. Staphyloma is a term employed to signify any protrusion on the anterior surface of the eye. 1. Staphyloma iridis signifies a protrusion of the iris, which occurs when the cornea is perforated by ulcers or wounds. The term mijocephalon is applied to the protrusion of a very small piece of the iris through an ulcerated opening in the cornea. For the treatment see 2 Staphyloma of the cornea is said to exist when a portion or the whole of the cornea, whose texture has been disorganized by injury or disease has perished ; and the cicatrix with which the iris has become covered, bulges before the pressure of the humors of the eye, and forms an opaque white prominence If partial, it is usual to recommend that the nitrate of silver or butter of antimony be applied to the apex of the staphyloma, so that the inflammation excited may thicken the cornea, and enable it to resist further protrusion • the caustic to be well washed off with milk before the lids are closed But besides sympathetically affecting the other eye, it is seldom that the use either of the nitrate of silver or butter of antimony checks the increase of staphyloma, and sooner or later the eye collapses from the neces- sarily extensive use of the knife. Therefore, when the staphyloma is still limited Mr II Walton shaves it off; by which means the cut part frequently 362 DISEASES OF THE SCLEROTIC. cicatrizes, and no further protrusion is effected. This treatment is appli- cable to small staphylomata, and especially those that rise suddenly, and have a small, well-defined base. Fig. 199. Fig. 200. Staphyloma of the cornea. VIII. Hernia Corner.—When the cornea is nearly perforated by an ulcer, a thin transparent vesicle is apt to protrude from the aperture, con- sisting of a thin lamella of the cornea ; the posterior elastic membrane. The best plan is to keep the eyelids closed for a few days. Cicatrization to the edges of the cornea soon ensues. IX. Conical Cornea.—In this curious affection the cornea becomes exceedingly convex, but remains transparent, and it often gives a peculiarly brilliant appearance to the eye. As it increases it causes almost total deprivation of vision, which, however, can be partially remedied by looking through a minute aperture in a piece of blackened wood, and sometimes by using concave glasses ; sometimes by a combination of the concave glasses with the wood having the hole in it, or a perforated diaphragm set in a spectacle-frame. Tonics may be of service. See Artificial Pupil, p. 367. X. Arcus Senilis is the name given to a circumferential opacity of the cornea, which has been shown by Mr. Canton to depend on fatty degene- ration. As its name implies, it is most generally met with in the aged, and affects each eye symmetrically. When existing in one eye only, it is gene- rally connected with some previous injury or disease which has spoiled the corneal tissue. Mr. Canton has pointed out that the arcus, when met with in early life, as at fifty, forty, thirty, or earlier, is often associated with fatty degeneration of the heart.1 [Dr. Wilks, an excellent authority on such subjects, does not believe arcus senilis to indicate any particular change within the body, but that it accompanies concomitant senile changes in the body generally; the term being still applicable if old age should be pre- mature. See his paper in Guy's Hospital Reports, third series, vol. iii.; also the Amer. Journ. Med. Sci. for October, 1858, p. 483.] section vii.—diseases of the sclerotic. I. Acute Inflammation of the Sclerotic is commonly called Rheu- matic Ophthalmia ; because the structure affected is similar to that which is commonly said to be attacked by rheumatism. But sclerotitis is, pro- perly speaking, an inflammation of the sclerotic, and in some measure also of the cornea, iris, and other proper structures of the eyeball; and it ought not to be called rheumatic, unless there are pains in the joints, acid per- spiration, or other evidences of the rheumatic diathesis 1 Lancet, Jan. 11, 1851. AFFECTIONS OF THE ANTERIOR CHAMBER. 363 Symptoms.—It is known by redness of the sclerotic,—dimness of sight, sometimes great intolerance of light, sometimes not—severe stinging pain of the eye, and aching of the bones around, which is greatly aggravated at night,—and fever. It may be caused by cold ; and sometimes is a sequel of gonorrhoea; but it is a rare disease. It may lead to opacity of the cornea, or to iritis. Diagnosis.—This form of ophthalmia may be distinguished from inflam- mation of the conjunctiva, 1st, by the character of the pain, which is a severe aching, principally felt in the eyebrow, temple, and cheek, and is greatly aggravated every evening; being excessively severe during the night, but remitting towards morning. Whereas, in conjunctivitis, the pain is of a scalding nature, and accompanied with a sensation as if sand was in the eye. 2dly, by the character of the redness ; which is deep-seated, and of a pale pink; and by the vessels running in straight lines from the circumference of the eye towards the cornea ; whereas in conjunctivitis the redness is scarlet and superficial, and more vivid ; the vessels are tortuous, and freely anastomose, and can be moved about with the finger. Treatment—In severe cases, it is commonly said to be necessary to bleed generally or locally ; at all events, to purge, and administer mercury with opium till the gums begin to suffer. But Mr. Taylor says, that he has seen severe cases treated by bleeding, leeching, and mercury, and that ail have been made worse. The plan which he has found rather successful, is to give mercury in small doses, with bark or iodide of potassium, or with tincture of colchicum ; and he says that blisters to the temple or eyebrow are some- times useful. The pain may be relieved by friction of the forehead every afternoon, with extract of belladonna dissolved in warm laudanum (3j. ad $'].), or with mercurial ointment and opium, or F. 149,—warm pediluvia or warm bath,—blisters behind the ears,—and Dover's powder at bed-time. Dry warmth, by means of muslin bags filled with chamomile flowers, and heated on a hot plate, is a very soothing application. In genuine rheumatic cases, tonics should be early resorted to, especially decoction of bark with potass, or with iodide of potassium. II. Catarrho-rheumatic Ophthalmia is a combination of inflammation of the sclerotic with that of the conjunctiva. The symptoms of conjunctivitis, that is to say, roughness and sense of dust in the eye, muco-purulent discharge and superficial scarlet redness,—are combined with the deeper-seated, straight- lined redness, and with the zone around the cornea, and fits of nocturnal aching that characterize inflammation of the sclerotic. This disease generally occurs in broken-down constitutions, and is very apt to lead to onyx, and to ulceration of the cornea, and suppuration of the anterior chamber. Treatment—Warm opiate collyria, F. 142, weak citrine ointment, and the other topical applications for conjunctival inflammation, must be used in addi- tion to the remedies prescribed for inflammation of the sclerotic. III. Tumors of the Sclerotic require caution in meddling with them, lest the cavity of the eye be opened. SECTION VIII.—AFFECTIONS OF THE ANTERIOR CHAMBER. I. The term Aquo-capsulitis has been applied to signify inflammation of the membrane of the aqueous humor. But it will be highly satisfactory to know, that as there is no such membrane, so there can be no such disease ; and that the appearances commonly considered to denote this disease,— namely, a mottled opacity of the posterior layers of the cornea—really denote inflammation of the posterior layers of the cornea.1 i See a Clinical Lecture by H. Haynes Walton, on the non-existence of Aquo-Cap- sulitis, Med. Times, 5th May, 1855. 364 DISEASES OF THE IRIS. II. Entozoa.—The Cysticercus Celluloses (see p. 169) has on several occasions been found within the, anterior chamber. In most of the recorded cases the patient has been the subject of one or more acute attacks of inflam- mation of the eye leading to opacity of the cornea. On examination a globu- lar vesicle was discerned floating in the anterior chamber. It requires to be extracted by incision.1 SECTION IX.—DISEASES OF THE IRIS. I. Inflammation of the Iris, or Iritis.—The iris is exceedingly liable to inflammation, which generally involves also the sclerotic, the anterior cap- sule of the lens, and in fact most of the deeper structures in the eyeball. Dr. Jacob has well remarked, that " The use of the term iritis has the effect of directing the practitioner's attention to the iris, which bears a great deal of inflammation without destruction to the organ, and of withdrawing it from the retina, which bears very little, without permanent injury to vision." Symptoms.—In the first stage, the fibrous texture of the iris is indistinct, appearing confused, and it loses its color ; if dark, it becomes reddish ; if blue, it becomes greenish [or, in other words, it generally becomes of that color which would result from mixing a dirty red with the normal color of the membrane]. The pupil, also, loses its mobility, is contracted and irregu- lar. In the next stage, lymph begins to be effused ; sometimes in the form of a thin layer, causing the surface to appear rusty and villous—sometimes in small nodules; sometimes the pupil is filled with a film of it, sometimes, but very rarely, it is poured out in such abundance as to fill the whole cavity of the aqueous humor. The eye displays that kind of redness which arises from vascularity of the sclerotic ; that is to say, a pink redness, with vessels running in straight lines from the circumference of the eye, and terminating in a vascular zone around the cornea ; but in very acute cases the entire conjunctiva becomes injected likewise. Sometimes the cornea is slightly hazy. • The patient complains of intolerance of light and dimness of vision, and of more or less burning, stinging pain in the eye ; but besides this, there is also a severe neuralgic aching of the brow and parts around the orbit, coming on in nocturnal paroxysms. Causes.—Iritis, as we explained in the first section, may be caused by injuries, or by over-exertion of the eye ; but it more frequently depends on constitutional taint, syphilis, or gout. Prognosis.—Favorable, if the disease is recent, although the impairment of vision may be considerable ; but doubt- F'g- 201. ful, if it be of very long duration, if there be much deep-seated pain, and especially if there be effusion of lymph behind the iris. Varieties.—Iritis may vary in the de- gree of acute inflammation which attends it; being active and rapid, attended with bright redness, great pain and fever, if it occurs in a robust plethoric subject; but in other cases, slow and insidious. It is also divided into several species, ac- xoduies of lymph effused in syphilitic cording to the nature of the cause pro- iritis, ducing it. Thus :— 1. The traumatic iritis is that which arises from penetrating wounds of the eye. 1 See Mackenzie, Med. Chir. Trans, vol. xxxii. ; Canton, Surgical Observations, Lond. 1853 : Haynes Walton, Operative Ophthalmic Surgery, p. 502. DISEASES OF THE IRIS. 365 2. Syphilitic iritis.—This is the most frequent variety. It is distin- guished by the effusion of lymph on both surfaces of the iris, and in little nodules of a reddish or dirty-brown color, which cause the pupil to become irregular. There is great pain at night, and but little by day, and second- ary venereal affections of the throat or skin are usually present at the same time, or have preceded it. It may occur to infants who are affected with constitutional syphilis. 3. The rheumatic iritis arises under the conditions that cause the develop- ment of rheumatism in other organs. It differs from the syphilitic variety in the fact that there is less tendency to the deposit of lymph on the iris, and in the anterior chamber. The iris becomes dull and discolored, without showing nodules of lymph, yet the pupil is more likely to become irregular and adherent; and the adhesion is, too, for the most part more general. Occasionally a little ring of fibrinous matter is deposited on the capsule of the lens, just within the circle of the adherent pupil. It is from such depo- sits, the accumulated effect of many attacks of inflammation, that the eye becomes destroyed. The surface of the eyeball is more inflamed, and fre- quently of a purplish-red color, consequently there is not the definite zone of sclerotic redness that is usually so clearly defined in syphilitic iritis. The cornea, especially the posterior elastic lamina, is prone to become more or less opaque in patches, remains of which opacity may be permanent. But there is no greater characteristic of the disease than its tendency to return, insomuch that a person may have an attack once or twice a year, or at longer intervals, during a long life, and this, even after the pupil has been closed by plastic material. It may be well to state that a white ring around the cornea is present in all inflammations of the surface of the eye in which the cornea remains clear and vascular. 4. Scrofulous Iritis.—This term maybe used to signify either idiopathic iritis occurring in a scrofulous habit, and generally combined with corneitis ; or else a deposit of cachectic lymph on the iris, which leads to scrofulous sup- puration of the eyeball, or atrophy. Treatment—The indications are, 1, to subdue inflammation; 2, to arrest the effusion of lymph, and cause absorption of what is already effused ; 3, to preserve the pupil entire ; 4, to allay pain. 1. If the patient be strong, and the disease acute, with full strong pulse, and much fever, bleeding from the arm, or cupping from the temple may be requisite. The bowels must be well cleared, the antiphlogistic regimen generally be observed, without bringing the patient into a state of debility, and blisters be applied after the most acute stage has subsided. 2. To fulfil the second indication, the principal remedy is mercury ; and the ordinary plan of administering it is to give gr. i.—ii. of calomel with gr. 1—i of opium at intervals of six or eight hours. But a most salutary change has come over the practice of surgeons in the administration of mercury, as well as in the use of bloodletting. It is now some years since, in attending a case with Mr. Walton, that the* writer learned from him, with much satisfaction, the efficacy of small doses in iritis; such as two or three grains of hyd. c. creta, combined with hyoscyamus or conium, and given twice, thrice, or perhaps four times in the twenty-four hours, and the doctrine that the curative effect of mercury is almost always to be produced, short of salivation, which may well be termed one of the poisonous effects. If the remedy be thus gently administered, the dose being lessened so soon as the mouth begins to. be tender, the lymph will generally be found to break up, and gradually disappear, leaving the pupil clear. In debilitated or scrofu- lous subjects, and in tedious cases, tonics, such as bark, cod-liver oil, or iodide of potassium may be given with the mercury. Turpentine in drachm doses, 366 DISEASES OF THE IRIS. F. 74, has been recommended in iritis instead of mercury; but its efficacy admits of doubt. 3. The pupil should be kept well dilated by means of a filtered solution of one scruple of extract of belladonna in an ounce of distilled water. But the most elegant way is to drop into the eye a solution of the sulphate of atropine (gr. i. ad %'\. aquas destill.). Stramonium and hyoscyanius have the same effect, but in a much less degree. 4. The pain must be relieved by nightly doses of opium, and the applica- tion of poppy fomentation to the eye, and the rubbing in of the unguentum opii to the temple. In the rheumatic iritis the secretions of the liver and bowels should first be well cleared out by calomel with warm aperients ; then the hyd. c. creta in very small doses twice daily, with colchicum, alkalies, and purgatives, and counter-irritants, are the best remedies. Pediluvia containing mustard should be used every night. The same plan of treatment will serve for the gouty iritis, if such a disease should be met with. II. Synechia Posterior, adhesion of the uvea to the capsule of the lens; Synechia Anterior, adhesion of the iris to the cornea; and Atresia Iridis, or closure of the pupil—three consequences of organization of lymph from protracted iritis—may be partially removed by mercury, if recent, but are irremediable, except by operation, if of long standing. But belladonna should always be applied ; because if a very small portion of the pupil is by chance unadherent, it may be dilated, so as to afford a very useful degree of vision. III. Myosis—a preternaturally-contracted pupil—is sometimes met with in persons accustomed to look at minute objects, and is attended with great obscurity of vision, especially in a feeble light, because the iris is unable to dilate. To give repose to the eyes, and attend to the health, are the only available indications of treatment: Mackenzie says that belladonna is hurtful. IV. Mydriasis signifies a preternatural dilatation of the pupil, which does not contract on exposure to light. This state, as is well known, is readily produced by belladonna and many other narcotico-acrid poisons;, it is caused also by any injury of the brain affecting the tubercula quad- rigemina, as in apoplexy and compression of the brain ; and is often an attendant of confirmed amaurosis. But sometimes it seems to depend simply on a derangement of the nerves supplying the iris, without diminution of the sensibility of the retina; and this form of it may also be attended with ptosis ; as a further evidence of paralysis of the third nerve. Sometimes it depends on gastric irritation and general debility, and is lessened as the health improves. If the retina is sound, which will be known by the per- ception of light, and by vision being improved by looking through a small round aperture in a piece of blackened card, concave glasses are often in service. One case is recorded which was said to be cured by ergot of rye, in scruple doses four times a*day.1 Generally speaking, in uncomplicated cases, the prognosis is good if a tonic plan of treatment be adopted. Mr. R. Taylor has seen good results follow a succession of blisters to the temple or brow, and the application of stimulating vapor—as of ammonia—to the eye. He also believes that nux vomica is of service. V. Cysts filled with watery fluid, and growing from some part of the iris, may be mistaken for cysticercus, or dislocated lens; the chief distinction being that they have a fixed attachment. A cyst may be congenital, or may grow after some injury. If allowed to remain and increase, the whole eye- ball becomes disorganized. The usual treatment recommended is, to incise 1 L'Experience, Sept. 1839. DISEASES OF THE IRIS. 367 the cornea, draw out the cyst, and cut it off. But this is a most severe operation, and one likely to be followed by the loss of vision ; whereas Mr. Walton gives cases which show that if the cyst be punctured freely with an iris knife, it will collapse and give no further trouble. The operation may, however, require to be repeated. VI. Artificial Pupil.—By this is meant an alteration in the shape or position of the pupil, or a new aperture in the iris, effected by surgical ope- ration, for the purpose of allowing the rays of light to reach the retina. The cases in which such an operation may be expedient, are, 1, partial opacity of the cornea ; 2, complete or partial closure of the pupil by lymph; 3, closure of the pupil from prolapse of the iris, or adhesion of it to the cornea, in consequence of ulceration or of wound of the cornea, which, in this case, is more or less opaque ; 4, closure of the pupil, after the crystal- line lens has been extricated or absorbed. Respecting the various forms of operation which have been proposed for these and for the other combina- tions of circumstances that may Fig. 202. be met with, we must content our- selves with detailing such general principles as every surgeon ought to be acquainted with ; referring those who wish for fuller informa- tion to the works of Bowman, Wilde of Dublin, Mackenzie, Guthrie, Wharton Jones, Tyrrell, and Walton. Such particulars as we give are gathered chiefly from the " Operative Ophthalmic Sur- gery" of the last-named gentle- man. 1. There is the operation by incision (coretomia), which is es- pecially available when the pupil is closed, after the removal of the lens, and when the cornea is clear, and the iris tolerably healthy in Structure, SO that it is capable Of Operation by incision for artificial pupil. retracting and forming a roundish pupillary aperture, after incision. The instrument employed is the iris knife, a lancet-shaped knife of various dimensions, according to the size of the aperture required. This is carried through the cornea, near its margin, across the anterior chamber, and thrust up to its shoulder into the iris. 2. The operation of incision vjith extension was proposed by Mr. Walton for cases in which, owing to loss of contractility in the iris, a sufficiently large aperture could not be made by simple incision. The iris is divided by incision, and then, by means of a fine blunt hook, the outer lip of the incision is drawn outwards till a sufficient opening is made. 3. A third operation, similar in principle to the last, is effected by intro- ducing a very fine pair of scissors, through a wound in the margin of the cornea; thrusting one blade through the iris, and making first one cut, then a second, meeting at an acute angle like the letter V. 4. The operation of excision (corectomia) consists in incising the cornea, close to the margin, drawing out the iris by a hook or forceps (if it does not protrude of itself), and cutting out a small portion of it. This is applica- ble to cases of opacity of the cornea, with the iris and lens healthy ; or to closure of the pupil from lymph, with adhesion to the centre of the capsule, 368 CATARACT. without opacity of the lens or of the rest of the* capsule ; for it is now estab- lished that the centre of the capsule may be opaque from lymphy deposit after iritis, and the lens and rest of the capsule remain transparent. 5. Another operation adaptable to cases of closure, complete or partial, of the pupil, the lens being healthy, consists in puncturing the cornea, intro- ducing the very fine canula forceps, seizing the iris close to the pupil, and tearing away a portion of it; or else introducing a hook, seizing the edge of the pupil, and tearing a thin strip outwards. 6. The operation of separation (coredialysis), which consists in tearing away a portion of the circumference of the iris, is resorted to when there is central opacity of the cornea, with a portion of the circumference clear; the pupil being also closed from prolapse or adhesion to the cornea. The best position for the pupil is as nearly central as possible : if it can- not be made central, it is better, according to Mr. Walton, at the inferior margin of the iris.1 But before resorting to any of these operations, it must be ascertained, 1st, that the adhesions of the iris cannot be removed by mercury or belladonna ; or opacity of the cornea by external applications, aided by time, which, if the health be kept in good order, does much towards restoring every im- paired organ to its normal condition ; 2dly, that the retina is perfectly sound; 3dly, that all tendency to inflammation (syphilitic or otherwise) has ceased. It is not advisable to operate if one eye be quite sound; and supposing one eye to be irrecoverably lost, it is not* advisable to form an artificial pupil in the other, provided the patient find his way about with it. Moreover, tha new pupil should be made large, because it will always contract somewhat afterwards. SECTION X.—INFLAMMATION OF THE CAPSULE OF THE CRYSTALLINE LENS. This is a very rare affection, and always chronic. Vision is confused— objects looking as if they were seen through a fine gauze. On examining the eye with a strong lens in a good light, the pupil being well dilated with belladonna, a number of minute red vessels are seen in the pupil. If the anterior capsule be affected, the vessels form a circular wreath of vascular arches with the centre clear ; if it be the posterior capsule, they are central and arborescent. The iris is always slightly discolored and sluggish. Treatment—Local bleeding, if necessary ; mercury, counter-irritation, change of air, and alteratives. SECTION XI.--CATARACT. Definition.—An opacity of the crystalline lens or of its capsule, or of both. Symptoms.—Before examining any patient with suspected cataract, the pupil should be dilated with belladonna, or F. 198, and then, if there be cap- sular cataract, there will be seen behind the pupil an opaque body of a gray dead-white ; if lenticular cataract, of a bluish-white, or amber-color. The patient usually gives as his history, that his vision has become gradually im- paired ; that objects appear of irregular outline, or multiplied, or as if sur- rounded with a mist, or as if a cloud was interposed between them and the eye. If lenticular cataract alone be present, he will say that the sight is better in the evening, or in a subdued light, or when the back is turned to ' the window ; or perhaps after the application of belladonna or atropine— obviously because the pupil, being dilated under these circumstances, per- 1 Vide Lecture, Med. Times for 1849, p. 331. CATARACT. 36 9 mits more light to pass through that part of the lens which is as yet trans- parent, or which, though opaque, is thinner, and therefore affords less obstruction to light than the centre. In the most confirmed cases, the patient is yet able to distinguish day from night. There is also the catoptric test,—that is, the mode of examining the eye by the reflection of light, which was proposed by M. Sanson. When a lighted taper is moved before the eye of a healthy person, three images of it may be observed. 1st. An erect image, that moves upwards when the candle is moved upwards, and that is produced by reflection from the surface of the cornea. 2dly. Another erect image, produced by reflection from the anterior surface of the crystalline lens, which also moves upwards when the candle is moved upwards ; and 3dly. A very small inverted image, that is reflected from the posterior surface of the crystalline lens, and that moves downwards when the candle is raised upwards. To render this most dis- tinct, the pupil should be dilated, and the examination be made in a dark room. Xow, in lenticular cataract, this inverted image is from the first rendered indistinct, and soon abolished ; and the deep erect one is soon afterwards abolished also. In capsular cataract, from the first, only the front erect image, that, namely, produced by reflection from the cornea, is visible. But the disease must be advanced, and the observer experienced, if this test is to avail; and the ophthalmoscope gives the earliest means of detecting opacity of the posterior part of the lens. Diagnosis will be spoken of under Amaurosis and Glaucoma. Causes.—Cataract, especially capsular, is sometimes attributable to in- flammation, and may be caused in a short space of time by wounds or other injuries of the lens and capsule, or of the eye in general. But the ordinary cataract of the old, seems to be a mere effect of impaired nutrition. 1. Hard Cataract—-This form is met with in elderly people only. _ It is caused, according to Mr. Walton, by grayness or opacity appearing in an already discolored lens ; and the greater the coloration of the lens, the less will be the amount of grayness required to obstruct vision. After thirty, the lens naturally acquires a yellow color, and the hue becomes deeper, till it is like a piece of amber. The amber color, therefore, the characteristic hue of cataract in aged persons, is not the effect of disease. Sometimes the color is as deep as that of dark mahogany : and Mr. Walton has brought before the Royal Medical and Chirurgical Society the particulars of a case in which the cataract was so black that it could not be detected till the eye was examined with the ophthalmoscope, or the concentrated light of a powerful lens. According to Mr. R. Taylor1 the change in such cataractous lenses is twofold. The nucleus becomes hard and dry, to a degree far exceeding what is ever seen in the healthy lens; while the superficial layers are soft- ened, frequently to the state of a semi-fluid pulp. The nuclear lens-tubes are hard, atrophied, and brittle, and are rendered more or less opaque by fine molecular deposit, as well as by little cracks and fissures. Those of the superficies are softened, and more or less disintegrated ; they, also, are dotted over with fine molecular matter, which is also found floating free in masses, and filling up, and rendering opaque, many of the superficial lens- cells This molecular matter is probably the result of the coagulation of the albuminous blastema by which the whole of the lens textures are pervaded. . The opacity generally commences in the superficial layers ot the lens, tor the most part in the form of streaks or radii, converging towards the centre or, more correctly speaking, following the course of the natural divisions of 1 Pathological Transactions, vol. vii. 24 370 CATARACT. the lens. Less frequently it commences in the nucleus, in the form of a cloudy opacity. When the disease is of long standing, the surface of the cataract frequently assumes a uniform milk or cream-white color. 2. Soft Cataract.—While hard cataract is seen only in persons above thirty-five years of age, soft cataract may occur at any period of life. It appears to be due to disintegration affecting the whole substance of the lens, similar to that which affects the surface alone in hard cataract. The color in infancy is bluish white, like milk and water; later in life there is gene- rally less of the blue tint. The surface frequently presents an appearance like that of fractured spermaceti; or it may be traversed by radii and streaks, which glisten like a piece of tendon. In this variety vision is generally more imperfect than in the hard kind. The iris is frequently pressed upon by soft cataract; but this may also occur in hard cataract when the surface of the lens is much degenerated. This phenomenon is probably due, in the majority of instances, to the swelling of the diseased lens from the imbibition of moisture ; but in other instances, the opinion of Mr Walton is doubtless correct, that it is caused by unnatural vascularity in the deep-seated textures of the eyeball. 3. Congenital Cataract must, therefore, always be soft. In this variety vision is generally more imperfect than in the hard kind. 4. Capsular Cataract.—In this variety the opacity may be general, or may commence partially. It is almost invariably of a dead or chalky white- ness, scarcely ever shining, and always showing the same opacity in what- ever position it may be viewed. It is not unfrequently the result of a slow inflammation, which may be accompanied with pain in the eye. It may be produced also by inflammation extending from the iris. Opacity of the anterior portion may be seen immediately behind the iris. That of the posterior appears at some little distance behind the pupil, and presents a concave striated surface, of a dull-yellowish appearance. 5. Capsulo-lenticular cataract is very common,—in fact, entire opacity of the capsule is always followed by opacity of the lens. Treatment.—The cataract must be removed by operation. No other treatment is of any avail to get rid of the disease. It is, however, a general rule not to operate till the cataract is mature—that is, not whilst the degree of vision is sufficient for ordinary purposes ; more particularly if the patient is very old and feeble, or if one eye is already lost; because, under these circumstances, a failure of the operation would entail utter blindness. There- fore the patient should assist his vision by dropping into the eye one or two drops of a carefully-filtered solution of extract of belladonna Qi. ad ^i.) in distilled water, night and morning, or F. 198, so as to dilate the pupil, and defer the operation till, despite of that aid, his blindness is complete. Prognosis.—This will be favorable if the patient is in good health and of temperate habits; if the iris moves freely, and if the retina seems per- fectly sensible to light. On the other hand, it will be doubtful if there are signs of vascular disturbance in the eye ; if the iris is motionless or altered in color; or if the cataract is complicated with amaurosis, softness of the eyeball, or glaucoma. Preparation.—Before operating, the patient should be put into as perfect a state of health as possible. The state of the biliary, and more especially of the urinary excretion, should be examined, and purging, exercise, and low diet be enjoined, if the habit is inflammatory. But no rude lowering measures, or violent purgation, or sudden change of diet should be resorted to indiscriminately; and some patients require a better diet, with tonics and wine. There are three methods of operating :—1, extraction; 2, displacement (or couching) ; and 3, solution, or the operation for causing absorption. CATARACT. 371 I. Extraction.—The object of this operation is, to make an.incision through half of the circumference of the cornea, almost close to the sclerotic ; to lacerate the capsule of the lens ; and then to extract the cataract entire, through the pupil. Its advantage is, that it effectually removes the cataract; but it is the most difficult of all the operations for cataract, and demands, for its success, much knowledge and much practice. It is best adapted for hard cataracts in elderly people. But it should not be attempted, 1st, if the patient is very feeble, in case the wound of the cornea might not unite. 2dly. If the anterior chamber is very small and the cornea very flat, so that a sufficiently large opening cannot be made in it. 3dly. If the iris adheres to the cornea, or if the cataract pushes it forward against the cornea, thus rendering it impossible to incise the cornea without wounding the iris, or if the pupil is habitually contracted. 4thly. If the eye is sunken, or if the fissure of the lids is preternaturally small. 5thly. If the eyes are very unsteady, or if the patient is subject to habitual cough or asthma, or is unmanageable in consequence of idiocy. Some practitioners direct that one eye only should be operated on at a time, the other being kept as a reserve, whilst others operate on both together. Operation.—In the precise manner of performing this, there are very many varieties. Some surgeons incise the lower, others the upper, part of the cornea; some sit before, others behind the patient; some are ambidexter, others use the right hand only. But, referring those who may wish for fuller information to the various works on ophthalmology before quoted, p. 367, we shall content ourselves with describing one method of operating which is, we believe, most generally employed at the present day. The instruments required are, 1, a knife having a triangular blade ; the back straight and blunt; the point sharp ; the edge slanting obliquely ; the blade increasing in thickness, as well as in breadth, as it ap- Fig. 203. proaches the handle. The ad- vantages of this shape are, that it fills up the incision which it makes, and prevents the escape of the aqueous humor ; and that the flap of the cornea is made by one simple motion, that is, by pushing the knife onwards. That used by Mr. Walton mea- sures from the point to the shoulder T§th of an inch, and aCrOSS the broadest part ^7?tll Operation for extracting the crystalline lens. of an inch, which gives a longer blade and a more acute angle than that shown in the drawing. But dif- ferent operators use knives of different shapes. 2. A curette; an instrument with a curved needle at one end, and a small spoon at the other. Mr. Walton has devised a guarded curette, in which the hook is concealed till protruded by a spring. 3. A secondary knife to enlarge the incision in the cornea if required. 4. A sharp hook. The patient may be either sitting, or lying on his back with the head properly supported, and in a good light. The operator, behind him, uses his ri«-ht hand for the right, and his left for the left eye. An assistant draws down°the lower lid, and steadies it against the malar bone, without pressing on the globe. The operator, with the forefinger of the non-operating hand, raises the upper lid and locks it under the edge of the orbit, just resting the point of this forefinger against the upper surface of the globe, and that of the middle fino-er against its inner surface, so as to steady it. Then holding the 372 CATARACT. knife lightly with the thumb and first two fingers of the other hand, and resting his hand against the side of the face, he commences by—1. Punc- turing the cornea at the centre of its outer margin, half a line, or even less, from the sclerotica. 2dly. The blade is pushed gently across, parallel with the iris, in such a way that the point shall penetrate the other side of the cornea, exactly opposite to the first puncture ; and that the edge shall cut an even semicircular flap of the upper half of the cornea. Just when the incision is completed, which should be slowly and carefully done, the eyelids should be dropped, and all pressure be ceased. 3dly. Having waited a few seconds, the surgeon lifts the upper lid sufficiently to expose the cornea, tells the patient to look towards his feet, so that the globe may be directed down- wards ; then introduces the curette, and freely lacerates the capsule of the lens. 4thly. He makes very gentle pressure on the under part of the globe, and on the upper eyelid, till the lens rises through the pupil and escapes. Lastly, the eye should be opened after a minute or two, to see that the flap of the cornea is rightly adjusted, and that the iris is not prolapsed : if it is, the eyes should be exposed to a bright light, so as to make the pupil con- tract, and the prolapsed portion should be gently pressed upon with the spoon of the curette. Then the operation is finished. Complications.—1. Sometimes, in consequence of the premature escape of the aqueous humor, the iris falls forwards under the edge of the knife. If the point of the knife is completely entangled in the iris, it is necessary to withdraw the instrument, heal the wound, and repeat the operation after- wards. If, however, a little bit of it should get under the edge of the knife, when the section is nearly complete, an attempt should be made to extricate it by pressing on the cornea just over it with the nail; but if this does not readily succeed, the operator may push on boldly, since, if a little piece of it be cut, it will be of no great consequence. 2. • If the opening of the cor- nea is not large enough, it must be enlarged with the secondary knife. 3. If a portion of the lens remain behind, it should be left to be absorbed—unless it has passed into the anterior chamber, and can be removed very easily indeed. 4. If the vitreous humor seem disposed to escape, the cataract should be hooked out with the hook. After-Treatment.—The patient should be put to bed, with the shoulders raised, the room darkened, and with a very soft dry linen rag over both eyes. [It is a very good plan to keep the eyelids closed by means of strips of court-plaster, passing from the forehead over the eye, down to the cheek.] The bowels should be kept open, and everything be avoided which is likely to provoke coughing, sneezing, or vomiting. Mr. Walton allows the usual diet, at the usual times, only in rather diminished quantity; and this plan seems preferable to that of keeping the patient exclusively on slops. If all goes on comfortably, the eyelid may be raised on the seventh day, and then if there be no prolapse of the iris, and the cornea be united, he may get up occasionally, wearing a shade, sitting in a darkened room, and walking about a little. After a fortnight the eye may be opened in a weak light, and be gradually brought into use. But, inasmuch as it remains weak and irritable, the patient must take the greatest care to avoid exposure to cold, excess in diet, over-exertion of the eye, or exposure of it to too strong a light. Gray spectacles are the best protectors against too glaring a light. The patient will require convex spectacles for exact vision, but they must be used very sparingly for some weeks. He should have two pairs, one with a short focus for near objects, and another of long focus for distant objects. The inflammation which may come on after the operation may be of two kinds. If the eyelids are swollen, and florid, and tender, and there is a thick yellow secretiftn about the lids, and the conjunctiva is red, swollen, and che- mosed, the inflammation is acute, and requires to be treated by bleeding and CATARACT. 373 [Fig. 204. Operation of couching.] purging. But if, as Mr. Tyrrell shows, the palpebral are not much disco- lored, and are cedematous, and if the secretion is thin and light-colored, and the conjunctiva cedematous, the patient will be benefited by good broth, carbonate of ammonia, and opium. II. Displacement, or Couching.—The object of this operation is to remove the cataract from the axis of vision. It is a clumsy and violent operation, and adapted only to those cases of hard cataract, of which the extraction would be unadvisable, for reasons mentioned in a preceding page. The disadvantages of it are, that the pressure of the lens on the ciliary processes and retina is liable to be followed by protracted inflamma- tion or amaurosis ; and that the lens may rise again to its old place, and obstruct vision as before. The pre- paration of the patient, his position during the operation, as well as that of the surgeon, and the duties of the assistant, are the same as required for the operation of extraction The pupil should be dilated with atropine. Operation.—A curved needle is passed through the outer side of the scle- rotic, the £th part of an inch.behind the margin of the cornea, and in the transverse axis of the globe. It is carried into the vitreous humor, the pos- terior capsule of the lens lacerated, then upwards and forwards behind the iris, and in front of the cataract; which then is steadily and gently pressed upon till it is carried downwards out of sight. It should be held down for a few moments to fix it, and if it rise again, it must be again depressed for a short time. Then the needle is withdrawn. III. The Operation for producing Absorption is very easily per- formed, and excites very little inflammation ; but it requires to be repeated several times, and the cure occupies several weeks or months. It is well adapted for soft cataracts, especially the congenital, but does not answer with the hard cataracts of old people. The instruments employed are needles, straight or curved ; which are now made of great delicacy, strength, and sharpness. The pupil must be freely dilated. Operations.__1. The needle may be introduced behind the iris in the same manner as for depression. 2. Or the needle may be introduced through the cornea, an operation now styled the anterior operation ; formerly, keratony.ris. It is safer, simpler, less painful, and less injurious to the eye than the first mentioned : inasmuch as a wound of the cornea alone is less serious than one implicating vitreous humor, sclerotic, conjunctiva, and perhaps retina or ciliary processes. The needle is passed through the cornea about an eighth of an inch from its mar- gin, and is made to lacerate the capsule to the extent of the pupil, so as to admit the aqueous humor to the substance of the lens; but without dis- placing or cutting it into fragments, or, in fact, attempting to do too much. This operation is liable to be followed by severe pain and vomiting, if the cataract be so fluid that it mixes readily with the aqueous humor ; or if por- tions of the cataract press on the iris ; in the latter case, the irritation may be so severe as to render it necessary to perform extraction. The operation may require to be repeated after two or three months. 3. There is a third modification of this operation, which Mr. Tyrrell termed drilling. It is particularly adapted for cases of capsular or capsulo- lenticular cataract with adhesion of the pupil, caused by iritis. It is per- 374 GLAUCOMA. formed by introducing a fine straight needle through the cornea near its margin, and passing it through the pupil into the lens to the depth of about one-sixteenth of an inch, and rotating it freely. This operation may be re- peated at intervals of four, five, or more weeks. It causes the lens to be dissolved by the aqueous humor; and if the puncture be made in a fresh place at each operation, that portion of the capsule which is behind the pupil may become loosened and detached. This operation may also, accord- ing to Mr. Tyrrell, be occasionally resorted to, in order to diminish the size of the lens, previously to depression or extraction. Operation on Infants.—Congenital cataracts should be operated on early—within four months, if possible, lest the eye, which, when born blind, habitually oscillates from side to side, may never acquire the power of being directed to one particular object. The pupil being well dilated, the child, narcotized by chloroform to insure quietness, should be placed on a table— the head on a pillow, and rather hanging over it—one assistant holding the legs and trunk, a second the arms and chest, a third, fixing the head between his two hands, and a fourth, depressing the lower eyelid with one hand, and steadying the chin with the other. The operator then, seated behind the patient, performs the operation for absorption as before described. Care must be taken not to dislocate the lens. The operation on children, and, in fact, on persons under twenty, generally excites so little inflammation, that both eyes may be operated on at once, but the bowels must be kept open, and leeches should be applied if there be pain. Capsular Cataract.—When congenital cataract of the capsulo-lenti- cular sort is left to itself, the lens often becomes absorbed, and the capsule, which is mostly tough or opaque, remains in the field of vision ; and it some- times happens that an opaque capsule is left, or that it becomes opaque after one of the operations for cataract. There are three plans of treatment. 1. A needle may be introduced, as for depression ; and then may be made to tear through the opaque capsule, which then may shrink and leave the pupil clear. 2. The upper part of the capsule, for four-fifths of its circumference, may be detached by the needle from the suspensory ligament, and then be pushed down below the pupil. 3. If no other plan succeed, an opening may be made in the cornea, through which it may be extracted by means of a small hook or forceps. Mr. Middlemore has proposed a plan for removing such bodies through the sclerotic. There is great uncertainty of clearing the pupil of capsule by any other mode but extracting it, yet so dangerous has that operation been deemed, from the escape of the vitreous humor, which is almost sure to occur when previous operations have been done within the eye, that the extraction is seldom attempted. To meet this difficulty, Mr. Haynes Walton has intro- duced into practice a peculiar sort of forceps for the removal of the capsule. The instrument is no larger than a needle, so that the opening in the cornea need not be larger than necessary to allow of the exit of the strip of capsule to be removed, and all the objections to extraction are overcome.1 SECTION XII.—GLAUCOMA. Glaucoma was formerly defined to be a state of impaired vision, accom- panied with a greenish discoloration of the pupil. The green appearance is in the eye of the observer. The disease is, in fact, disorganization of the eyeball. Acute Glaucoma.—There is rapid loss of sight; the iris is dusky and thrust against the cornea by the lens, which is more or less discolored ; the 1 See also Bowman on the Employment of Two Needles, Med. Times, Oct. 30th, 1852. THE OPHTHALMOSCOPE. 375 pupil is large and fixed ; the cornea loses its lustre ; the epithelium gets uneven and may be vesicated. The sclerotic is discolored, being darkish, with large tortuous veins, often without branches, purplish, or of a dark red. The eyeball is of stony hardness, and vision is nearly or quite extinct. There is very great pain. The disease is usually ushered in by occasional dimness of vision, and perhaps by an attack of inflammation ; and always with pain in the eyeball, muscae, flashes, or sparks. Any improvement is but temporary; blindness always ensues. Later the sclerotic is staphylo- matous. Xow and then there is atrophy of the eyeball. Chronic Glaucoma is merely a manifestation of the same symptoms in less severity. The ophthalmoscope shows enlargement of the retinal veins, ecchymosed spots about the retina, pulsation of the arteria centralis retinae, small clots of blood in the vitreous humor, and a cupped or excavated state of the optic papilla. Morbid anatomy shows the vitreous humor often yellowish from coloring matter derived from the extravasated blood, and thicker than natural; ecchy- mosis on the inner surface of the retina, with enlargement of the veins ; dilatation of the retinal capillaries, with aneurismal enlargements filled with blood corpuscles. The lens has generally a yellowish tint, supposed to be due to the same cause that colors the vitreous humor. The choroid coat beyond being congested is scarcely altered, except where there has been staphyloma, when it is degenerated. The effusion supposed to exist between the choroid and the retina does not actually occur. Treatment.__It is of no use to adopt any other treatment for the ordinary chronic glaucomatous degeneration of age, beyond abstinence from exertion of the eye and from anything likely to disorder the health. If the affection begin suddenly, with acute symptoms of a gouty character, as it does some- times, they must be combated by cupping, counter-irritation, and the other remedies proposed for the rheumatic iritis. Opium must be freely given to lessen or subdue the pain. But Von Grafe, who has made out more of the pathology of the disease than any other man, has suggested an operation for its cure. He makes a small linear incision in the sclerotica one millimetre behind the cornea, and removes a sixth of the iris. Von Grafe gives no theory whatever, and can- didly says that his practice is wholly empirical. SECTION XIII.--THE OPHTHALMOSCOPE. I This instrument is to the eye what the stethoscope is to the chest. It has already rendered obsolete nearly all that has been written on the deep- seated diseases of the eye ; for it has been the means of detecting changes unaccompanied with any objective symptoms, and not known till quite lately to exist Its use is quite indispensable in all cases of impaired vision, not attended with extreme intolerance of light. Very seldom indeed does a patient complain, from the use of the instrument, except in cases m which such a result miMit fairly be expected, and might be avoided by ordinary caution. II The ophthalmoscope, in its simplest form, is a concave circular mirror of about ten inches focus, made of silvered glass or polished steel, and hav- ing a hole in the centre. As an appendage there is needed a convex lens an inch and a half in diameter, with a focus of from two and a half to three inches set in a common eye-glass frame with a handle three inches long The investigation must be made in a dark room. The patient's pupil should be dilated as a rule. The light of a candle is hardly sufficient, certainly not for beginners. An oil lamp is better, but by far the best is an argand burner that slides on a vertical rod. The patient sits by a table, and the lamp is placed by his side close to his 376 THE OPHTHALMOSCOPE. head, with the flame on a level with the eye, from which it is screened by a little flat plate of metal attached to the burner. The operator sits directly in front; and, holding the instrument close to his eye, and a little obliquely to catch the light from the lamp, he commences at the distance of about eighteen inches from the patient, to direct the reflection on the eye. When this is got, the convex lens must be held at the distance of two and a half inches from the eye and the focusing commenced, by moving them slowly backwards and forwards. When the light fairly enters the eye a reddish glare appears, and as it is focused, an orange-red or orange-yellow is seen ; then the bloodvessels of the retina come into view. The retina itself pre- sents a whitish aspect, through which the choroid is more or less discernible. The entrance of the optic nerve should now be sought; probably a part of it will already have been seen as a whitish spot; but the way to discern it properly is to make the patient look inwards. It appears as a whitish circular spot, in the centre of which are the central vein and artery of the retina, giving forth a variable number of branches, usually six or eight. The convex lens is not usually needed for examining near-sighted eyes, nor, in general, for the anterior structures of the eye. The annexed sketch (Fig. 205) illustrates the above description, and accurately shows the proper position of the lamp, the direction of the patient, and the slightly-raised position of the observer. [Mode of making an ophthalmoscopic examination.] III. But what is the principle of the ophthalmoscope ; why is a reflector needed ; why cannot the eye be illuminated with the very lamp from which the light is borrowed ? When a stream of light is thrown into the eye, the rays are reflected back by the retina and choroid, and, returning as they enter, are brought to a convergence at the spot whence they emanated. This takes place when any luminous body is held before the eye; hence when a candle or lamp is used, we see no illumination, simply because the flame is in the focus of reflection, and our eye cannot be there too, nor can it see through the flame. This difficulty is overcome by using a mirror with a hole in the centre (the ophthalmoscope), which represents the flame, and, by looking through the hole, we place our eye in the centre of the reflection, and thus see the lighted interior of the patient's eye. It is possible, by cer- THE OPHTHALMOSCOPE. 377 Fis. 206. tain arrangements of light, and position of the beholder, that the eye may be to an extent seen illuminated ; but for the full effect, the ophthalmoscope is requisite. IV. Healthy Appearances.—The arteries and veins—the latter being larger and darker—radiate on the retina, and branch and anastomose almost to the ora serrata. Xo vessels cross the situation of the macula lutea. It is not uncommon in eyeballs that are diseased to see the pulsation of these vessels ; sometimes it may be seen in health, especially if the eyeball be pressed. Mr. Hulme has a patient attending at the Central London Ophthalmic Hospital, with pulsating retinal vessels, although the sight is unimpaired. The Choroid must be focused to be examined. The irregularly arranged markings of a dusky hue indicate the vessels. The coloration of the choroid is darker in persons of a dark complexion, and of a lighter and less distinct shade in those of a fairer skin. The Retina is a perfectly transparent colorless structure, and is best recognized by means of the vessels which pervade it. The arteries are of a smaller calibre, and have a more direct course than the veins, which are more tortuous, and of a darker color, derived from their contents; but this last feature is not always well marked. The Optic Disk, or termination of the optic nerve, as it enters the sclerotic, is the most important part to be noted in an ophthalmoscopic examination. In health it is circular in form, of a bright white color, and perforated gene- rally in its centre, but frequently in dif- ferent parts of its surface, by three or four arteries entering the globe for dis- tribution, and by as many veins which leave the interior of the eye. (See Fig. 206.) A slight hyperaemia of the disk is not incompatible with healthy vision. The Macula Lutea is that part of the retina which lies directly in the axis' of vision, and which is brought into view by causing the patient to look directly forwards. Frequently there is no parti- cular structure to be made out, and the part is generally recognized by the ab- sence of the retinal vessels, which seem to avoid this situation. Sometimes a paler, and at other times a darker appearance are the only indications of it. It must, however, be borne in mind that it is often the seat of hemorrhages, morbid deposits, &c, which are always more or less detrimental to perfect vision. It should therefore be carefully examined. The Vitreous Humor, the aqueous, the lens, and its capsule, and the cornea, are all parts which in the healthy state of the eye are transparent, and admit of a clear definition and observation of the whole of the posterior part of the interior of the eyeball. V. Morbid Appearances.—Such is a description of the parts seen by the ophthalmoscope in the healthy state. We now propose, for the guidance of the student, to give an outline of the morbid appearances to be observed, premising that a thorough knowledge and use of this instrument can only be acquired by most careful practical study.1 ' To those interested more especially in the diseases of the eye, as revealed by the ophthalmoscope, the following works are recommended for study and reference:— [Healthy appearances of the eye.] 378 THE OPHTHALMOSCOPE. The Optic Disk is the first point to which attention should be directed in an internal examination of the eyeball. The changes in the disk itself are so frequently connected with changes in the parts around its circumference, that during its examination, the state of these circumferential parts must be carefully noted. Hyperaemia of the Disk is of very frequent occurrence ; the retinal vessels may be enlarged and dilated, and the veins varicose ; in addition to which the surface of the disk may be seen finely injected, instead of showing its white normal appearance. This in- jection may proceed to such an extent as almost to hide the disk (Fig. 207). Hyperaemia of the disk is common in those cases of impaired vision from over- work, which are met with in the case of engravers, compositors, sempstresses, &c. Blood may be effused on the sur- face of the disk, constituting what has been called apoplexy of the papilla. Black pigmental deposits are occasion- ally-seen on its surface, and frequently at its edge. The disk may present a cupped appearance, as in glaucoma, where it is said to be indicative of intra- ocular pressure ; or an elevated appear- ance of its centre. The form of the vessels entering and leaving the centre, and the nature of the shadow, as shown by varying the light, will be the best means of ascertaining in these cases which state is present. Atrophy of the Disk is far from uncommon ; it is often congenital; it is sometimes found in a squinting eye, and is often associated with excessive myopia. In cases of atrophy of the disk, the retina generally preserves its normal -condition and vascularity. The optic disk does not always preserve its circular form ; it is occasionally jagged in its outline, and pigmentary deposits are of frequent occurrence at its edge. From the choroidal degene- ration which is often seen around its circumference, and from the white shining appearance of the sclerotic through the retina, the edge of the disk may be but indistinctly defined, and the crescentic patches of sclerotic may be confounded with the outline of the disk by the beginner; but to the practised eye the outline may always be distinguished. The Retina.—Its transparency should be unimpaired, and its vascularity not greatly different from that of the healthy state. If the disk be hyperae- mic, it will naturally partake of the extra vascularity, but not always; for the disk may be injected with small vessels, while the retinal vessels are natural. Its vessels are subject to varicosities ; and a certain indistinctness of outline is frequently observable in its overloaded veins. The arteries often show plastic exudations in their course, which have evidently been deposits during an inflammatory state (Fig. 208). Extravasations of blood are occasionally seen from the rupture of one or more of the vessels (Fig. 209); the gradual absorption of which may be watched. Serous effusions between the retina and choroid are attended always with more or less danger Edward Jaeger; Beitrage zur Pathologie des Auges, folio, Vienna; Ruete's Bildliche Darstellung der Krankheiten des Menschlichen Auges, folio, Leipzig. Desmarres, Ma- ladies des Yeux, vol. iii. 1858; The Ophthalmic Hospital Reports, and Messrs. Taylor and Hulme's Ophthalmoscopic Sketches, now publishing serially in the Archives of Medicine. [Also, last Am. Ed. of Mackenzie.] Fig. 207. [Hyperemia of the disk.] THE OPHTHALMOSCOPE. 379 to sight, according to the locality and amount of the effused fluid. The retina may be seen, floating as it were, or lying in folds over the part, the Fig. 208. Fig. 209. [Inflammatory deposits on the retina ] [Extravasations of blood on the retina.] bright-red choroid of course being hidden from sight. As the effusion is over or near the macula lutea, so is a more unfavorable prognosis to be feared. The retina is often anaemic and even atrophied. M. Desmarres describes an affection which he calls oedema of the retina. It is doubtless affected in secondary syphilis. The Choroid, as may be anticipated from the vascularity of its structure, is most importantly involved in chronic changes in the deep-seated structures of the eye ; and although we are by no means disposed to draw any strict line between the inflammation of the different tunics of the eye, as existing independently of each other; yet this structure shows changes so marked that the effects of choroiditis may be safely classed under one head. The principal affections of the choroid are hyperaemia; when, instead of its usual somewhat orange-red color, it becomes of a bright scarlet, the vessels are enlarged, and the pigmental striations are more or less indistinguishable. The absorption of the pigment from some parts causing white patches, and its redeposition in others forming the black deposits so often met with, are signs of the atrophy and disorganization of this important structure. These black deposits may take place at any part of the fundus, but they are most frequently met with around the edge of the optic disk. They are always situated between the choroid and retina. Atrophy of fche choroid when occupying the situation of the macula lutea, is always attended with considerable impairment and confusion of vision, and is of course irremediable. Plastic exudations from its surface, pushing the retina forwards, are sometimes seen. The appearance of an eye which has been the subject of chronic choroiditis is most striking. The black, white, yellowish, and red variations of color have been described by Des- marres as the Choroide tigree. Effusions of blood from the surface of the choroid may take place, and probably many of the deposits on its surface have had this origin. Colloid degeneration has been described by Donders.1 An affection often met with in short-sighted persons, and involving both the choroid and sclerotic, must be noticed. The sclerotic is thinned at the posterior part of the eyeball, and bulges backward into a conical shape, 1 Archiv fur Ophthalmologic, 1855-6. 380 DISEASES OF THE CHOROID. carrying the choroid with it, and thus altering the antero-posterior diameter of the eye. It has been denominated sclero-choroiditis posterior. It gene- rally takes place near the optic disk, and appears as a semi-lunar white patch, which more or less completely surrounds the optic disk. That the retina is perfect over this white patch is evident from the retinal vessels being continued over it in their normal size and distribution. The Macula Lutea may be the seat of morbid deposits, hemorrhages, and plastic exudations. Small vessels sometimes enter about these parts abnor- mally. All alterations from the healthy state in these structures are more or less detrimental to vision. TJie vitreous humor is often the seat of hemorrhage. Floating particles may exist in its substance, which is generally more fluid than in its normal state, or a greater or less degree of turbidity may interfere with its transpa- rency, and envelop in a fog the parts posterior to it. Cholesterine scales may be seen floating about in it, and the cysticercus is occasionally seen in its substance. The vitreous humor should be thoroughly examined both with and without the lens. Floating particles and alterations in its anterior portion are best seen with the mirror alone. The use of the ophthalmoscope in diagnosing cataract in its incipient stage must be very evident. It is necessary that the pupil should be fully dilated with atropine. The frequency with which cataract commences in striae at the edge of the lens, makes it impossible to state with any precision the condition of the whole structure with an undilated pupil. The striae, which were undiscernible before the introduction of this instrument, are re- cognized with the greatest facility, appearing as black markings on the red field of the choroid. By fully dilating the pupil, also, we are able to exa- mine well the capsule of the lens, which is often rendered spotted by deposits of uvea from the surface of the iris, and thus gives rise to muscae and in- distinctness of vision. SECTION XIV.--DISEASES OF THE CHOROID ; ASTHENOPIA; SYNCHYSIS; AND HYDROPHTHALMIA. I. Inflammation of the Choroid, or Choroiditis, is not a common disease ; Dr. Mackenzie has generally met with it in strumous females. Symp>toms.—It commences with more or less intolerance of light, and dimness of vision, together with pain in the eye, eyebrow, and forehead, and lachrymation. The conjunctiva is not uniformly red, but one or more en- larged vessels are seen to proceed from the back of the eye, and to terminate in a vascular zone partially surrounding the cornea. The pupil is often displaced, and brought towards the affected side of the choroid. If it pro- ceed, the sclerotic becomes thin and blue, showing the choroid through it— (staphyloma sclerotices), and finally the cornea may become opaque, and the whole globe very much enlarged and protruding from the socket. The di- gestive organs are generally much deranged from the first, and hectic and emaciation come on when the eye becomes much distended and painful. See ophthalmoscopic appearances of diseased choroid, page 379. Treatment.—If an acute case of the sort should occur in a strong consti- tution, local bleeding, purgatives, blisters to the nape of the neck, and warm, or vapor baths, and mercury, may be necessary. But in cases of de- bility, great caution must be used in regard to depleting measures and mercury ; and together with the latter some tonic should always be given. Counter-irritation is always of service. When the sclerotic becomes much distended, it may be punctured with a needle—the instrument being intro- duced for one-eighth of an inch towards the centre of the eye, so as not to wound the lens; this will cause temporary relief. retinitis. 381 II. Weakness of Sight, or Asthenopia : Muscle Volitantes.—Persons of delicate constitutions and sedentary habits, especially if they are in the habit of writing much, or otherwise exerting their eyes on minute objects, are liable to suffer from dimness of sight; uneasiness on exposure to a strong light; and the vision of floating black specks or streaks, which, from their resemblance to flies, have acquired the name of musces volitantes. In one form of the affection the patient is unable to continue for any length of time to look at minute or near objects ; partly on account of the confusion and obscurity which overspread them, and partly from a sense of fatigue in the eyes. A short interval of repose is sufficient to recruit the eyes, so that the power of vision returns. The disease is apt to increase unless the particular employment that seems to produce it be abandoned, but it never ends in total destruction of sight, and must not be confounded with amaurosis. It is often improperly called Choroiditis. These symptoms evidently depend on weakness of organization, either original or produced by over-exertion; and the principal measures to be adopted are tonics, aperients, shower-bath- ing, and change of air, with perfect rest of the eyes, which afterwards should not be used too long at a time. It is almost always associated with hy- peraemia of the optic disk; see page 378. Weakness of sight, with intoler- ance of light, is very commonly an accompaniment of short sight; it may always be recognized by an uneasy bashful look about the patient's eyes, the lids of which are half closed, and perpetually winking, and the brow con- tracted. Dr. Mackenzie has shown that the appearance of muscae is caused either by globules of mucus on the surface of the cornea, or by minute par- ticles floating within the eyeball.1 This is confirmed by the ophthalmoscope, although in all cases the floating particles cannot be seen. The surgeon should take care not to mistake the effects of mere fatigue of the eye, such as aching, increasing vascularity, intolerance of light, and muscae, for inflammation; and not to treat such symptoms indiscriminately by depletion. III. Synchysis (often attended with shrinking of the eyeball) is an un- natural fluidity of the vitreous humor, apparently from the breaking up and absorption of its containing tissue ; it may or may not be also discolored. The eye feels soft and flaccid, the iris is peculiarly tremulous, shaking back- wards and forwards like a rag in a bottle of water, the retina becomes insen- sible, and the lens opaque. This affection is sometimes the result of wounds or concussions, and sometimes comes on without obvious cause. It is sup- posed to depend on slow inflammation. It is irremediable. It sometimes follows operations for cataract in which the needle has been too freely used. But although there is this great change of structure, vision may still be wonderfully perfect. For the ophthalmoscopic changes see page 379. IV. Dropsy of the vitreous humor, or Hydrophthalmia, probably de- pends on slow inflammation of the inner tissues of the eyes, generally the result of injury. It causes enlargement of the globe, with loss of sight. In some cases there is constant excruciating pain, only to be relieved by punc- turing the sclerotic with a needle. In others, there is no pain ; the disease advances a certain length, and then becomes stationary; and the only thing complained of, besides the loss of vision, is the deformity. SECTION XV.—RETINITIS. The Retina must of necessity be more or less involved in any inflamma- tory process which affects the deeper structures of the eyeball; but some- times it appears to be the original or sole seat of inflammation. That 1 Mackenzie, Edin. Med. and Surg. Journ. No. 164. 382 AMAUROSIS. inflammation may be confined to the retina, without affecting the other tex- tures of the globe, is rendered probable by the distribution of the arteria centralis retinae, and its very slight vascular connection with any other tissue.1 Authors describe three forms: the acute, subacute, and chronic. 1. In the acute form the symptoms are—severe, deep-seated, and throbbing pain in the eye, extending to the temples and head; vision rapidly impaired, or even altogether lost; frequently sensations of flashes of light, with great fever and delirium. The pupil gradually closes, the iris loses its brilliancy, and the sclerotic is highly vascular and rose-red. If unrelieved, the whole globe may suppurate. 2. Subacute.—Dimness of sight, headache or giddi- ness, flushed countenance and fever; the pupil soon becoming motionless, and the iris turbid. 3. Chronic.—Gradually-increasing dimness of sight; visions of black spots or flashes of light; irritability of the eye and intoler- ance of light; tenderness of the eyeball, and of the parts around ; but the patient, though he may shade the eye, does not always shut it. These affec- tions are distinguished by the circumstance that dimness of sight and intoler- ance of light occur before redness or any external sign of inflammation. But the practitioner must carefully discern between these symptoms and the intolerance of light, or photophobia, which occurs in Strumous Ophthalmia, as the treatment for the two complaints should be diametrically opposite. The age of the patient, and the fact that in Strumous Ophthalmia the sufferer has periods of remission, and can usually open the eyes towards evening, will sufficiently mark the difference ; besides, in acute Retinitis, there is deep-seated pain felt at all times, while in Strumous Ophthalmia the pain is very little felt, so long as light is completely excluded. See retinal changes, page 378. Causes.—Exposure to vivid light, flashes of lightning, strong fires, the reflection of the sun from snow, and the like ; or habitual exertion of the eye on minute objects, together with neglect of exercise, confinement of the bowels, and over-indulgence in food and spirituous liquors, or else with debility, and want of nourishment. Prognosis.—If, in the acute or subacute form, vision is not much im- paired, nor the iris altered, nor the pupil much contracted, the prognosis may be favorable. Treatment.—For the acute, local bleeding, purgatives, mercury adminis- tered so as gently to affect the mouth ; for the chronic form, a gentle course of mercury, and the antiphlogistic treatment generally, according to the urgency of the symptoms, and the strength of the patient. The eyes should not be closely covered, but the patient should be kept in a darkened apart- ment, observing at the same time that it is thoroughly ventilated. So soon as the symptoms abate, bark and change of air will be found of great service. SECTION XVI.—AMAUROSIS. Definition.—Imperfection of vision, depending on some change in the retina, optic nerve, or brain. Symptoms.—1. Of course the first and most prominent symptom is impair- ment of vision ; the mode and degree of which are, however, subject to very great variety. Sometimes the sight becomes suddenly dim, and is soon ex- tinguished altogether; more frequently it becomes impaired by slow degrees; and at first it is so only at intervals; after the eyes have been fatigued, for instance, or when the spirits are low, or the stomach disordered. Some- times it commences as indistinct vision, or amblyopia; or as diplopia, objects appearing double; or, as hemiopia, one-half only of the objects looked at 1 Taylor, Med. Times and Gaz., June 5th, 1852. AMAUROSIS. 383 being seen; or objects may appear crooked, disfigured, or discolored; or they may be seen covered with patches; or the affection may commence as near-sightedness or far-sightedness. The patient finds himself unable to estimate distances, and misses his aim when trying to snuff a candle, or pour wine into a glass. The flame of a candle generally appears split, lengthened, or broken into an iridescent halo. 2. Ocular spectra, sometimes in the form of floating black spots (muscae volitantes), sometimes as flashes of light, or as a colored cloud or network.1 3. Sometimes incipient amaurosis is attended with great intolerance of light—sometimes, on the contrary, with a constant thirst for light, or feeling as if objects were not illuminated enough. 4. The patient walks with a peculiar uncertain gait, and his eyes have a vacant stare ; the eyelids move imperfectly and seldom—the pupil is gene- rally dilated (unless it be an incipient case, attended with intolerance of light) ; the iris moves sluggishly, and in confirmed cases is totally motionless. But if one eye be sound, and be exposed to light during the examination, the pupillary movements may not be lost. The ophthalmoscope enables us to state with tolerable accuracy when the cause is strictly cerebral; for if with impairment or loss of sight, the eye looks perfectly healthy, we may without much doubt say that the disease is within the skull. Whenever the state of the eye will admit it, the ophthalmoscope should be used not only for diagnosis, but to ascertain the arrest or the progress of the affection. Diagnosis.—Amaurosis may be distinguished from cataract by noticing, 1. That, in cataract, an opaque body can be seen behind the pupil, and that the impairment of vision is, for the most part, in proportion to the extent of that opacity; whereas, in pure amaurosis, in young persons, the pupil shows its natural color. A greenish color of the pupil has sometimes been considered a diagnostic mark of amaurosis. On this point, says Mr. Walton, " the paleness or light yellowness, that exists behind the pupil after middle life, is often thought to be symptomatic of amaurosis ; it is, however, but the effect of the coloration of the lens, and is seen with or without defective nervous power : young persons with amaurosis never exhibit this appearance. It is this coloration that produces so much difficulty in diagnosis in adults;" and unless the symptoms be taken into account, it is often impossible, from the mere look of the pupil, to determine between the earliest stages of the two diseases. 2. That, in cataract (with the exception of the radiating variety), vision is simply clouded, and that a lighted candle appears as if enveloped in a mist; whereas, in amaurosis, objects are seen cfo's-colored or perverted in shape ; and that a lighted candle seems split, or lengthened, or iridescent; and that muscae volitantes, and flashes of fire when the eyes are shut, are not present in pure cataract. 3. That, in cataract, vision is better in a dull light, whereas it is generally the reverse in amaurosis. 4. That a patient with cataract is always able to discern light from darkness, and that he looks about him, and moves his eyes, as though conscious that vision still exists, although he may be unable to discern particular objects ; whereas, in confirmed amaurosis, there is the fixed vacant stare of utter darkness, and the eyeball is protruded and motionless. 5. That in pure amaurosis in young persons, before the lens has begun to change color, the three images of a candle are as distinct as in the healthy eye, which is not the case in cataract. In the aged, says Mr. Walton, the catoptric test may enable the surgeon to compare the existing degree of opacity with the amount of im- 1 The student will do well to read Milton's account of his own blindness, as given in Dr. Johnson's Lives of the Poets, and in Travers's Treatise on the Eye. 384 AMAUROSIS. perfection of vision; for instance, he may judge the case to be amaurotic if the degree of blindness is great, out of all proportion to the degree of opacity of the lens ; but the ophthalmoscope will be found the greatest aid to diagnosis. Prognosis.—This is generally unfavorable—unless the disease depends on some palpable cause which admits of removal, and unless the remedial mea- sures employed very soon produce good effects. Varieties.—Amaurosis has been divided into the functional and organic; the former depending on some sympathetic or other disorder which does not primarily affect the structure of the nervous apparatus of the eye—the latter on organic disease. Causes.—The usual causes of amaurosis are circumstances that overstimu- late and exhaust the retina ; such as long-continued exertion of the eye on minute objects ; or exposure to glaring light, especially if combined with heat—and these exciting causes are particularly aided by intemperance, stooping, too much sleep, and any other circumstances capable of pro- ducing determination of blood to the head. Amaurosis may also be a consequence of anaemia, and want of power; of organic change, inflam- mation, concussion, compression from extravasated blood, fractured bone, morbid effusions, tumors, or aneurisms—whether affecting the brain, optic nerves, or eye. Treatment—The indications in every case are, 1. To rectify any palpable disorder—inflammation or plethora by depletion ; debility by tonics; bad habits, if possible, by moral means. 2. To neutralize determination of blood to the eye or head by counter irritation. 3. To stimulate and restore the excitability of the retina. For practical purposes it will be convenient to classify the disease under the five following heads, viz., 1. Inflammatory; 2. Atonic ; 3. Sympathetic cases ; 4. Those produced by poisons ; and 5. By organic disease. Inflammatory.—If amaurosis be attended with any of the symptoms of retinitis, iritis, or choroiditis, that have been before enumerated— Bleeding or cupping from the temple or mastoid process may be performed at intervals. The bowels should be well cleared, the diet should be devoid of alcohol, and all employment of the affected organ, and all violent bodily exertion, should be desisted from. Mercury should be administered so as to bring the system gently under its influence. (F. 64.) Counter-irritants of all sorts are beneficial; blisters, or the tartar-emetic ointment applied behind the ears or to the nape of the neck; immersion of the feet in hot water and mustard ; or an issue in the arms in chronic cases. In cases where gout is evident, colchicum; where rheumatism, iodide of potassium ; where scro- fula, cod-liver oil and iodide of iron may be beneficial. 2. Atonic amaurosis may come on at the close of any exhausting illness, or may be produced by great loss of blood, menorrhagia, immoderate suck- ling, leucorrhoea, excessive venery, or other debilitating circumstances. It has been frequently noticed after diphtheria.1 It may be distinguished by its being attended with debility,-pallid lips, weak pulse, dilated pupils, and an anaemic state of the retina; and the patient generally sees best after a meal or a few glasses of wine, and in a strong light. The treatment consists, first, in suppressing any habitual discharge, or other source of exhaustion. Secondly, in strengthening the system by change of air, tonics, quinine, steel and zinc, and especially by good living. At the same time the abdominal se- cretions should be well regulated by aperients (such as aloes and rhubarb), that act copiously, but not drastically ; and the cutaneous and general circulation be promoted by exercise and bathing, especially the shower-bath. F. 9, 13, 1 See Med. Times, 1859, vol. i. p. G59. AMAUROSIS. 385 Fig. 210. 21, 190. It is in this form, if in any, that local stimulants are applicable— such as exposing the eye to the vapor of aether or sal volatile (a teaspoonful of either being held in the hand); stimulating snuff (F. 184), cataplasms of capsicum to the temples; friction of the forehead with cajeput or croton oil, or with an alcoholic solution of veratria. 3. Sympathetic.—(a.) Amaurosis not unfrequently supervenes on an attack of jaundice. If there be evidence of congestion in the head, as there fre- quently will be, blood should be taken by cupping, whilst the abdominal disorder should be removed by appropriate measures. (b.) If there be headache, vertigo, foul tongue, and other evidence of abdominal disorder, an emetic, blue pill or hyd. c. creta, in small doses every night; and purgatives, till the secretions are set to rights, followed by tonics and counter-irritants, are the requisite measures. In similar cases, some foreign authors recommend the use of Schmucker's or Richter's resolvent pills, F. 185. Turpentine, or the kousso, or the oil of male fern should be given if there be signs of tapeworm. (c.) Amaurosis sometimes arises from irritation of the fifth pair of nerves. If it follows a wound on the forehead, the latter should be dilated, or if it have healed, the cicatrix should be cut out. Tumors of all sorts near the eye, and ca- rious teeth should be removed. 4. From Poisons.—Amaurosis is liable to be induced by certain poisons, such as lead and belladonna. If the amaurosis persist after the ordinary effects of the poison have been got rid of by the usual measures, the cold shower-bath, counter irritation, electricity, and iodide of potas- sium, are the remedies most likely to be of service. 5. Organic.—These cases are the most hopeless. If the disease has followed an injury of the head, or fit of apoplexy, or syphilis, or if there be reason to suspect a tumor in the brain, or in the course of the optic nerve,—a moderate course of mercury, or of iodide of potassium with alkalies and sarsaparilla, and with counter-irritants, should be tried, and sometimes may effect a cure. Amaurosis arising from a tumor within the brain will usually be accompanied by symptoms that will sufficiently point out the hopeless nature of the disease. There is an interesting case of this kind related by Mr. Browne, of Belfast, in the " Dublin Journal of Medical Science," for May, 1849, in which there was increasing amaurosis, with complete paralysis of the motores oculi nerves : after death a tumor, nearly three drachms in weight, was found in one of the crura cerebri. For other cases of amau- rosis arising from organic disease, especially if there be fixed pain in the head, palsy, or epilepsy, or idiocy, the best thing that the surgeon can do will be to prevent congestion in the head by occasional depletion, and coun- ter-irritation ; to maintain the secretions of the liver and bowels; to keep up the strength by a nutritious but not stimulating diet, and to guard the patient from every excess or exertion, mental or bodily, that is capable of accelerating the cerebral circulation. 25 Atrophy of the left "optic nerve and right tractus opticus consequent on From the Middlesex Mu- amaurosis. 3b6 SHORT AND LONG SIGHT. SECTION XVII.—SHORT AND LONG SIGHT. I. Short Sight, or Myopia.—This affection may depend either on an increase in the refractive power of the eye, or else on an elongation of its axis, so that in either case the rays of light are brought to a focus before they reach the retina. The cornea is often exceedingly convex, and the secretion of aqueous humor abundant; and the crystalline lens is also too convex, all of which circumstances would cause the refractive power of the eye to be increased. The ophthalmoscope detects certain changes in the ■choroid and sclerotica close to the optic disk (see p. 378). It is caused by Fig. 211. Diagram exhibiting the effects of concave glasses in myopia. too close attention to study, and by habits of looking at minute objects, as in reading, learning music, and the like ; by which the ciliary muscle is brought constantly into play in the adaptation of vision, and thus, probably, the curves, both of the cornea and crystalline lens become altered, and their surfaces become sections of smaller spheres than normal; hence, the increase in the refractive powers of the eye. It is often an indication of delicacy of constitution. It is a popular error to imagine that the sight improves as the individual grows older. Treatment—The eyes should be exercised and accustomed to look at distant objects. When children display any tendency to short sight, their studies should be abridged, and they should have plenty of exercise in the "open air. Shooting, archery, cricket, and field sports in general, are highly beneficial. It is worth while also to try a plan of treatment invented by Berthold, and consisting in the use of an instrument which has received the sesquipedalian title of myopodiorthoticon. This is really nothing more than a support for the chin, to prevent the patient stooping forwards, whilst he reads from a book with large print. And the book is every day to be placed at a slightly-greater distance from the eyes, till the patient has ac- quired the faculty of reading at the ordinary focal distance—that is to say, at about fifteen inches. The glasses which are adapted for shortness of sight are concave ; since they tend to disperse the rays of light, and prevent their coming to a focus so soon. They should not on any account be re- sorted to, however, if the patient can go on pretty comfortably without them; or, at all events, should only be worn when required to prevent him from stooping awkwardly whilst reading or playing music. But if the myopia is very decided, or if the eyes feel fatigued after any ordinary use of them, it will be better to wear the glasses continually. Spectacles should always be used in preference to a single glass. The patient should choose a pair that enables him to see objects within forty feet as distinctly as other people—the names on the corners of the street, for instance ; but should not have them so concave as to make objects appear dazzling, or smaller than usual. II. Presbyopia, or long-sightedness, depends apparently on a diminished quantity and density of the humors of the eyeball, through which it becomes flatter, and its refractive powers are diminished. It needs scarcely be said, SQUINTING. 387 that it is one of the earliest signs of impaired nutrition in old age. The patient's sight must be remedied by convex glasses; and whilst in myopia Fig. 212. Diagram exhibiting the effects of convex glasses in presbyopia. the patient should abstain from the use of glasses if at all possible, in pres- byopia, on the contrary, glasses should be used immediately that the patient perceives that he cannot read at the usual distance without fatigue to the eye ; taking care that the lenses chosen are of the lowest power, that will as- sist vision and restore the faculty of reading at the distance of from twelve to sixteen inches. The sight should be spared by candle-light as much as pos- sible. The glasses should cause minute objects near the eye to appear bright and distinct, but not larger than natural. If they do, they are too convex.1 SECTION XVIII.—SQUINTING. Squinting, or Strabismus, may be defined to be a want of parallelism in the position and motion of the eyeballs. The essential cause of the affection is very obscure. Probably our know- ledge is best expressed by the statement that for the most part there is some weakness of sight, or some want of adjustment in the visual axis of one eye, in consequence of which it is involuntarily turned aside in order to avoid the double or distorted vision that would result from looking at objects with two eyes of different powers. The ordinary form of squint in young persons is the convergent, or that in which the eye is turned inwards; the divergent, or that in which the eye is turned outwards, is more rare, and is chiefly met with in elderly persons, for the most part from partial paralysis of the internal rectus. It occa- sionally happens that both eyes squint: but it must be remarked that the appearance of this is more frequent than the reality. A squinting patient may change eyes as it were : that is to say, he habitually uses one eye only; and although he habitually uses the stronger eye, and squints with the weaker, yet, at times, and especially if excited, he will look straight with the squinting eye, and squint with the sound one. Hence, there is often some difficulty in deciding at first which eye is the really squinting one ; a point that must be determined by quietly watching the patient, and finding out which eye squints habitually when at rest. Occasionally, it is true, how- ever, both eyes converge at the same time. When one eye is distorted and fixed, the affection is called luscitas. Causes.—1. Squinting may be congenital. 2. It may be induced by bad habits ; such as the imitation of parents, nurses, or school-fellows, if they happen to squint; or by constantly looking at spots and pimples on the nose ; or it may follow affections (such as hordeolum) which render motion 1 An elderly gentleman, who had been some time presbyopic, met with a violent fall and contusion of the uvea, which doubtless produced an increased secretion of aqueous humor, and restored his power of seeing at the ordinary focal distance. Presbyopia oc- curring in young persons generally arises from intestinal irritation, and may be a pre- cursor of amaurosis. 3S8 SQUINTING. Fig. 213. of the eye painful, and during which the patient turns the eye inwards and keeps it motionless. 3. It may be caused by using one eye constantly to the neglect of the other. It has been known to occur after one eye has been for a long time shaded, in consequence of an inflammatory attack; which shows the expediency of always covering both eyes when a shade is necessary. 4. If there happens to be an opacity on the cornea of one eye, and that eye is the better one, the patient will sometimes continue to use it for ordinary vision, but for that purpose is obliged to distort it so as to remove the corneal opacity from the visual axis. 5. Squinting, like almost every other conceivable consequence of defect of nervous influence, is sometimes a relique of fevers and the exanthemata. 6. It may be in- duced by irritation or disorder of the stomach and bowels, teething, worms, constipation, and so forth ; it may, more- over, be caused by fright or violent fits of passion ; and in some children it always appears when the health is out of order, and disappears when it is restored. Lastly, it may be caused by some disorder of the circulation in the brain. Thus, it is pretty frequently the precursor of acute hydro- cephalus or convulsions in children ; and when it is asso- ciated with dropping of one or both eyelids, and with unusual sleepiness, or torpor of the intellect, or faltering in the gait, some mischief within the head may fairly be anticipated. Treatment.—If the affection be recent, that is to say, of not more than a few weeks' duration, it may perhaps be removed or mitigated by judicious medical treatment, espe- cially by purgatives, antacids, and tonics (F. 37), and by abstinence from study, and plenty of exercise in the open fields. Various devices have been proposed for strength- ening and exercising the weak eye, by shutting up the sound one, wearing goggles, placing black patches on the nose, and so forth. But if the squint is of long standing and is habitual, and, above all, if there is any disparity in vision, very little, if any good can be done unless the internal rectus muscle is divided. This is easily performed in the follow- ing manner:—The patient, if an adult, and manageable, sits in a low chair ; if an unruly child, he should be quieted by chloroform and laid on a table. The instruments re- quired are a pair of blunt-pointed scissors, a smooth slightly- curved blunt hook, and a wire speculum or retractor. Then the lids of the squinting eye being held apart by a spring retractor wire speculum, the surgeon, desiring the patient to look outwards, pinches up a fold of the conjunctiva with the forceps opposite the lower edge of the internal rectus, a little behind its insertion into the sclerotic. This is snipped with the point of the scissors; and next the sub- conjunctival cellular tissue is snipped through, so as to expose the glistening surface of the sclerotic. It must be remarked that this subconjunctival tissue is sometimes so thick as to be mistaken for the muscle. The aperture thus made should be quite small, only just sufficient fairly to in- troduce the blunt hook, which should next be thrust upwards between the muscle and sclerotic. Lastly, the tendinous insertion of the muscle, and the conjunctiva which covers it, are to be divided with the scissors. " In order," says Mr. Walton, "to secure effectually everv Curved blunt hook, in operating for stra- bismus. TUMORS IN THE ORBIT. 389 portion of the tendinous expansion of the muscle, the hook should be passed a little below the level of the pupil in its ordinary state of dilatation, directed backwards to a sufficient distance, swept along the side of the globe, and its point made to project just a little above the level of the pupil." It should be the desire of the operator to cut no more of the con- junctiva than is required to insure the complete division of the muscle, and of this latter there cannot be the same certainty except the membrane be cut at the spot directed. Mr. Walton has lately brought the edges of the conjunctival wound together by one or two fine sutures passed through the very margin of the edges. The sutures do not cause the least irritation. They drop out about the third or fourth day. The advantages of this plan are that it prevents the dropping of the caruncle, the falling in of which to a great degree causes the vacancy sometimes so marked after the ordinary operation ; that rapid union is effected instead of the slow granulating of an open wound ; and that there rarely appear any of those fungous growths that are otherwise common. When the operation is complete, the surgeon will find that the patient can move the eye more freely than before in all other directions, but that he cannot move it directly inwards. In cases in which, after division of one of the recti, the eye has not re- turned to its central position, Mr. Wilde has drawn and retained it in its proper place by means of a ligature passed through the sclerotic attachment of the divided rectus, and fixed by sticking-plaster to the nose or temple, and allowed to remain two or three days. The external rectus may be divided by a similar operation, for the diver- gent squint; and in some instances it has been done for the relief of diver- gent, which has followed the cure of the convergent squint. Xo operation should be attempted when the squint depends on opacity of the cornea, or on cicatrices, tumors, or other mechanical causes; and it should always be ascertained, before dividing any muscle, that its antagonist is not paralyzed. SECTION XIX.—TUMORS IN THE ORBIT, CANCER OF THE EYE, ETC. I. Protrusion of the Eyeball.—We have already spoken of tumors in the eyelids ; of tumors on the surface of the conjunctiva; and of tumors resulting from disease of the lachrymal gland. AVe have yet to allude to the fact that tumors, fatty, osseous, encysted, and solid or sarcomatous, as they were formerly called (which have not yet been sufficiently examined), may occur within the orbit, causing, as their general symptoms, protrusion, with more or less displacement of the eyeball, and projection at the seat of the tumor. The danger of tumors in this situation is twofold : destruction of the eye from continued pressure ; and protrusion through the roof of the orbit into the cavity of the skull, with compression of the brain ; which should be averted by extirpation so soon as the morbid growth is of a size to threaten mischief. Sometimes it is fair practice to puncture, or still better to lay open, an encysted tumor by a free incision. But it is not every protrusion of the eyeball that is caused by tumors. For instance,—1. An excessively protruded and goggled state of the eyeball sometimes occurs in connection with anaemia, general debility, and enlarge- ment of the thyroid gland : the mechanism of this is ill understood ; the best remedy is steel. 2. Suppuration, or inflammatory effusion, may take place within the orbit. This may occur either internal or external to the ocular sheath of Bonnet and O'Ferrall; a layer of fascia, immediately sur- rounding the eye, extending from the posterior margin of each palpebra to the apex of the orbit, and perforated by the ocular muscles. Effusion may take place in the orbit either internal or external to this sheath. If internal to it, there will be a chemosed-like projection of the conjunctiva at its angle 390 tumors in the orbit. of reflection from the eyeball to the palpebra. If intense pain, unrelieved by treatment, with shivering, indicates the presence of pus, a puncture should be cautiously made within the palpebrae by the side of the eyeball. II. Cancer may affect the eye or other contents of the orbit, particularly during the earlier periods of life. It may occur in any form, or affect any structure; for the common opinion that it usually first attacks the optic nerve or retina, is, according to Lebert and Paget, not well founded. The scirrhous, or hard variety, is very rare; most ocular cancers being of the soft or else of the melanotic variety. 1. Cancer within the Orbit.—Weight, perhaps pain in the orbit, and dis- placement of the eye, with dimness of vision, are the earliest symptoms; which are followed by the protrusion Fig. 214. of a tumor. Engorgement of the sur- rounding bloodvessels, destruction of the eyeball, adhesion of the palpebrae, protrusion of a large tumor, bleeding, sloughing, or exuding thin offensive discharge, cancerous deposits in the cranial cavity, in the cervical glands, :and in distant organs, follow in suc- cession. 2. Cancer within the Eye.—After some amount of vascularity, and of other signs of derangement of the eye —or, perhaps, after it has been dis- [Cancer of the eye.] covered (if the patient is a child) that From a drawing of a preparation in King's tne sj™nt Qf tne eye jg logt---&n exami_ College Museum, with which the author was ,. . -, ' -, , i D . ,,• favored by Mr. Partridge. natl0n 1S made> alld a Patch °f metallic lustre, of a grayish, reddish, or yellow- ish-white color is discovered deep in the eye, behind the crystalline lens. The iris is tarnished, and sluggish. As the tumor grows, and Comes nearer to the cornea, it can usually be clearly distinguished as being lobulated, and covered with bloodvessels. In time, it fills the eye, and presses the iris against the surface of the cornea, the eyeball is tense and painful, and the surrounding parts very vascular. Finally, it bursts through the cornea or sclerotica ; a huge fungus protrudes, and the disease arrives at a fatal ter- mination through the stages we have just indicated. The diagnosis of intra-ocular cancer is important, because deposits of lymph or tuberculous matter may occur in the depth of the eye, and present all the outward and visible signs of a cancerous growth. In fact, the diag- nosis of such a growth is considered by the best authorities to be impossi- ble, until time reveals whether the eye is to burst before a protruding fungus, and the health to exhibit the decay consequent on the extension of cancer; or whether, on the other hand, the eyeball is, 1, to remain blind but unal- tered ; or, 2, to be the seat of scrofulous suppuration; or, 3, to waste and become atrophied ; one of which three contingencies usually results when this peculiar appearance is the result of injury or of slow inflammation in a scrofulous subject. 3. Melanotic cancer is common in this situation, Lebert having found it in £§ cases: it may primarily affect the orbit, conjunctiva, or optic nerve, but, curiously enough, has not been found primarily in the iris or choroid, where it might naturally have been expected. Melanotic cancer pursues the course of soft cancer, but perhaps more rapidly. Protrusion of a tumor exuding a darkish sepia-like fluid, and a great multiplicity of organs affected with secondary deposits, are leading features. There is at present considerable confusion existing in the use of the term cancer of the eye. 391 melanosis, which is often used as if synonymous with cancer. But, as we have before observed, melanotic cancer is true soft cancer, combined and infiltrated with large quantities of black pigment. On the other hand, col- lections of black pigment may exist in natural and morbid structures with- out cancer. Patches of black pigment may be found, and may remain for years on the conjunctiva unaltered. 4. Cancer may commence in the conjunctiva in the form of small vascular tumors, which soon display the characters of soft cancer, or the dusky hue of melanosis. Scirrhus is treated of by authors, but is extremely rare. Can- cer, likewise, may affect the caruncle, constituting the disease formerly called encanthis. 5. It may also affect the lids; but here we must note the not unfrequent occurrence in aged persons, first of epithelioma on the lower lid ; com- mencing as a wart, lasting an indefinite time, but, if irritated, terminating in incurable ulceration; yet altogether different from cancer in structure, and giving much more hope for extirpation. Secondly of a glassy ulcer of the lupus kind. Treatment.—The treatment of cancer of the eye comprises two classes of measures : 1, the various palliatives mentioned at p. 130; 2, extirpation, which latter is also to be regarded as palliative, since, in cancer of the eye, the disease (if not already developed within the cranium) is sure to appear there or elsewhere. It seems to be the general opinion of surgeons, that it is use- less to extirpate soft cancer of the eyeball, especially in children ; but that, in the melanotic cancers, the extirpation of the contents of the orbit affords a greater chance of prolonging life ; and that all superficial cancerous tu- mors of the conjunctiva should be freely extirpated as soon as possible III. Extirpation of the Eye is required occasionally, not only for can- cer but for disorganizing suppuration, and other diseases which may render a sightless eyeball a source of great irritation. When the eyeball alone is to be extirpated, for a non-cancerous growth, Bonnet's operation may be performed, which consists in dividing the conjunctiva, cutting through the insertion of the recti and oblique muscles, drawing the eyeball forwards, and severing the optic nerve. Sometimes it is necessary to slit up the external commissure of the lids; but in most cases the entire contents of the orbit require to be removed. During this'operation, Mr. H. Walton places the patient on his side, to allow the blood to run away more easily. The first step is to slit up the external commissure of the lids, with the conjunctiva and adjoining skin, to a sufficient extent. The eyelids then being held apart with retractors or spatulas, the operator takes hold of the eyeball with his fingers, or with hooked forceps, cuts through the conjunctiva above and below; cuts through the levator palpebrae, dissects away the attachments of the superior and in- ferior oblique, and all vascular and cellular attachments to the walls of the orbit; then drawing the globe strongly inwards, cuts through the optic nerve, vessels, and muscles at the apex of the orbit, by means of a straight scalpel passed along the outer wall of that cavity. Mr. Walton does not find that crooked instruments have any advantages for this last purpose over straight ones. The lachrymal gland should be taken away; bleeding be arrested by syringing with cold water; if troublesome, by a solution of alum on lint. The lids must then be closed, and a compress dipped in cold water be ap- plied over the face. IV. Artificial Eyes consist of a thin scale of enamel colored to imi- tate the natural eye. They are adapted for cases in which the globe is sightless and shrunken, after the removal of staphyloma,for instance. "Be- sides the removal of deformity," says Mr. Walton, "the presence of the false eye may be of essential service in keeping the lids in their natural position; 392 EXAMINATION OF THE MEATUS. and preventing the cilia from irritating the shrunken globe ; in placing the puncta in a more natural position for conveying away the tears ; in acting as a defence against intruding bodies, which are apt to be retained within the lids and to produce irritation, and as a means of keeping the cavity free from collections of lachrymal secretions." After staphyloma or any other disease which has rendered the eyeball shrunken and sightless, if the patient objects to the trouble and expense of an artificial eye, it may be convenient to divide the levator palpebrae, in order that the lids may remain permanently closed. This may be effected by mak- ing a transverse incision in the upper eyelid just below the orbit, and seizing the belly of the muscle as far back as possible. Then a piece should be snip- ped out of it with the scissors.1 CHAPTER XIII. DISEASES AND INJURIES OF THE EAR. SECTION I.—EXAMINATION OF THE EAR. Examination of the Meatus.—Every surgeon ought to accustom him- self to examine the external passage of the ear, and to become familiar with its appearances, both in health and in disease. We may premise that this canal is about an inch long; that its course is forwards and inwards, but that it presents a slight curve with the convexity upwards, and is narrowest about its middle. It may be said to have three divisions, which differ from one another in structure and appearance. In the first or outermost part of the tube, the passage is "formed almost entirely of pure fibro-cartilage covered with its perichondrium," and lined by the same fine dermal struc- ture that invests the auricle.8 " Here the skin is studded over with fine white hairs pointing inwards, and also with numerous sebaceous glands or follicles. It is here also more loosely connected to the cartilage than at any other part of the tube ; and this accounts for the fact that small circum- scribed abscesses occur in this part of the canal more frequently than in any other. The next portion of the tube may be called the glandular division, because in it are seated the ceruminous glands that secrete the earwax; this is about three-eighths of an inch long, and is the narrowest portion of the tube." Its walls have less of cartilage, and more of dense fibrous membrane in their composition and its dermal lining is finer. When in a healthy state it is generally lined with wax, which forms a ring, coating this part of the meatus. The third and last portion of the passage is slightly dilated, and contained principally within the bony part of the meatus. It can only be seen satisfactorily by means of a speculum, of which instrument several 1 Vide Lectures by Professor Green, in Sir A. Cooper's Lectures ; Copland, Diet., art. Eye, Amaurosis, &c. ; Middlemore on Diseases of the Eye ; Guthrie on the Operative Surgery of the Eye ; Morgan on the Eye by France, Lond. 1848 ; Tyrrell on the Eye, Lond. 1840; Mackenzie on Diseases of the Eye, 3d edit., Lond. 1840; Hull on the Morbid Eye, Lond. 1840. See also.Mackmurdo's Lectures on Diseases of the Eye, Lan- cet, 1850; Bowman's Lectures on Operations on the Eye, Lond. 1849 ; Haynes Wal- ton's Lectures in the Medical Times, 1850 ; and Operative Ophthalmic Surgery, Lond. 1853 ; G. Critchett, on Excision of Iris ; Ophthalmic Hospital Reports, 1857 ; Alfred Poland on Protrusion of Eyeball, ib.; Jabez Hogg on the Ophthalmoscope, 1858. 2 The quotations are from the Practical Observations on Aural tiurgery, by W. R. Wilde, Lond. 1853. FOREIGN SUBSTANCES IN THE EAR. 393 sorts are sold, and some of them intended to dilate the ear. But since it is only the outer extremity of the meatus that can be dilated, these dilators are of no great use, and the most convenient in- strument will probably be found to bo a simple Fig. 215. conical silver tube, of the size and shape de- picted in the annexed cut, and intended solely to transmit light For the examination it is advisable to have a good stream of direct sunshine ; but if this cannot be had, the best substitute is a lamp or candle with a reflector.1 The patient, accord- ing to his height, should sit, kneel, or stand sideways before the surgeon; who should take the auricle with one hand and gently draw it outwards and backwards, whilst with the other he inserts the speculum as far as it will go without pain. Then, by placing the patient's head at the proper angle, and by gently moving the large end of the speculum from side to side, a stream of light may be made to play on the innermost portion of the meatus, and on the membrana tympani. But the operator must take care not to put his own head in the light. When the innermost portion of the meatus is thus examined, its lining exhibits, if healthy, a "fine, smooth, dry, pearly-white, shining appearance," and in a perfectly healthy state it is not coated with wax. The membrana tympani also is seen closing the passage obliquely; grayish-white, dry, and semi-transparent. " Within it is seen the handle of the malleus, proceeding from above downwards, and slightly forwards. This bone, which runs about half-way across the membrane, divides it into an anterior superior and poste- rior inferior portion, the former of which is flat or slightly concave, whilst that part " which is below and behind the malleus is, in a perfectly healthy living human ear, convex towards the external aperture. This lower portion is also more glistening in appearance than the upper or anterior part, and when viewed through the speculum, a bright spot of light shines upon its most convex portion, which is a little below and behind the point of the malleus." Under inflammation, this innermost division of the meatus be- comes thickened, highly vascular, and villous or granular, like the granular conjunctiva, and secretes a purulent matter. SECTION II.—AFFECTIONS OF THE EXTERNAL EAR. I. Foreign Substances in the Ear.—Children not unfrequently poke bits of slate pencil, peas, glass beads, &c, into the passage of the ear, which, if allowed to remain, would give rise to violent inflammation and deafness; any such body should, therefore, be removed as quickly and as gently as possible, either by syringing the ear with warm water, or by means of a small forceps, curette, or scoop. If it cannot be removed by gentle means, it should be allowed to remain quietly, says Mr. Vincent, when probably it will become coated with wax, and the passage will enlarge by interstitial absorption, so that it may be removed without trouble. The surgeon should always make certain, by an examination with the speculum, that there is a foreign body present, before he begins poking instruments into the ear, re- membering that a late eminent hospital surgeon is said to have dragged out the stapes whilst fishing for a small nail, which was not in the ear after all. [For the removal of foreign bodies from the ear the instrument invented 1 One made by Fergusson, of Smithfield, is very cheap and portable, and answers all purposes for the examination of any internal organ with a speculum. The ophthal- moscope would do still better. 394 OTORRHEA. by Dr. Corse, and described by him in the Amer. Journ. of Med. Sci. for October, 1858, p. 409, may be found very useful. The thin blades can be applied separately, and then united by the fulcrum. Fig. 216. Corse's instrument for removing foreign bodies from the ear.] II. Accumulation of Wax, mixed with hair and cuticle, in the external meatus, is a common cause of deafness. Syringing the ear gently with warm water is an effectual mode of dislodging it.' Syringing, however, is not always to be done with impunity, for if the membrana tympani be in- flamed or dry, and the passage devoid of wax, great irritation may be in- duced by a jet of water, especially if it be forcibly injected. The condition of the membrane, therefore, ought to be previously ascertained, by an exa- mination with the speculum ; avoiding the too common practice of using a probe without first ascertaining the cause of deafness. A little cotton should be inserted into the concha after syringing. The water used should be quite warm enough to be comfortable, and the syringe should hold one or two ounces ; its piston should work easily and accurately, so that no air- bubbles may be squirted in ; the patient should be carefully protected by towels ; and the water injected should be clean, and in a separate basin ; the dirty water that has been already used should not be injected over again.' A large metal syringe is the best instrument for washing out accumula- tions of wax; a small elastic bottle is the best for applying lotions or in- jections ; and one of the small elastic suction-bottles with a tube, commonly known as Margett's, is a capital thing to enable patients themselves to pass a gentle stream of warm water into the ear, as a fomentation, in any case of pain or inflammation. This is a most soothing process. Margett's syringe is also useful for douching the eye. III. Otorrhea.—This term signifies a purulent or muco-purulent dis- charge from the external auditory passage. Its most frequent cause is— Catarrhal Inflammation of the lining membrane of the meatus, which is excited by cold or stomach disorder, and is most frequent in children whilst cutting their teeth; it may accompany strumous ophthalmia, porrigo, and other eruptions ; or it may be a sequel of either of the exanthemata, or, in fact, of any weakening illness. The little patient is feverish and complains of earache; the meatus is swelled and vascular; and these symptoms are soon followed by thin yellowish discharge. A purgative should be given; during the early stage the ear should be fomented or soothed with a large bran poultice ; the discharge should be constantly washed away; and if it continue after the health is restored, the astringent applications to be pre- sently mentioned must be used. The surgeon should not allow the parents to believe that an habitual discharge is salutary, or that there is any fear, under proper treatment, of "driving it in upon the brain." In otorrhoea, i. e., purulent discharge, following internal otitis, the general health must be improved by tonics, alteratives, and aperients ; and by warm baths (cold bathing is almost sure to be injurious) ; and the local disease must be treated by the cautious use of stimulants and astringents. The ear should be twice daily, very gently, syringed out with warm water; and im- mediately afterwards a tepid lotion of alum or sulphate of zinc, or acetate 1 A simple kind of water-spout is made by Coxeter, which may be applied to the ear, and entirely prevent the patient from being wetted. POLYPUS. 395 of lead may be dropped into the meatus till it is filled, and after remaining there two or three minutes, be allowed to run out, F. 135, 136, 140. If the discharge is very fetid, a lotion of two drachms of solution of chloride of lime to half a pint of water may be used, or F. 117 ; and if the case is obstinate, the whole interior of the meatus may be pencilled twice a week with a solution of nitrate of silver (gr. v. ad |i.), by means of a camel's-hair pencil. If the discharge, as sometimes happens, causes excoria- tion of the auricle, or of the neck, these parts must be first fomented, and then smeared with an ointment of hyd. praecip. alb. But it seems advisable not—as a general rule—to insert ointments into the meatus. If at any time during the treatment, an attack of acute pain and fever should come on, and the discharge should stop suddenly, leeches, purgatives, and fomentations must be resorted to, and all astringent applications be abandoned till these acute symptoms have subsided. IV. A thickened state of the cuticle lining the meatus is not an un- common sequel of neglected otorrhoea. The loose flakes of cuticle that sometimes fill the meatus, and the discharge, must be removed by syringing with warm water; and then the membrane should be brushed over with a weak solution of nitrate of silver, and afterwards with dilute citrine oint- ment (F. 168) melted and applied warm with a brush. Cleanliness is of the greatest consequence, as this affection is very apt to return if it is ne- glected. V. Polypus.—This term includes two sorts of morbid growths. The ' first, says Mr. Wilde, consists of fleshy pedunculated growths, nearly color- less, having a thin cuticular covering, unattended with pain, not appearing as the result of inflammation, and not accompanied with discharge, and usually attached to the middle glandular portion of the meatus. These are extremely rare. The others, which are very common, and which grow chiefly from the very bottom of the meatus, are consequences of otorrhoea, and are always attended with discharge. They are usually found of the size of a pea or bean, but may, of course, be much smaller, or may be so large as to project from the meatus. When small they are usually of a florid red color. The author has examined several specimens which had been removed by Mr. Harvey, and which consisted of fibro-plastic cells, with more or less of per- fectly-developed fibro-cellular tissue, and of almost structureless gelatinous substance. There is yet another polypus-like tumor which may be met with in the external meatus—viz., cancer. In its earliest stage, this may not be distinguishable, except by microscopic examination after removal; the rapid return of the growth, and the occurrence of palsy of the face, and other signs of the contamination of neighboring organs, will in time reveal the nature of the case. Treatment.—The polypus must be removed completely ; the point of its attachment be touched with lunar caustic, which must be applied from time to time, whenever it seems likely to sprout again, and the meatus must be regularly syringed with an astringent lotion. The lunar caustic should either be cast in very fine sticks, like the leads of a patent pencil, or the tip of a fine probe should be coated with it, so that it may be applied exactly to the spot where it is required. For the removal, the surgeon may employ either a stout Assalini forceps, here shown; from which the writer has seen excellent results in the hands of Mr. Harvey, whom he has had to thank for abundance of specimens sent him for microscopical examination; or Mr. Wilde's snare. This consists of a fine steel stem, five inches long, and bent in the-middle, in order that the hand which holds it may not get into the way of the eye. It has loops at the end and at the angle, through which a fine wire passes ; there is a movable cross-bar, to which the ends of the wire are tied: and a thumb- 396 POLYPUS. hole to hold it with. The wire should be just long enough to enable the cross-bar to be drawn back to the thumb-hole. In using the instrument, Fig. 217. [Assalini's forceps.] the bar is pushed forwards so that the wire may form a loop at the end ; this is to be put carefully round the neck of the polypus; when, by pulling the bar back to the handle, it will cut the neck through.1 [Wilde's snare for removing polypus of the ear.] Another ingenious instrument was constructed by the late Mr. Avery, and is shown here. The forceps' blades, a, when properly introduced, can be Fig. 219. [Fig. 220. Toynbee's lever-ring forceps, open.] made to grasp the neck of the polypus, by the pressure of the thumb on the button B, which pushes forwards the canula, c, so as to close the blades. [Mr. Toynbee is in the habit of using, with most satis- factory results, an instrument he calls the lever-ring forceps. It is thus described : " In the interior of a tube is a deli- cate steel rod, the end of which is split into two portions, each having a small oval ring at its extremity, measuring four or five lines long and from two to three broad. These rings (the inner surfaces of which are slightly serrated), are separated from each other when the lever is not pressed; but as soon as it is pressed, the rings are brought into contact."2] [Avery's instru- ment for removing polypus of the ear ] 1 Wilde's Aural Surgery, p. 420. 2 [•' The Diseases of the Ear, their Nature, Diagnosis and Treatment," by Joseph Toyn- bee. Philad. 1860, p. 119.] DISEASES OF THE EAR. 397 VI. Fungous Granulations are exceedingly common consequences of otorrhoea. They generally occur at the very bottom of the meatus, or grow from the membrana tympani, or from the cavity of the tympanum after the membrane has been perforated by ulceration. Sometimes the membrane is covered with florid vascular granulations, so as to resemble the granular conjunctiva. The common polypus is but an exaggeration of this condition. Treatment.—The solutkm of nitrate of silver should be regularly applied to the diseased surface by a camel's-hair pencil, and astringent washes should be injected. VII. Hypertrophy of the External Ear.—Dr. Graves mentions a case in which the pendant lobes of the ear became thickened and elongated through a deposit of fat into their cellular tissue, in a patient who died of fatty degeneration of the liver. The author has seen one or two cases in which the whole external ear was excessively enlarged and thickened ; but he would not have included them in this chapter, had not Dr. Graves ap- peared to consider the affection an uncommon one.1 Gouty deposits are not seldom met with. [The lobe of the ear sometimes becomes greatly enlarged after its perforation and the wearing of a ring; the enlargement being of a fibrous character. This affection is said to be much more common in blacks than in whites. See Gross, op. cit. vol. ii. p. 444.] VIII. Eczema of the auricle is a very troublesome affection ; and if it becomes chronic, is apt to produce thickening of the lining membrane of the meatus, and opacity of the membrana tympani. The treatment consists, during'the acute stage, in active purgation (F. 33, &c.) and warm poppy fomentations; saline and alkaline medicines, and good diet. In the later stage, the black wash may be used as an injection, and the dilute citrine ointment be smeared over the auricle at bed-time. Bark, with liquor po- tassa^ or iodide of potassium, may be given with benefit, or cod-liver oil; and in obstinate cases chloride of arsenic. (F. 97.) SECTION III.__AFFECTIONS OF THE TYMPANUM AND INTERNAL EAR. I. Acute Inflammation of the membrana tympani, the myringitis of Wilde, is so closely connected with inflammation of the tympanal cavity, or otitis interna, both in its causes, symptoms, and consequences, that we may treat of them together. The usual causes are cold, especially exposure to currents of cold air ; or sea-bathing; or violent syringing or probing, or otherwise irritating an inflamed ear. These inflammations may also come on during the course of fever, and most particularly during scarlatina, and mav be caused by rheumatism and gout. Symptoms —Sudden and intense pain in the ear ; often so excruciating as to produce delirium ; increased by coughing, sneezing, and swallowing ; and generally coming on first at night, and always worse at night; feeling of fulness in the ear; tenderness and soreness in its vicinity; tinnitus au- rium that is, unnatural noises of various sorts, heard by the patient; deaf- ness 'partial or complete (except that in some rare cases there is morbid sensibility to sound), and violent fever. On examination during the first stas-e the meatus is found more or less red, swelled and tender, and dry ; the membrana tympani dull, opaque, and vascular. If the acute symptoms go on from bad to worse, suppuration occurs within the tympanum and mastoid cells with most intense pain, and possibly facial paralysis ; and at last the membrane ulcerates or bursts, and allows of the discharge of pus from the evternal meatus In other more severe or neglected cases inflammation vrithin the cranium may occur and prove fatal. See p. 400. In less severe 1 Graves's Clinical Medicine, p. 581. 398 CHRONIC INFLAMMATION. cases, the membrane may be left thickened and opaque, and the cavity blocked up by adhesions; or there may remain an obstinate otorrhoea, which may give rise to caries of the bone, and mischief within the cranium here- after. Treatment—This disease must be combated by vigorous antiphlogistic measures. Leeches should be repeatedly applied both to the mastoid bone, and in the depression immediately below the auricle between the jaw and mastoid bone, and as Mr. Wilde directs, by means of a leech glass to the orifice of the meatus itself. Fomentations (p. 394) and poultices should be incessantly applied, and the bowels should be opened by calomel and efficient purgatives. Should the acute symptoms not be mitigated by these measures, and especially if there should be any sense of fulness, or swelling, or fluctua- tion over the mastoid process, Mr. Wilde recommends an incision, an inch or more long, to be made with, a stout scalpel through the periosteum, down to the bone, parallel to and an inch from the attachment of the auricle; and Mr. Harvey1 also strongly advocates this measure, not merely to relieve effu- sion already existing under the periosteum, but by creating a free discharge of blood, to cut the disease short, and prevent further mischief. Mercury should be given so as gently to affect the mouth, and blisters be applied when the acute stage is subsiding; or a portion of the incision, if made, may be converted into an issue. Extreme pain of a neuralgic or rheumatic character accompanying otitis may be allayed by painting with tincture of aconite, or with solution of ex- tract of belladonna in warm laudanum, behind the auricle; as in treating the so-called rheumatic ophthalmia. II. Subacute and Chronic Inflammation.—The researches of Toynbee and Wilde have shown most conclusively, that by far the majority of cases of deafness are not nervous, as is sometimes thought, but depend on changes wrought in the tympanic cavity by subacute or chronic inflammation. Mr. Toynbee divides the diseased appearances in the tympanic cavity into three stages. In the first stage, the lining membrane retains its natural delicacy of structure, but its vessels are enlarged and tortuous; blood is sometimes effused into its substance, or on its attached surface, or sometimes between it and the membrane of the fenestra rotunda ; and sometimes lymph is effused on its free surface. In the second stage the membrane is thickened and floc- culent; and occasionally covered with cheesy, tuberculous, or fibro-calcare- ous concretions; but the morbid change most frequently observed consists of fibrous bands, which are sometimes numerous enough to occupy nearly the whole of the cavity. In some instances they connect the inner surface of the membrana tympani to the inner wall of the tympanic cavity ; or to the incus and stapes ; bnt by far most frequently they extend from the crura of the stapes to the adjoining wall of the tympanum, so that this bone is, as it were, completely enveloped in a fog of adhesions. In the third stage, the membrana tympani is ulcerated; the ossicles discharged, and the whole middle ear disorganized ; caries of the bone and abscess may follow. The causes of the less severe varieties of otitis are the same as those of the acute, but of less intensity;—exposure to cold ; injudicious bathing; the weak and unhealthy states of the system left by fever, or the exanthemata; the scrofulous diathesis, especially if food, clothing, and fresh air be deficient; and the gouty and rheumatic diathesis. Symptoms.—These, unfortunately, are often so slight, that the patient gives no heed to them, till in process of time he finds himself altogether deaf in one or both ears. A slight woolly sensation, or occasional noises 1 On Rheumatism, Gout, and Neuralgia of the Ear and Head, by William Harvey, Lond. 1852. CARIES. 399 or ringing, with variable cbtuseness of hearing, and slight aching, are the most frequent. Treatment—The general indications are to improve the health; to re- lieve local inflammation by leeches—applied repeatedly, so long as they give relief to pain, noises, and headache—and by counter-irritants, such as small blisters, applied in succession over the mastoid bone, or to the nape of the neck. The feet should be kept warm, and the skin be cleansed by warm baths. Any diseased state of the external meatus should be remedied by the measures spoken of in the preceding section, and all discharges should be treated by mild astringent injections. Mercury is of all remedies the most efficacious for removing the consequences of protracted otitis. It should be given in small doses, long-continued, such as one grain of the hyd. c. creta, night and morning; or the bichloride, which is spoken of in the highest terms, both by Harvey and Wilde. It may be given alone, or with the tincture of bark, or of steel, F. 87. There are some forms of otitis, connected with peculiar diatheses which require notice, and especially, first, the rheumatic, which has been much studied by Mr. Harvey. This may be acute, and may be accompanied with general rheumatism, and may require the treatment already prescribed for acute otitis ; or may be subacute or chronic. Loud noises in the ear, deaf- ness, rheumatic or neuralgic pains about the head or face or other parts, generally becoming worse at night, and tenderness or stiffness of the scalp or neck, are the common symptoms : leeching, and colchicum given in regular small doses, with or without mercury, are the remedies for the more acute cases; the iodide of potassium, guaiacum (which is strongly recommended by Harvey), with bark or sarsaparilla, for the more chronic. Otitis may also be connected with gout,—for the treatment of which, the remarks on inflammation, p. 65, may be consulted ;—or with scrofula, or with mere debility and cachexia, in which case the cod-liver oil and bark, or steel, will be of great use ; or with secondary syphilis, for which the iodide of potassium and sarsaparilla, or corrosive sublimate, are the most appro- priate remedies. The local treatment of chronic deafness from inflammation of the mem- brana tvmpani, comprises the following points Discharge must be washed away by the remedies prescribed for otorrhoea. A granular or vascular state of the bottom of the meatus, or a thickened and opaque condition of the membrana tympani, may further be remedied by the regular application, once or twice a week, with a camel's-hair pencil, of a solution of from two to four grains of nitrate of silver, to an ounce of distilled water, and after- wards of the dilute citrine ointment. When the secretion of wax is absent, and when the membrana tympani is tense and dry, the dropping of a few drops of glycerine into the meatus at bed-time, as recommended by Mr. T. Wakley, is a great comfort to the patient. III. Caries, or necrosis of the petrous or mastoid bones, is a frequent consequence of suppuration within the tympanum or mastoid cells, or of nco-lected otorrhoea. Constant fetid discharge, fungous granulations choking the meatus ; deafness ; palsy of the side of the face ; dead bone felt with the probe; probably abscess over the mastoid process, or abscess occurring amongst the muscles of the neck, and pointing low down, are the symptoms. We may reiterate the injunction, that prevention is better than cure ; that an early incision down to the mastoid bone may prevent caries, but that, at all events if matter forms, it should be at once freely evacuated. Any loose portions of bone should be extracted. Sir P. Crampton drew from the meatus of a young lady a piece of bone comprising the entire internal ear- vestibule, cochlea, and semicircular canals, with a small portion of the inner wall of the tympanum. The patient had urgent symptoms of inflammation 400 PERFORATION OF THE MEMBRANA TYMPANI. of the brain, with hemiplegia, and total deafness of one ear, but ultimately recovered. The discharge should be carefully washed away by injections, as F. 136. IV. Inflammation of the Dura Mater, with effusion of greenish yel- low fibrine ; abscess within the brain ; plugging of the sinuses or jugular vein with dirty-looking fibrine, from the entrance of fetid secretion into them ; and general pyaemia, may be consequences of ear disease, just as they may of fracture of the skull, p. 330, and the observations we have made on the insidious approach of mischief within the head in the one set of cases apply equally to the other. V. Earache—(otalgia). This term ought to be restricted to signify neuralgia of the ear. Genuine neuralgia of the ear,—occurring in fits of excruciating pain, shooting over the head and face—may be distinguished from otitis by the sudden intensity of the pain—which is not throbbing,— does not increase in severity,—is not attended with fever,—and comes and goes capriciously. Its causes are the same as those of neuralgia generally, but particularly caries of the teeth ; and its treatment principally consists in removing carious teeth, or stopping them, and giving purgatives, followed by quinine and afterwards iron. The tincture of aconite may be painted behind the auricle. We cannot too strongly impress on the surgeon that what is popularly called earache is an inflammatory pain, to be treated by leeches, fomentations, and purgatives. VI. Perforation of the Membrana Tympani may be the consequence of laceration by violence. As we have before said, this very often accom- panies fracture of the petrous bone ; but it may be caused also by blows on the head, boxes, as they are called, on the ear; by violent blowing of the nose, by which means a current of air is forcibly injected through the Eustachian tube ; by forcibly syringing, which, as Mr. Toynbee observes, may easily rupture a thinned and dry membrane ; by descent in the diving- bell ; by the introduction of foreign substances; and lastly, by loud noises, especially the discharge of cannon. Sense of shock in the ear, bleeding and deafness, are the immediate symptoms. If inflammation comes on, it must be met by the measures detailed above ; and if deafness continue, as a result of the aperture, it must be treated as we shall show presently. 2. Perfora- tion is far more commonly the result of acute otitis, and suppuration within the tympanum. (See Otorrhoea and Otitis.) 3. It may also result from chronic inflammation and ulceration. The symptoms which indicate an aperture in the membrane are, that per- haps the patient is conscious of air passing from the ear during swallowing; or that he can taste or perceive in his throat substances applied within the meatus On examination with the speculum, the aperture, if large, may be discovered, and may, perhaps, be seen to cast a shadow on the tympanum beyond ; or if the patient inflate the tympanum, in the manner to be pre- sently described, air-bubbles and mucus may be seen to issue from it. The consequences of perforation, if so small that it is capable of being closed by a film of the natural moisture of the parts, are very slight. But a large opening causes great deafness. Treatment.—Otorrhoea, or any other diseased condition, should be treated as already directed ; and the nitrate of silver may be applied by means of a fine probe coated with it (F. 193) to the aperture. But if the opening should not heal, or if the case be chronic with a considerable loss of sub- stance of the membrane, some means should be devised to render the tym- panum again a closed cavity, which is essential for perfect hearing. Some patients had long been in the habit of putting a drop of water or of oil into the ear, with great benefit; the good effects, no doubt, resulting from the closure of the aperture by a thin film of the liquid. But in 1848, Mr. Years- eustachian tubes. 401 ley made known the simple but important fact, that a little bit of cotton- wool, moistened with water or oil, or, still better, with glycerine, if passed down the meatus, and applied against the orifice, will act as an excellent . substitute for the lost membrane. The patient can usually be taught to in- troduce and withdraw this cotton with great nicety, by means of a for- [Fig. 221. ceps or bodkin, and to place it ex- actly in the right spot. Whether it requires to be renewed twice, or once daily, or not so often, depends upon cir- cumstances. Mr. Toynbee uses, instead Of COtton, artificial membranes Of Small Artificial membrana tympani, of Toynbee.] oval pieces of thin India-rubber.1 VII. Collapse of the Membrana Tympani is a condition in which that part is drawn inwards, so as to be concave externally and leave the handle of the malleus unnaturally prominent. It is usually a consequence of chronic otitis, the membrane being opaque and thickened ; but sometimes is said to be a functional disorder, and the structure of the membrane to be normal. The latter is the condition in which it is said that the patient can hear better in a noise, or when stimulants, such as a few drops of nitric ether, are dropped into the meatus, supposing all traces of inflammation to have subsided. Any plan of drawing the membrane outwards seems hopeless. VIII. The Eustachian Tubes, as is well known, are passages between the cavity of the tympanum and the throat, allowing the air to enter and es- cape from that cavity as may be required. But Mr. Toynbee has given good reason for believing that, contrary to the common opinion, the tubes are not habitually open ; and that so far from permitting constant and uninterrupted communication, their orifice is always closed, except during the act of swal- lowing. During this act, the tensor and levator palati muscles "open the guttural orifice of the tube, afford free egress to the mucus secreted by the lining membrane of the tympanum, and allow air to enter or leave the tym- panic cavity." That this is so, is rendered probable by the circumstance that the act of swallowing gives relief to the uneasy feelings in the ear ex- perienced by persons who descend in a diving-bell; which it does by allowing the condensed air to enter the tympanum, and so to make the pressure on its inner surface equal to that on its outer. "Again," says Mr. Toynbee, "if an attempt is made to swallow, while the nostrils are closed by the finger and thumb, a sensation of fulness and pressure is experienced in the tympanic cavity ; in consequence of the air being then forced, during the act of deglu- tition, through the open tube into the tympanum ; and this sensation con- tinues until, by another act of swallowing, the tube is reopened, and the confined air escapes into the fauces." It has further been shown, as we ob- served when treating of perforation of the membrana tympani, that the cavity requires to be a closed one for perfect hearing, and that the Eustachian tube ought to be pervious, but not always open. These things being premised, we are prepared to understand the nature of that which has been called throat deafness, and which depends on the morbid states of the tympanum, extending from the throat through the Eus- tachian tubes. In the first place, the common catarrhal deafness—the ring- ing and crackling noises in the ear, with which every one is familiar; the change of sensation experienced on blowing the nose or swallowing—sup- plies the commonest instance. This, in most cases, is trivial, and soon gets well. But in delicate children it is often otherwise, and a slight but increas- ing amount of deafness remains, depending, no doubt, on a swelled condition 26 1 [Toynbee, op. cit. p. 191.] 402 EUSTACHIAN tubes. of the tympanal membrane, and accompanied, as is natural, with a general flabby and relaxed condition of the mucous membrane of the nose and fauces. The same thing may happen to adults. This condition will be distinguished by the swelled tonsils and relaxed throat; by the aggravation each time cold is caught; by the sudden noises from bursting of mucous bubbles, heard by the patient, and by the surgeon through the otoscope. This, as improved by Mr. Harvey, is a flexible stethoscope, one end of which, expanded into a hollow bell, is put over the patient's ear [or, if [Fig. 222. Otoscope.] rounded, as in Mr. Toynbee's, into his ear], whilst the other is applied to the surgeon's. Then, if the patient be desired to close his nose and mouth firmly, and while doing so, to make an effort as in blowing the nose, or to [Fig. 223. Mode of using the otoscope.] swallow, the surgeon may hear the shock of air against the membrana tym- pani if the tubes are pervious ; he will hear a squeeling or gurgling sound if they contain fluid ; whilst if they are impervious, he will of course hear EUSTACHIAN TUBES. 403 nothing. Yet he must recollect that some patients cannot acquire the knack of inflating their tympanum, and it must not be too hastily assumed that they are impervious. Of the severer forms of inflammation of the tympanal cavity we have already spoken. Treatment—The general health must be braced by bark, steel, cod-liver oil, and other tonics (F. 87, 65, &c); and the relaxed mucous membrane, by gargles, of which the author can recommend the sulphate and chloride of zinc (F. 109) most strongly, and by creasote inhalation; and repeated blisters may be applied behind the ears. It has been proposed that the tonsils and uvula should be extirpated in these cases. But although it may be justifiable to remove a superficial slice of enlarged tonsils, on other grounds, yet it is now amply proved, that enlargement of the tonsils by itself is not a cause of deafness; and, a fortiori, that the cutting out of healthy tonsils cannot improve the hearing: besides that, there is good reason for believing, that this mutilation rashly performed, may have the most disastrous consequences on the voice, on the general health, and, as Mr. Harvey believes, on the proper development of the generative organs. See chap. xv. The operation of catheterism of the Eustachian tubes, for the purpose of dilating them; or of injecting warm water or air, or medicated liquids or # vapors into the cavity of the tympanum, has also been much advocated. But the author cannot recommend these operations for general adoption ; first, because they are painful, and because he believes they very seldom, if ever, do any real good ; and secondly, because they are dangerous, and have proved fatal in more instances than one. [Mr. Toynbee uses the Eustachian catheter and the explorer, here represented, in order to blow air through the Fig. 224. Eustachian catheter, and the explorer. tu »e into the tympanum. While blowing gently through the explorer, the su ti'eon should listen through the ' ,oscope to ascertain whether the air enters the ear.] When it is considered that in some cases the bony partition between the Eustachian tube and the carotid canal is almost entirely ab- sorbed ; and that in others there is but the thinnest shell of bone, or, perhaps, only a mere membrane between the tympanic cavity, or mastoid cells, and the cavity of the cranium or jugular fossa (all of which morbid changes the author has seen in Mr. Toynbee's collection), it will be readily understood how the pokings in the dark at the Eustachian tube, and forcible injections of the tympanum that we read of, may have very easily produced fatal results. Possiblv the reason why more mischief has not been done, is, that the cathe- ter has been poked somewhere, but not into the Eustachian tube. Perfora- tion of the membrana tympani, which has been proposed to be done, in order 404 DEAFNESS. to allow the access of air to the tympanum when the natural openings in the throat are obliterated, is another operation of very doubtful utility. [Fig. 225. Mode of using the Eustachian catheter and the explorer.] IX. Functional Nervous Deafness.—Deafness is said to be nervous, when it depends on general torpor and debility, and is better at some times than at others, especially in fine weather, and when the patient is cheerful or excited, and the stomach in good order, and when there is an entire absence of all symptoms or vestiges of inflammation. But such a form of deafness is rare ; and Mr. Toynbee has shown, that even in very old persons, in whom it is often supposed to be common, the usual cause of deafness is not defect in the nervous apparatus, but thickening, adhesions, and other effects of inflammation of the tympanal cavity. Treatment.—Aperients, with diffusible stimulants, especially ammonia, arnica, and valerian; stimulating gargles, masticatories of pellitory, &c. If the meatus is dry, and altogether deficient in cerumen, great benefit may be derived from the introduction of a few drops of fish-oil, or of ox-gall, or of aether, or of sp. am. ar. into the meatus, and the application of mustard, and other counter-irritants behind the ear. Electricity may be mischievous. X. Organic Nervous Deafness.—Deafness may be caused by Movjs on the head, or fracture, which produces either concussion or rupture of the auditory nerve. Depletion, if any inflammatory symptoms are present, with alteratives and counter-irritants afterwards, are the only remedies. Deafness may also be produced by organic alterations in the brain, and may be attended with epilepsy or idiocy, or may be a consequence of apo- plexy or convulsions. The treatment must be the same as for amaurosis arising from similar causes (p. 385).1 1 Copland, Diet., art. Ear; Kramer on Disease of the Ear, translated by Bennett: Pilcher on the Structure and Diseases of the Ear, Lond. 1838 ; Essay on the Ear, by Joseph Williams, M. D., Lond. 1840 ; Harvey on Deafness and Enlargement of the Tonsils, Lond. 1850; Toynbee, in Med.-Chir. Trans, vol. xxiv.; Med. Gaz., 7th July, 1843 ; on Senile Deafness, Edin. Monthly Journ. of Med. So., Feb. 1849 ; On an Arti- ficial Membrana Tympani, Lond. 1853; Yearsley on the Application of Cotton, &c, Lancet for 1848, vol. ii. pp. 10, 64, &c.; Toynbee, Lectures in Med. Times, vol. ii. 1855 ; W. R. Wilde, op. cit. [Toynbee, op. cit.] rhinoplastic operations. 405 CHAPTER XIV. DISEASES AND INJURIES OF THE FACE AND NOSE. SECTION I.—AFFECTIONS OF THE OUTER PARTS OF THE FACE, NOSE, AND LIPS. I. Salivary Fistula is said to exist when the stenonian duct has been perforated by a wound or ulcer, so that the saliva dribbles out on the cheek. Treatment—In the first place, a good passage must be established from the duct into the mouth. This may be done by puncturing the mouth through the fistula in two places, passing a small skein of silk, or, still better, a piece of very flexible wire, through the apertures, and securing the two ends in the mouth by a knot. After a few days, when a sufficient aperture into the mouth has been established, means must be employed for closing the fistula. Its edges may be pared and brought together in a straight line, by means of needles and the twisted suture. To facilitate this, the skin may, in some cases, be dissected up, so that it may be shifted along. In some cases, the cautery, a small blunt one, at a black heat, may be passed round the edges, to make them contract. In cases of deep narrow fistula, Marhall's galvanic cautery may be used. In other cases, the aperture may be covered with a flap of skin raised from the adjoining parts. II. Hypertrophy.—The nose sometimes becomes prodigiously enlarged through an hypertrophy of the areolar tissue and skin, especially in persons who have been addicted to the pleasures of the table. Such tumors are very inconvenient and unsightly, but not dangerous. They grow slowly— are indolent and painless—the sebaceous follicles are much enlarged, and secrete profusely, and the skin is more or less mottled with veins. Treatment—If the patient desires it, the tumor may be removed with the knife; but the surgeon must first well examine his general health, and put him on regular diet. An incision may be made in the median line nearly down to the cartilage. Then an assistant distends the nostril with his fore- finger whilst the surgeon seizes the morbid growth, and shaves it clean off, close to the cartilage. After the operation, there will be considerable he- morrhage from numerous vessels. Some of these may be tied, some maybe pinched°with a forceps, some may be secured with a very fine cambric needle and thread; and any general oozing may be restrained by the application of cold water or matico leaf, or, if it be obstinate, by plugging the nostrils, and making pressure with strips of plaster. Ill Rhinoplastic, or Taliacotian Operations.—When a portion or the whole of the nose has been destroyed by disease or accident, the defi- ciency may be restored by a transplantation of skin from an adjoining part; the operation being varied according to the extent of the deformity. But whether this mutilation arises from scrofulous ulceration, or from lupus non- exedens p 95 or from scrofulous disease of the bones, or from syphilitic disease plenty'of time should be allowed before any operation is thought of, else it may be frustrated by a return of the disease. _ 1 When the whole or greater part of the nose has perished, a triangular niece of leather should be cut into the shape which the nose formerly pre- sented ind be spread out flat on the forehead, with its base uppermost, and its boundaries should be marked out on the skin with ink. Then the remains of the old nose (if am) are to be pared, and the margins of the nasal aper- ture are to be-cut into deep narrow grooves. When the bleeding from these 406 RHINOPLASTIC OPERATIONS. wounds has ceased, the flap of skin marked out on the forehead is to be dis- sected up, and all the cellular tissue down to the periosteum with it, so that it may hang attached, merely by a narrow strip of skin between the eye- brows. When all bleeding has ceased, the flap is to be twisted on itself, and its edges are to be fitted into the grooves made for their reception, and to be fastened with sutures. The nose thus made is to be supported, but not stuffed, with oiled lint; it should be wrapped in flannel to support its temperature, and if it become black and turgid, owing to a deficiency in the return of blood from it, a leech may be applied. When adhesion has thoroughly taken place, the twisted strip of skin, by which its connection with the forehead was maintained, may be cut through, or a little strip may be cut out of it, so that it may be laid down smoothly. 2. The septum or columna nasi is often restored by the same operation with the nose itself, by means of a flap from the forehead ; but it is better, as Mr. Liston proposed, to form it out of the upper lip at a subsequent ope- ration. A strip is cut out of the centre of the upper lip, a quarter of an inch in breadth, and of its whole thickness. The fraenulum having been divided, this strip is turned up, but not twisted ; and its labial surface hav- ing been pared off, and the inside of the apex having been made raw, the two latter surfaces are united by the twisted suture, and the wound of the lip is also united by the same. During the cure, the nostrils must be kept of their proper size by introducing silver tubes occasionally. 3. When one ala nasi alone is destroyed, a portion of integument may be measured out on the cheek, and be raised to supply the deficiency. But if both alae are lost, or if the cheek be spare and thin, it is better to supply their place with skin brought from the forehead. The slip which connects the engrafted portion with the forehead will of course be long and thin ; and in order to maintain its vitality, a groove may be made to receive it on the dorsum of the nose. But when union has occurred, this connecting slip may be raised and cut off, and the groove which contained it be united by sutures. 4. Depression of the apex of the nose is to be remedied by raising the parts, dividing any adhesions that may have formed, making, if necessary, a new columna, in the manner described above, and supporting the parts carefully with plugs of lint, till they have acquired firmness. But it may be done still more completely by a method which was proposed by Dieffenbach, and a modification of which has been practised with great success by Mr. W. Fergusson. "The point of a small scalpel," says Mr. Fergusson, "was introduced under the apex, and the alae were separated from the parts un- derneath ; next the knife was carried on each side between the skin and the bones, as far as the infra-orbital foramen, taking care not to interfere with the nerves, when, by passing the point of my finger below the nose, I caused the latter organ to be as prominent as could be wished. I now passed a couple of long silver needles, which had been prepared for the purpose, with round heads and steel points, across from one cheek to the other, having previously applied on each side a small piece of sole leather, perforated with holes at a proper distance ; then I cut off the steel points, and with tweezers so twisted the end of each needle, as to cause the cheeks to come close to each other, and thus to render the nose prominent. Thus, by bring- ing the cheeks more into the mesial line, a new foundation, as it were, was given to the organ. Adhesion occurred in some places, granulations in others; in the lapse of ten days the needles were withdrawn, and in the course of a few weeks, when cicatrization was complete, the nose presented as favorable an appearance as could reasonably have been desired.'" '5. Depression of the ridge, owing to the loss of the ossa nasi, may be 1 Practical Surgery, 3d edit. p. 578 ; [4th Amer. p. 43(1.] HARE-LIP. 407 Fig. 226. [Hare-lip.] remedied by paring the surface, and covering it with a flap of skin from the forehead ; or by making a longitudinal incision, and engrafting a small por- tion of skin from the forehead into it; or, if the case is slight, by cutting out one or two transverse slips, and bringing the cut edges together by sutures, so that thus the surface may be stretched to its proper level. IV. Hare-Lip signifies a congenital fissure of the upper lip, arising from arrest of development. Its usual place is just on the left side of the middle line; and it may exist on one side only, or there may be a double fissure with a small flap of skin between. With the imperfect development of the skin there is usually more or less of the same condition in the bone. That part of each superior maxillary bone which con- tains the incisor teeth, and which constitutes a dis- tinct bone in the human embryo, and in many animals —the intermaxillary, or premaxillary of Owen—the divided haemal spine of the nasal vertebra—may be disconnected on one or both sides, leaving a gap in the alveolus, which may possibly extend backwards to be complicated with fissure of the palate. This inter- mediate portion may be displaced and attached like a snout to the end of the septum narium. Sometimes the upper incisor teeth and their alveoli project through the fissure in the lip. Treatment—The first consideration is the age at which treatment shall be undertaken. Sir A. Cooper used to recommend that it should be put off till the child was two years old, and had cut some teeth, because of the supposed liability of young infants to be carried off by convulsions ; but Mr. Fergusson and most modern surgeons believe the risk to be overrated, and prefer operating as soon as possible. Mr. Henry Smith has operated on the fourth day, and Mr. Bateman, of Islington, on the fourth hour after birth with success. Infants may die (just as little Jews die sometimes after circumcision), but such an event is especially rare. The second point to be considered is, how to deal with the bone, should it project through the fissure. The old plan was to cut it off; but conserva- tism has gained the day here, as in most other departments of medicine, and at present the plan proposed by Gensoul, and improved by Haynes Walton, is adopted, of cutting perpendicularly through the alveolus with bone for- ceps between the incisor teeth, and gently bending back the projecting part to a convenient level. In some cases related in Cooper's Dictionary, this object was gained by the use of a truss worn for several hours daily; but if the operation is performed soon after birth, there will be no time for this. The next step is one recommended by Mr. Walton; and consists in freely detaching the lip from the bones behind, so that it may hang loosely, and be brought together easily. Fourthly, the edges of the fissure are to be pared. We take it for granted that the child has been quieted by chloroform, and that it is laid flat on the lap of a nurse, with its head on the knees of the surgeon, who sits in front. Then the bone having been bent back if necessary, and the lip freed as just described, the surgeon, seizing the lip by the corner of the fissure with his left fore- finger and thumb, pierces it with a narrow knife at the top of the fissure just under the nose, and carries the instrument downwards, so as to shave off the edge of the fissure ; and it is better to remove too much than too little There is a nice manoeuvre that should be adopted in finishing the Fig. 227. [Operation for hare-lip.] 408 HARE-LIP. incision. The knife should not be carried straight down, but should be car- ried inwards, so as to save the very bottom of the cleft; by this means, when the parts are healed, there will be less of a notch left. This process is repeated on the other side, and the two strips are next detached from the upper angle. The edges of the fissure being made raw, the next step is to bring them into the nicest adaptation possible, and to keep them so. The usual method employed is the twisted suture, described at p. 138. Three of the fine lancet-pointed needles are thrust through the raw edges of the fissure. They should go through about two-thirds of the thickness of the lip. The first should be put through the lower angles, where it is most es- sential that the adaptation should be most exact; another may run through and compress any artery that bleeds ; a third higher up. Then the centre of a long slip of lint, or of twine, should be wound round the uppermost pin and be brought round the others as shown at p. 139 ; besides which, Mr. Fergusson cements the suture and lip by a plentiful application of collodion. In order to prevent any strain on the stitches, it is now usual to put on a spring truss invented by Dr. Dewar, of Aberdeen, and so contrived as gently to press the cheeks towards the middle line. This is worn till adhesion is firmly established. The diet of the patient, if an infant, will give no trouble. If he be older, it should be nutritious. There need be no hurry in withdrawing the pins; the fifth or seventh day will be soon enough ; and then the Fi°-. 228. cicatrix should be supported,by plaster. If union should fail, the pins or some other suture should £fk dBsj$\ be inserted again, to take the chance of union during the ^t§p hsf granulation stage. Mr. wood's hut- Instead of the twisted suture, some surgeons trust to the tons—natural size, common interrupted suture. The button suture, represented in the adjoining cut, is warmly recommended by Mr. Wood, of the Gloucester Hospital, who has very successfully cultivated this branch of plastic surgery. He uses on each side two perforated silver disks, having wires soldered to their backs, over which a Fig. 229. double ligature is tied, after having been passed through the lip. Mr. Wood believes that by thus avoiding the pinching and rigidity of the needles, he obtains a more efficient and unobjectionable mode of union ; and recommends the same suture in cases of divided perineum and similar cases.1 If the hare-lip is double, both sides may be ope- rated on at once, the middle flap being transfixed [Button suture used in ope- by the sutures. But care should be taken to push ration for hare-iip.] up the middle flap towards the nose, so as to ren- der the latter organ more prominent, as it is in general very flat in cases of hare-lip. [A method of operating for hare-lip, to which great importance is justly attached by many distinguished surgeons, is that known as the method by living suture. The inverted V-shaped incision is made as in the ordinary operation, but the knife is not carried altogether down to the free edge of the lip ; the flap is then turned down and the sides of the lozenge-shaped opening which is thus made are placed in contact by one or more sutures. Even if the sutures yield, the depressed portion of the lip, the living suture, still holds, and by degrees the hole that is left becomes obliterated. We have seen the advantages of this plan so often, that we strongly urge its 1 See paper by Mr. Wood, in Med. Gaz. 1841; Haynes Walton, Med. Times, June, 1S4S ; Fergusson, op. cit. EPITHELIOMA. 409 adoption. A child must suck, and he will cry and rub his lips. All this destroys the dressings placed over the parts, and the sutures ulcerate and become loose. When, however, this operation has been performed, the edges of the incision swell and become covered with granulations, and a natural suture is formed, and will remain, even if the others do give way, and exactly at the inferior part of the lip, where it is most needed. Even if primary union do not take place, a secondary union will, just as regular and just as good. Of course there is no danger of the disfiguring notch, which is so often left by other operations ; and if the parts project too much, it is very easy to remove a portion.] V. Cancer of the Lip is a very rare disease, and, according to Lebert, more commonly attacks the upper than the lower lip. It must be treated on the principles laid down at p. 129. What is popularly called cancer of the lip is in reality— VI. Epithelioma, of which disorder the lower lip is the favorite seat. Epithelioma, the so-called cancer, or epithelial cancer of the lip, is a disease of middle, or paulo-post-mid&le life, and affects the lower rather than the higher classes, men much more often than women, and the left more often than the right side. There F'g- 230. must be some sort of predisposition ; but the first attack can very often be traced to some slight but incessantly renewed irritation, and especially smoking short earthen tobacco-pipes. Teeth encrusted with tartar, and the habit of holding rough twine between the lips, have been alleged as causes in particular cases. The disease be- gins as a crack or excoriation, covered with thick epidermis; or as a wart; or as a super- [Epithelioma of the lower nP.] ficial hardness of the skin ; and it usually begins on the red prolabium, or on the edge where this joins the skin. In its earliest stage it may continue, for a very long time, stationary or slowly progressing; most likely repeatedly shedding flakes of epidermis, and silently increasing in breadth and depth. At last, however, possibly from some irri- tating local application, a stage of active progress sets in, and is accompanied by corroding ulceration ; and then comes a foul ulcer with hardened base, fungous wart-like edges, and surface covered with scabs of dried pus and epithelium, or exuding a fetid sanious discharge. If it proceeds unchecked, the lip is destroyed ; the saliva dribbles from the mouth ; the glands under the jaw swell; the muscles and lower jaw-bone are attacked by ulceration and caries ; the teeth drop out. The health, sound at first, begins to give way; and the influence of this intense local irritation, combined with the difficulty of taking food, and the absorption of fetid secretions, are amply sufficient to destroy life. This disease, as to its nature, is probably in great measure local, and destroys life by its local progress, not by general diffusion over the system, as cancer. Its morbid anatomy has already been amply detailed, p. 119 ; suffice it to repeat that the dermis, the enlarged papilla?, muscles, glands, and bone are abundantly infiltrated with scaly epithelium ; and Paget relates that in two out of seven autopsies, epithelial deposits were found in the heart or lun3. [Fergusson's knot in sta- phyloraphy.] 422 tumors of the lower jaw. The incisions are carried along, parallel to the horizontal or ascending ramus, and are made so long that the tumor may be thoroughly exposed when the flap is raised. If the tumor is large, and situated near the middle of the bone, it must be laid bare as we have just described. A tooth must be extracted on each side of the tumor: next, the bone may be sawn hall through perpendicularly on each side, and then be divided completely by the straight cutting forceps, one blade being passed up on the inner side of the bone, and the other placed in the groove made by the saw ; and lastly, the parts attached to the inner side of the bone must be cautiously divided ; namely, the digastric, mylo-hyoid, genio-hyoid, and genio-hyoglossus muscles. When the attachments of these muscles are divided, care must be taken not to let the tongue retract into the throat, which might push back the epiglottis and cause suffocation. To prevent this, a ligature may be passed through the tip of the tongue, by which it may be held forwards during the operation, and which may be fastened to the twisted suture by which the wound is afterwards to be closed. If, however, the disease is not so very extensive, it may not be necessary to sacrifice the whole thickness of the bone, but a horizontal portion of the base of the bone may be saved, which will prevent the chin from falling in after the operation. In order to effect this, the bone may be sawn down- wards for half its depth on each side of the tumor, and a horizontal cut be made below it; and then the diseased portion be separated completely with the cutting pliers. • If a lateral portion is to be removed, an incision should be made along the basis of the bone, to its posterior angle, and up behind the ascending ramus. Thus a flap is formed, which may be turned up so as to furnish a good view of the tumor, and then the bone is to be divided as before de- scribed. If the extent of the disease renders it necessary to remove the entire side of the bone, and to separate it from its articulation with the temporal, the operator must begin by making a curved incision from beneath the ear, along the basis of the jaw to the chin. The flap so formed is to be dissected up, and the masseter with it; an incisor tooth is to be removed, and the bone to be sawn vertically through ; the end is next seized and depressed, and the temporal muscle dissected from the coronoid process; the pterygoid muscles and other internal attachments are then to be divided, and finally the ligaments of the joint. Whilst effecting the disarticulation of the con- dyle, the point of the knife should be kept close to the bone, so as to avoid all risk of wounding the external carotid artery. After bleeding has been restrained, the wound is to be closed by sutures, excepting at the middle, where an aperture should be left for the ligatures, and to permit the escape of discharge. The salivary ducts and facial nerves divided in these opera- tions may be left to themselves ; the muscular power of the face is usually recovered, and the saliva finds a channel into the mouth.1 VI. Necrosis of portions of the jaws is occasionally the result of me- chanical violence, carious teeth, or violent salivation ; but of late years a new source of this disease has been detected in phosphorus. This, when imbibed by persons employed in lucifep-match manufactories, especially if they have carious teeth, may cause inflammation of the periosteum, with thickening and infiltration, followed by inflammation and abscess, and result- 1 See Liston's Elements of Surgery, and Practical Surgery, 2d edition ; Guthrie, in Med. Gaz. vol. xvii. ; Brodie, ibid. vol. xv. ; Liston on Tumors of the F,ace, in Med.-Chii. Trans, vol. xx.; Bell on the Teeth ; Jobson on the Teeth, and Fergusson's Practical Surgery. Diseases of the lower jaw requiring amputation have been caused by a pro- jection anteriorly of the coronoid process, which hindered the evolution of the wisdom tooth.—Forbes's Rev. vol. viii. affections of the mouth and tongue. 423 ing in necrosis of a portion of bone with extensive sloughing of the soft parts around. The health is much broken down; the discharge particularly fetid and copious. " With loss of appetite, sallow countenance, and feeble circulation," says Mr. Stanley, " the first indication of the disease is usually toothache, followed by the dropping out of the teeth, more especially of the grinders, and then by the death of a portion of the jaw." There is no re- paration subsequently as in common necrosis. Treatment—In the earliest stage, free incisions through the gums and thickened periosteum ; when the necrosis has taken place, deodorizing lo- tions copiously applied ; meat beaten to a pulp, and other nourishing food ; loose portions to be removed as soon as detached.1 VII. Closure of the Jaws, with more or less inability to open the mouth and to masticate solid food, may be a result of disease of the bone implicating the joint; or of rigid cicatrices within the mouth, produced after sloughing, whether caused by drinking boiling water, or by the profuse administration of mercury. The division of any rigid bands of cicatrices, the division of the masseter muscles by subcutaneous section, a narrow knife being thrust from the mouth between the muscle and the skin, an operation which has been successfully performed by Mr. Fergusson, and the use of a screw dilator, are the only available remedies. SECTION IV.—AFFECTIONS OF THE MOUTH AND TONGUE. I. Tumors of almost every kind, including cartilaginous, glandular, vas- cular, and serocystic, may be found in the cheeks, but the commonest are encysted tumors, containing a glairy liquid. They may project on the inner surface of the lips, or may exist under the tongue, where such tumors are known by the term ranula. It was formerly supposed that ranula depended on obstruction of the Whartonian salivary duct; but this is not the case. These tumors should be treated in the first place by simple free incision, or by cutting out a piece of the sac. Should this not suffice, the interior may be touched with lunar caustic, or a small seton be passed through it, to cause it to suppurate and waste away; or the cyst, if loosely attached, may be dissected out. [A very good plan of treatment is to empty the cyst by means of a trocar, to wash it out thoroughly; and then to throw in a solu- tion of iodine. AVe have seen a number of cases thus successfully treated.], AVhen ranula has existed long, it may increase greatly and form a tumor of very considerable size, pushing the tongue over to the other side, or up to the roof of the mouth, interfering very seriously with speech, deglutition, and even respiration, not allowing the mouth to be closed, projecting under the jaw, and even, as in a case related by Mr. Mayo, of Winchester, reach- ing down between the sterno-mastoid muscle and trachea to the clavicle. The contents of such cysts become mortar-like, or almost solid, and the cysts themselves thickened and closely adherent to the surrounding parts, so as not to be detached without great bleeding. In any such case, if the tumor is too large to be extirpated, or its contents too solid to be removed by an incision within the mouth, an incision must be made in the middle line be- neath the jaw, between the muscles which pass from the jaw to the hyoid bone • or wherever else it is most superficial. The contents must be re- moved ; as much of the cyst as can be detached, be cut off; and the remain- der left to suppurate. Mr. Mayo fills the remainder of the cyst with lint dipped in turpentine, both to check bleeding and to cause the cyst to be quickly thrown off.3 i See Stanley on the Bones, and a Lecture by Mr. Simon, Lancet, 12th Jan. 1850. 2 Mr. Mavo's case, Lancet, 1847, i. O'b'7 ; also Fergusson's Pract. Surg., 3d edit. p. 599; [4th Am. e'dit. p. 444.] 424 AFFECTIONS OF THE TONGUE. II. Tongue-tie signifies a prolongation of the fraanum lingua?, confining the apex of the organ to the lower jaw. It is usually detected by the diffi- culty which the infant has in sucking ; and may easily be relieved by dividing the fraenum with a blunt-pointed pair of scissors, taking care to direct their points downwards, and to keep as close to the lower jaw as possible, so as to avoid the lingual artery. III. AArouNDS of the tongue are liable to be attended with severe hemor- rhage from the lingual artery or from veins. If the bleeding orifice cannot be otherwise tied, one or more ligatures must be introduced with curved needles, so as to include and constrict the bleeding parts, or a heated iron may be applied. Children are apt to inflict very severe bites, even some- times almost biting off the end of the tongue. The author has treated several such by leaving them entirely to nature. He has known surgeons put themselves to very great trouble to introduce sutures, but the patient fared none the better. IV. Inflammation of the tongue, known by great swelling, tenderness, and difficulty of speaking, and of deglutition ; generally accompanies severe salivation ; but it may occur in an acute form independently of this cause. It must be treated by purgatives and gargles ; by leeches, incisions, and the antiphlogistic regimen generally, if necessary. If abscess form, the fluctu- ating part should be opened. Abscesses which form under the tongue may cause suffocation by their pressure on the glottis : an incision beneath the chin, through the mylohyoid muscle is the only resource.1 V. Hypertrophy.—Enlargement, without tenderness or structural dis- ease, sometimes affects the tongue, causing it to protrude permanently from the mouth. It is usually the result of an attack of acute inflammation, which has caused the tongue to protrude. On this point the author believes the following case will supply a practical hint. He was some time since consulted in a case in which the tongue had protruded largely from the mouth, in consequence of severe salivation. He found that the continuance of the protrusion was owing, first, to the impaired function of the recently- inflamed organ ; and, secondly, to some amount of constriction by the teeth; but gentle pressure easily caused it gradually to return into the mouth. Had it been left to itself it might, to all appearances, have remained protruded for ever. Hence, in all such cases, the surgeon should replace the tongue, so soon as the acutest stage of inflammation has passed, and should not wait for it to go in of itself. Treatment—Steady compression should be first tried, by compress and bandage. Should this fail, a ^-shaped piece should be removed, and the cut surfaces be brought together by suture. If the surgeon has reason to fear bleeding, he may pass a needle armed with a strong double ligature through the centre of the tongue, and then tie one thread very tightly round each half. VI. Ulceration of the tongue presents many varieties. One of the commonest is that which arises from the irritation of decayed teeth, and is usually soon cured by removing the cause, and using aperients and an astringent gargle. A more troublesome sort begins with aphthous spots on the tongue or any other part of the inside of the mouth, which produce excessively irritable and tedious ulcers in succession. Aperients and tonics, 1 Sometimes the tongue enlarges suddenly to an immense size, so as almost to cause suffocation, but without any symptoms of inflammation, properly so called. A case which proved fatal, in spite of bleeding, leeching, calomel, and incisions, is related by Mr. Lyford, of Winchester, in the Lancet for 1828, p. 16 ; a similar case, cured by pur- gatives and incision, by Mr. Taynton, Med. Gaz. vol. xii., who speaks of it as the only case he had seen in a practice of forty years ; and one by Mr. Collins (ib. p. 042), in a pregnant woman, cured by an incision in the raphe on the under surface. affections of the teeth and gums. 425 and the application of nitrate of silver, or lin. aeruginis, are the remedies. Secondary and tertiary syphilis are also liable to cause ulcers here ; which are to be recognized by the history of the patient, and by the benefit pro- bably derivable from sarsaparilla with iodide of potassium. All. Cancer of the tongue usually soon produces a deep excavated ulcer, which will be distinguished from either of the simpler kinds by its having been preceded by nodular enlargement, and by pain and embarrass- ment in the use of the organ. In the case of the late Bransby Cooper, neuralgia of the right side of the neck and face was the first symptom ; fol- lowed by difficulty of swallowing and articulation, fetid breath, and loss of flesh. Death occurred from arterial hemorrhage in ten months. There was found a deep excavation at the root of the tongue ; the tissues around, as well as the muscles about the os hyoides and some adjoining lymphatic glands, infiltrated with cancer. VIII. Epithelioma of the tongue may be scarcely less fatal than cancer, from which it may be difficult to distinguish it except by microscopical examination. A typical case of it occurred in the person of the late Pro- fessor John Beid, of St. Andrew's. His age was 39, and health good. In December, 1841, he noticed a small ulcer on the right side of the tongue ; it slowly extended and acquired hard everted edges, but caused little inconve- nience. In July, 1848, it had attained the size of a five-shilling piece ; its surface and edge were ragged, and it caused considerable pain, especially at night. A hard ridge could be felt all round the ulcer, and glands enlarged beneath the jaw. The health, by the end of August, had completely given way from the pain, when the diseased part of the tongue was excised by Mr. Fergusson. In less than a month the wound had healed, and the health was re-established. In November the enlarged glands were removed by Dr. Duncan. The disease returned in the cicatrices of the wounds, and spread chiefly in the upper part of the neck. Death occurred in July, 1849. The diseased part of the tongue and the gland, which were excised, were infiltrated with epithelium. Paget observes, however, that a collection of epithelium may form deep in the tissues of this organ, without any primary changes of its surface. Treatment.—In any such cases, and in the case of any ulcer, when the failure of all treatment gives room for suspicion, free and early extirpation should be performed. Hemorrhage that cannot be checked by gargling with cold water, or zinc or creasote lotion, may be restrained by actual cautery [or the solution of perchloride of iron]. If near the tip, the parts should be seized with forceps and cut off; if further back, strangulation by ligature may cause less risk of hemorrhage. Portions of the tongue have been exposed by incision beneath the jaw, by Mr. Arnott and others, and then strangulated.1 Amongst palliative measures the application of ice may be found useful. The cases of these two eminent members of the profession present a subject for useful comparison. The epithelioma was here quite as ma- lignant as the cancer. Yet diseases, though equally fatal, should not be confounded, if their anatomical elements are distinct. SECTION V.—AFFECTIONS OF THE TEETH AND GUMS. I. Lancing of the Gums of children may be performed for two reasons. If the gum is swelled, inflamed, and tender, whether or not a tooth be quite ready to come through, a free incision may be made with a fine lancet, for i For Dr. Reid's case, see Hughes Bennett on Cancer, &c. ; Arnott, Med.-Chir. Trans. vol. xxii. The author has to "thank Mr. Birkett and Mr. Avery for some particulars of Mr. Cooper's case. 426 CARIES OF TEETH. the purpose of letting blood flow. But if it is tightly stretched over a tooth, which is bursting through, the incision should be carried down to and all along the tooth, so as to release it entirely. II. Irregularity of the Permanent Teeth is a consequence of con- tracted and ill-formed jaw-bones. If either of the canine teeth or of the incisors of either jaw project much, the patient should be taught perpetually to endeavor to push it back into its proper position with his fingers. But if at the age of fourteen or fifteen this method has not succeeded, and the teeth are much crowded, the projecting tooth may be removed, although in many cases it is better to sacrifice one of the bicuspides to make room for it. If a growing child is underhung, so that the under incisors come in front of the upper ones when the mouth is shut, or so that the teeth meet at the cutting edges, instead of the lower teeth being received within the upper, the child should be encouraged daily to push the upper teeth forwards with its tongue and fingers : and should frequently put the end of a spoon-handle behind the upper incisors, and then close the mouth, using the spoon as a lever to press the upper teeth forwards and the lower ones backwards. But if these simple means do not succeed, recourse should be had to the appliances used by professional dentists.1 The wisdom teeth, especially in the lower jaw, are extremely liable-to be misplaced, growing directly outwards or inwards, and producing ulceration of the cheek or tongue ; or projecting forwards against the neighboring molar, or backwards into the coronoid process, or even being contained within a tumor in the substance of that process. Tumors of either jaw may likewise arise from mal-development of either of the outer teeth; [and im- paction of the permanent teeth in the substance of the neighboring bones.3] III. Fracture and Dislocation of Teeth.—If a portion of a tooth is broken off, without exposing the pulp cavity, the exposed surface should be filed smooth, and then no inconvenience will probably follow. If it is snapped off at the neck, and the pulp cavity is exposed and very painful, it should be touched with lunar caustic, and the mouth be frequently bathed with strong poppy decoction ; and when pain and tenderness have ceased, an artificial tooth may be fastened by a pivot to the stump. If, however, the root of the tooth is loosened, it had better be extracted at once. If a tooth is loosened by a blow, it should be fastened by silk to its neighbors. If a tooth is entirely driven out, it should be replaced as soon as bleeding has ceased, and be fastened in by silk; no food should be allowed that requires mastication, and inflammation should be combated by repeatedly leeching the gums. IX. Caries of Teeth signifies a successive softening and decay, gradu- ally spreading till it reaches the central cavity of the tooth, which from that time is subject to fits of toothache. It depends on original imperfect forma- tion of the enamel and bone, especially in scrofulous and ill-nurtured per- sons, and may further be promoted by any circumstances which lower the general health. It is very frequently a consequence of pregnancy, and of nursing ; it may follow any serious illness, or loss of strength, or the abuse of mercury. It is rank nonsense to allege (as ill-educated dentists do) that it may be caused by steel or acids used as tonics, or by any abrasion or loss of enamel. It is as truly a constitutional disease as phthisis or scrofula. The author has seen the four upper incisors quite rotten in a scrofulous child at thirteen months. Treatment—If the caries be slight and recent, the whole of the decayed portion should be removed by proper instruments, and the cavity be filled 1 A good account of which will be found in Tomes's Lectures on Dental Surgery. 2 [See Mr. Salter's paper in Guy's Hospital Reports, third series, vol. v., also the Amer. Journ. Med. Sci. for July, 18ti0, p. 196.] TOOTHACHE. 421 up with gold, or an amalgam of silver and mercury. But if the decay has advanced far towards the pulp cavity, or has laid that open, it may be neces- sary first to employ aperients and tonics, and use some applications to deaden the sensibility of the tooth, so as to enable it to bear the stopping, and to protect it meanwhile from contact with food and saliva. For these purposes the best plan is, to fill the cavity with a bit of cotton wool, dipped in a solu- tion of mastic, in Eau de Cologne, or in alcohol, or in solution of gutta percha in chloroform : vide F. 183. By these means the tooth may very pro- bably be brought into a state to bear stopping with gold. The patient should avoid exposure to cold, errors in diet, and drinking very hot, or cold, or sweet, or acid fluids. There is a prejudice amongst dentists against extracting any of the first set of teeth in children, however carious; on the supposition that the jaw might become contracted, and the permanent teeth crowded in consequence. Mr. Tomes tells the author that this fear is groundless. These teeth cer- tainly should not be extracted needlessly : but it is better to do so than to allow them to cause much pain, or gum-boils ; or to cause the child to bolt his food from the pain of chewing it. Every case in which teeth decay with rapidity, should be looked upon as requiring medical treatment; and in particular the administration of cod- liver oil, steel, bone-dust, &c; F. 201. V. Toothache.—When the cavity of a tooth has been laid bare by caries, the delicate nervous pulp contained in it is extremely liable to pain from contact with the liquids of the mouth ; and if the health be at all out of order, or if it be much irritated, it is liable to acute inflammation, with most agonizing toothache. Treatment—AVe believe the best treatment for this kind of toothache to be as follows : let the patient have a dose of calomel and colocynth ; confine him to spoon diet; let him wash out the mouth with a solution of carbonate of soda in water; let the gum around the tooth, and between it and its neigh- bors, if tumid, or tender, be deeply scarified with a fine lancet; then let the cavity be filled loosely with a little bit of cotton dipped into the solution of tannin and mastic, F. 183 ; and if the toothache is curable at all, this plan, with a little patience, will be almost sure to succeed. If the pain is very violent, half a grain of powdered acetate of morphia may be taken up with the cotton imbued with the tannin; which should be warmed before it is put into the cavity. In some few cases, a whiff of chloroform will lull the pain. As soon as the pain is relieved, the tooth, if of use, should be stopped with gold or amalgam ; if of no use, it should be extracted. Other remedies occasionally of service are, warm poultices to the cheek; sialagogues, especially a little piece of pellitory chewed ; anodynes, espe- cially warm poppy decoction held in the mouth ; or a full opiate at bed-time, if the bowels have been well cleared : stimulant, escharotic and astringent substances introduced into the cavity of the tooth, such as a drop of strong solution of nitrate of silver, or solution of alum or of tannin ; respecting which last substance the author is most grateful to acknowledge the benefit he has derived from it, since it was introduced by his friend Mr. Tomes. It may be added, that most of the violent, burning, empirical nostrums, such as creasote, oil of thyme, &c, although they may be of service when intro- duced in small quantity by a skilful hand into the carious tooth, at the right time, yet that when employed indiscriminately, as they are by the vulgar, the^ can do nothing but mischief. It may be remarked that the gum in the interstice between a decayed tooth and its neighbor, often becomes spongy, and swelled, and excessively sensi- tive ; giving rise to a very wearing kind of toothache ; and causing excru- ciating pain if a portion of the food happens to be pressed down upon it. 428 EXTRACTION of teeth. This may be relieved by a deep incision through the swollen gum, and the use of tannin gargle, of pellitory chewed, and of such aperients, F. 34, 35, as tend to unload a congested mucous membrane. ArI. Inflammation of the central pulp sometimes affects a tooth that is apparently sound. It occasions severe, heavy throbbing pain extending to the head, and considerable tenderness of the tooth and of the gum around. It may lead to suppuration of the pulp, or to abscess in the alveolus, and death to the tooth in consequence. Treatment.—Leeches, low diet, and purgatives. VII. AVhen a tooth is partially decayed, it very frequently causes inflam- mation of the periosteum of its socket, which swells and so causes the tooth to feel looser and longer than natural. The gum around the neck of the tooth is generally highly vascular. This state of things often ends in a gum-boil or alveolar abscess. A leech, or a deep incision in the gum be- tween the diseased tooth and its neighbors, and fomentations of poppy to the interior of the mouth, are the remedies. ArIII. Neuralgic toothache, whether it occurs in teeth that are entirely sound, or partially carious, is to be distinguished by its occurring in parox- ysms which come and go suddenly, in more or less regular intervals. It is very common in the earlier months of pregnancy. Treatment.—Quinine in large doses, together with aperients and altera- tives, are the most successful remedies. IX. Toothache sometimes has the characters of chronic rheumatism ; flying about the jaw, affecting no tooth in particular, and not relieved by ex- traction, so much as by blue pill and aperients, with small doses of col- chicum. The muriate of ammonia, in half-drachm doses, every four hours, dissolved in water, and the iodide of potassium, deserve a trial in these and other ob- stinate cases of toothache.1 X. It sometimes happens that the fang of a tooth is thickened by a de- posit of bone ; in which case the tooth becomes affected with severe pain that can hardly be distinguished from that of Fig. 238. neuralgia. It sometimes occurs on teeth that are perfectly sound, but more generally on ca- rious teeth, or stumps. The excessive pain of this affection is in general only to be relieved by extraction. XI. Necrosis of Teeth.—A tooth is said to be necrosed when it has become black and unsightly, and loose in its socket. This affec- tion may be caused by blows which have torn across the nutrient vessels, or by inflammation of the pulp (perhaps from the abuse of mer- cury). Extraction must be performed, if the tooth cause inflammation or other inconve- nience. XII. Extraction of Teeth.—Nothing which relieves human suffering ought to be slighted or despised. Xo wise surgeon there- fore will fail to make himself acquainted with the way of pulling out teeth with dexterity. [Forceps in extracting teeth.] It is an operation which is easily performed, by any one who has the proper instruments, and uses them with ordinary care ; and it is one which if unskilfully or carelessly 1 Vide Dr. Watson's Lectures, Lect. 39. EXTRACTION OF TEETH. 429 [Forceps in extracting teeth.] performed may lead to very serious Fig- 239. results, to say nothing of the suf- fering which it inflicts. We beg the reader, therefore, to study well the construction of the instruments employed, and to practise with them on the dead body, before he tries his hand on the living. They are the forceps, the elevator, and the key. 1. Tlie forceps is the instrument that is now generally employed by dentists. It should be made with sharp edges, so that it may be pushed up between the tooth and the gum, and should seize the tooth by its neck, close to the alveolus. For this purpose, also, the jaws of the instrument should be made to incline towards each other in such a way, that they may slip up and embrace the neck of the tooth accurately when the handles are pressed together; and they should be ground in such a manner that they may be adapted accurately to the shape of each tooth. For this purpose the sur- geon will require seven sets of instruments. One instrument is required for the left upper molar (Fig. 240), and one for the right (Fig. 241), because Fig. 240. Fig. 241. Fig. 212. [Forceps for left upper, right upper, and lower molars.] of the peculiar conformation of those teeth. One will serve for the lower molars of either side (Fig. 242) ; one will serve for any single-fanged tooth Fi-. 243. Fig. 244. [Forceps for single-fanged teeth of upper and lower jaw.] of the upper jaw (Fig. 243), and one for any single-fanged tooth of the lower jaw (Fig. 244). Stumps in the upper jaw may be extracted with 430 EXTRACTION OF TEETH. the instrument Fig. 245, and those in the lower jaw with Fig. 246. The instruments here depicted were devised by Mr. Tomes some years since, and are made by Evrard, who lives opposite the Middlesex Hospital. Fig. 24G. [Instruments for extracting stumps of teeth.] In extracting teeth by the forceps, there are two things to be done ; first, to loosen the tooth, and then to pull it straight out. In extracting the incisors and canines of the upper jaw, they may first be loosened by giving them a gentle twist, combined with a slight rocking motion, and then may be pulled perpendicularly downwards with a slight inclination backwards.' The incisors and canines of the lower jaw are to be loosened by giving them a firm but gentle motion backwards and forwards, and then may be pulled straight up. The bicuspides and molars are to be loosened by moving them from side to side, so as to make the alveolar process yield a little, and then they may be pulled perpendicularly, upwards or downwards, as the case may be. The operator should grasp the forceps firmly, in such a manner that it may move altogether with his hand ; but yet not so forcibly as to run the risk of crushing the tooth. 2. The elevator is highly useful for stumps, and for old straggling teeth. The point is to be thrust firmly down between the tooth and its socket, and then by bringing the instrument into a horizontal position, and making a fulcrum of the edge of the alveolar process, or of the operator's fingers, the tooth may be lifted out. 3. TJie key is an instrument that is often employed for the extraction of the bicuspides and molars; but it is more painful than the forceps, and every one must know instances of laceration of the gum, and splintering of the alveoli, followed, perhaps, by tedious ex- foliation, that have been produced by the clumsy use of this instrument; not to mention the risk of the claw slipping from the decayed tooth and dragging out a sound one instead. If, however, it is preferred, care should be taken to select an instrument of proper size, and to place the fulcrum in a proper position. If the key is too small, and the fulcrum too high, very probably the crown of the tooth will be snapped off. If the key is too large, and the fulcrum too low, either the claw of the instrument may be snapped across, or the alveolar process be extensively splintered. The adjoining figure is intended to show the right position, which will draw the tooth more or less perpendicularly from its socket. The fulcrum ought to be placed on the inner side, for the bicuspides of the lower jaw, and molars of the upper; and on the outer Mode of using the key in extracting teeth. INFLAMMATORY SOFTENING AND ABSORPTION. 431 side for the molars of the lower jaw. The dentes sapientiae of the upper jaw should never, according to Bell, be extracted with the key, because of the delicate texture of the bone on which the fulcrum must rest. Before extracting teeth with the key, it is usual to cut away the gum from their necks by means of a gum lancet; a practice which some authorities consider unnecessary. It certainly is unnecessary in the majority of cases, especially for the extraction of the temporary teeth, and of the teeth of old persons which have separated from the gum, and become loose in their sockets; yet it may be performed either if the gum has been subject to repeated inflammation, which renders it adherent to the tooth,, and liable to be lacerated on its removal; or secondly, in order to afford room for the claw, if the tooth has decayed down to the gum. Some persons, instead of using a lancet, separate the gum by means of a small tenaculum. XIII. Hemorrhage after Extraction of Teeth.—This operation maybe followed by very severe and dangerous hemorrhage, which sometimes appears to come from the dental artery at the bottom of the socket; sometimes from the gums, when they have been long diseased. The cavity must first be tdeared of all coagulum ; then a piece of matico leaf, or a little strip of lint loaded with powdered matico ; or a bit of nitrate of silver may be put into the socket; but if neither of these remedies succeeds, the alveolus must be plugged in the following way: It is first to be cleansed from coagulum; then one end of a long thin strip of lint is to be firmly pressed into it, so as to come into contact with its very bottom, and the remainder in successive portions is to be forced in till the socket is filled up to the level of the gum. A compress should then be placed on the part, thick enough to be pressed upon by the antagonist teeth, and the mouth should be kept firmly closed by a bandage passing from under the chin to the vertex. XIAr. Tartar, or salivary calculus, is an earthy matter deposited on the teeth from the saliva. It is found most abundantly on the superior molars and inferior incisors, obviously because those teeth are nearest the orifices of the salivary ducts. If suffered to accumulate, it causes inflammation and absorption of the gums, and gradual loosening of the teeth. Treatment.—The deposit of this substance is to be prevented by taking care not to disorder the stomach, and by the strictest cleanliness. The teeth should be cleaned at least twice a day, with a soft tooth-powder (pre- cipitated chalk is the best) and a little soap. The hairs of the tooth-brush should be soft, and not too closely set; so that they may penetrate the bet- ter into the interstices of the teeth. AYhen any quantity of the tartar has accumulated, it should be removed by the scaling instruments. The edge or point of the instrument is to be introduced between the concretion and the gum, so as to detach the former in flakes ; in the meanwhile a finger or thumb, guarded with a towel, should be pressed firmly on the cutting edges of the teeth, so that they may not be loosened by the force necessarily em- ployed. Sometimes a small portion of this substance is found sticking in the orifice of one of the salivary ducts, and creating great discomfort by its irritation. It may easily be removed. XV. Inflammatory Softening and Absorption, vulgarly called scurvy of the gums, generally affects middle-aged or elderly people, and may be a consequence of the accumulation of tartar, but more frequently depends on a congested state of the liver and bowels. The gums are swollen, spongy, exceedingly tender, and subject to constant aching pain, and they bleed on the slightest touch. If the disease proceeds, they separate from the teeth ; the alveoli gradually become absorbed, and the teeth loosen, and at last fall out These consequences are sometimes speedy, and are attended with sup- puration in the alveoli; but more frequently they are slow, the teeth drop- ping out one by one in the course of years. 432 EPULIS. Treatment—The gums should be unloaded by deep and free scarifications and repeated leechings ; the bowels should be well cleared by a course of purgatives ; and gargles should be employed to correct the secretions of the mouth, and excite the vessels to contract. Whilst there is much pain and soreness, the soothing gargle, F. 113. Subsequently, recourse may be had to F. 109, 111, &c. XA^I. Gum-Boil (alveolar abscess, parulis) is a small abscess commenc- ing in the socket of a tooth, and bursting through the gum, or sometimes through the cheek. It is usually caused by the irritation of a dead or carious tooth. In neglected cases, extensive exfoliation of the bone may follow. Treatment.—Fomentations ; removal of the tooth, if much decayed ; and an incision as soon as matter can be detected. If the tooth is extracted soon, the sac of the abscess very often comes away with it. XA'II. Epulis signifies a fibro-plastic or fibrous tumor of the gum. It generally commences between two teeth, which it gradually separates, then loosens, and finally displaces, Fig. 248. and may spread so as to in- volve several of them. Or it may begin on the free surface of the gum, internal or ex- ternal, and may form a tumor flat, prominent, polypous, or pendulous. This tumor is in- dolent, painless, and of slow growth ; but it ought always to be extirpated without delay, because it is liable to increase, and might become the seat of offensive ulceration, to say no- thing of the deformity and in- convenience which it occasions. If possible, it must be cleanly shaven from the periosteum ; but if necessary, the tooth on either side must be extracted, and the tumor entirely cut out. A portion of the alveolar pro- cess must be removed likewise, if necessary, in order to render the extirpation complete. A similar tumor is sometimes formed when a dead portion of the root of a tooth remains in its socket, and the gum has healed over it. The tumor should be entirely removed with the knife, and the extraneous body should be sought for, and be extracted, if possible. Cancerous Tumors of the gums are exceedingly rare ; they will, however, be recognized by their rapid growth, and tendency to hemorrhage. This cut represents an epulis, in a patient of Mr. H. Wal- ton's ; it had existed many years, and interfered with the movements of the tongue and use of the jaws, and so pro- duced great emaciation. CHRONIC ENLARGEMENT OF THE TONSILS. 433 CHAPTER XV. SURGICAL DISEASES AND INJURIES OF THE NECK. SECTION I.—SURGICAL DISEASES OF THE FAUCES, TONSILS, AND UVULA. I. Acute Tonsillitis, Quinsy, or Inflammation of the Tonsil, is known by rapid swelling of the part, considerable throbbing pain; degluti- tion difficult, perhaps impossible ; headache, foul tongue, and fever. It must be treated by leeches, poultices, a dose of calomel followed by purgatives, inhalation of the steam of boiling water, gargles calculated to promote the secretion of saliva (F. 101), and the ordinary antiphlogistic routine. If the gland continues to swell, or if it occasion any embarrassment to the breathing, an incision should be made into it to unload the vessels, and give exit to matter. The tongue should be kept down with one forefinger, whilst a straight bistoury, wrapped round with lint except an inch and a half of its point, is plunged directly into the tumor, and made to cut its way out towards the median line. Abscesses behind the pharynx require similar treatment. II. Chronic Enlargement of the Tonsil is a frequent sequel of in- flammation, especially of reiterated catarrh in scrofulous children. It causes sundry inconveniences. The parts are liable to frequent attacks of acute inflammation ; deglutition is impeded ; the voice is rendered hoarse ; respi- ration is noisy and laborious, especially during "sleep; the diseased state of mucous membrane is extremely liable to be continued into the ear, as we explained when treating of throat deafness, and to lead to disorganization of the delicate structures in the tympanal cavity; and suffocation has even been caused by viscid mucus entangled between the swollen glands. Treatment—In the first place the system must be strengthened, and the secretions be kept up by proper tonics and alteratives. Steel, especially the iodide, bark, cod-liver oil, or F. 87, 65, 41, 37, &c, may be administered with benefit. At the same time contraction must be promoted by astringent gargles, F. 109, by swabbing the throat once a day with a lotion of arg: nit. 9j, aq. dest. 3j, or liq. iodinii, and by applying stimulating or ioduret- ted liniments to the skin. The method of swabbing is simple. A piece of sponge the size of a wal- nut must be put over the end of a stick, cane, or whalebone, in such a way that it completely covers the end of the stick; and it must be firmly sewn or fastened on. The patient sitting, opens his mouth, and the surgeon having made the sponge to imbibe a solution of nitrate of silver, presses down the tongue with the left forefinger, introduces the sponge into the pharynx, and fairly swabs out every part of it. Inhalation of vapor is another remedy of the greatest possible efficacy when the mucous membrane of the fauces, mouth, and tonsils is flabby and swollen ; as well as in the catarrhal rhinorrhcea, in throat deafness, and in coughs attended with copious expectoration. In order to inhale effectually it is necessary to have some apparatus; and the essence of all such appa- ratus is, that they have one passage for introducing the external air below the surface of the liquid whose vapor is employed ; another through which the patient can draw the air mixed with vapor into his mouth. The cheap- est and most efficient inhaler the author is acquainted with is a simple double tube with mouthpiece, sold by Gr. Mawe, of Aldersgate Street. But, for the 28 434 ENLARGEMENT OF THE UVULA. sake of the poor, he recommends one to be made thus :—Take any large stone or glass bottle with a wide mouth, and a soft cork; take two pieces Fig. 249. Fig. 250 [Fig. 251. [Inhalers.] of'German glass tubing ; bend the shorter one at an angle to serve as mouthpiece ; put the ends into a gas flame, to melt off any sharp edges; bore the cork, by means of a rat-tail file, with two holes for the tubes to pass through ; put the ne- cessary liquid into the bottle ; insert the cork with the tubes, and the machine is ready for use. The most efficient vapors are evolved from boiling water, to which twenty drops of crea- sote, or the same of tincture of iodine, have been added. Mr. Harvey tells the author that he sometimes adds tincture of guaiacum. If these measures fail, and such an operation is deemed ne- cessary, part of the gland should be removed with the knife— a much more expeditious and cleanly method than the liga- ture. The surgeon seizes the tumor with a hook or forceps (depressing the tongue with its handle), then introduces a blunt-pointed curved bistoury, and shaves a thin slice off, cut- ting upwards, parallel to the isthmus faucium. The nearest half of the blade of the bistoury should be wrapped in lint, to prevent the lips from being cut; and in operating on the right side, the surgeon will find it most convenient to cross his hands, the left, holding the forceps, being undermost. Very little should be removed ; not only to avoid hemorrhage, but likewise because of the possible truth of Mr. Harvey's theory that removal of the tonsils interfere with the development of the genital organs. There are certain guillotine instruments which can also be very adroitly used for this purpose. Specimens of excised tonsils which the author has examined have been infiltrated with cells, most of them exactly resembling pus. III. Enlargement of the Uvula produces tickling cough and expec- toration by irritating the larynx. If it does not yield to the treatment di- rected for enlarged tonsil, it should be stretched and steadied with a forceps, and be cut through in the middle with a pair of long scissors. Our design being to describe such affections only of these parts as require surgical remedies, we must pass over the various other sorts of sore throat, which are assigned to the physician ; merely remarking that the affection Instrument for removing the tonsils.] DISEASES OF THE 03SOPHAGUS. 435 which we have described as quinsy, is phlegmonous and deep, yet that the superficial and catarrhal inflammations require nearly similar treatment. SECTION II.—SURGICAL AFFECTIONS OF THE PHARYNX AND 03SOPHAGUS. I. Spasm of the (Esophagus (spasmodic stricture) is known by its ge- nerally occurring in sudden fits—the patient at a meal finding himself alto- gether incapable of swallowing, and the attempt to do so producing spasmodic pain and a sense of choking. The diagnosis between this and the organic or permanent stricture is founded on the suddenness of its ac- cession ; it being much better at some times than at others ; and the fact that the bougie, if passed, either meets with no obstruction, or with one that very easily yields. Treatment—This affection always depends on a weakened or hysterical state of the system, or on the presence of some other disorder, as has been mentioned whilst treating of neuralgia. Brodie relates a case that ceased on the removal of bleeding piles ; and Mayo another that was cured by re- lieving chronic disease of the liver. Tonics, antispasmodics, and alteratives, especially iron with aloes and galbanum at bedtime ; exercise in the open air; the shower-bath, and other forms of warm and cold bathing; great attention to the diet; care not to swallow anything imperfectly masticated or too hot; and the occasional passage of a bougie, are the remedies. II. Palsy of the (Esophagus occasions inability of swallowing, but without pain or other symptoms of spasm; and a bougie, when passed, meets with no obstruction. It generally depends on organic disease of the brain or spinal cord, which must be examined into and cured if possible. The patient should be fed by the stomach-pump, by nutrient enemata, and by pushing soft food occasionally down the oesophagus with a probang. The palsy has sometimes been temporarily relieved by electrifying the patient on an insulating stool. Nutrient enemata should be composed of very strong beef or mutton broth, without salt or spice. The quantity injected at one time should not exceed four ounces ; and if the rectum does not retain it a few drops of laudanum should be added. * III. Dilatation and Sacculation.—The oesophagus has been found after death exceedingly dilated. The symptoms during life were great dys- phagia—food, when swallowed, never seemed to reach the stomach, and was vomited in a few minutes. If this condition should be ascertained during life, the patient should be fed as in palsy. Sometimes a blind pouch is con- nected with the oesophagus, and occasions great distress in swallowing, by intercepting the food. It may be formed either by a protrusion of the mu- cous membrane through the muscular fibres, or by the sac of an abscess which has burst into the tube. The only remedy is to feed the patient con- stantly with the stomach-pump, so that the pouch may be allowed to close. IAr. Permanent Stricture of the oesophagus signifies a narrowing pro- duced by a thickening of its coats, which form a firm ring, encroaching on the canal. It is generally found just below the termination of the pharynx; that is, opposite the cricoid cartilage, and is most frequent in females. The symptoms are, difficulty of swallowing, noticed probably for years, gradu- ally increasing ; never absent; and occasionally aggravated by fits of spasm. The act of swallowing frequently produces pain in the chest, which shoots between the shoulders, and up to the head. When a bougie is passed, it meets with an obstruction. The causes of this affection are generally un- known ; sometimes, however, it appears to be a sequel of repeated quinsy, or to be caused by swallowing boiling or corrosive liquids ; in one case it appeared to be induced by violent retching in sea-sickness. The prognosis is always serious, especially if the complaint is of long duration. If unre- 436 DISEASES OF THE 03S0PHAGUS. Fig. 252. lieved, its consequences will be ulceration of the oesophagus, either above or below'the stricture, with salivation, vomiting of purulent matter, and impos- sibility of deglutition, which in no long time will be followed by death. The fatal termina- tion may be owing either to sheer starvation, or to the irritation of the local disease, or the ex- tension of ulceration to the lungs. Treatment—A mild course of mercury, so as just to affect the gums ;—occasional leeching, to relieve exacerbations of pain or spasm;— hyoscyamus or conium, if there be much irrita- bility ;—a seton between the scapulae ; and the occasional passage of a bougie, or of a ball probang—an ivory ball attached to a piece of whalebone or flexible wire—or of a piece of sponge moistened with a weak solution of nitrate of silver, and attached to a stout copper wire, as recommended by Sir C. Bell, are the reme- dies. The method of introducing the bougie is as follows :—The patient sits upright, with the head thrown as far back as possible, and the mouth wide open. The bougie, which should be previously warmed in the hand and oiled, and gently curved, is passed down into the pharynx in such a manner that its point may slide along the vertebrae. In order that it may not excite cough by interfering with the epi- glottis, the patient should be directed to pro- trude the tongue from the mouth as far as pos- sible ; or to perform the act of deglutition just when the bougie is entering the pharynx. If it meets with an obstruction in its descent, the surgeon should slightly withdraw it, then again press it gently against the obstruc- tion, increasing the pressure for a'few minutes if it gives no pam. It it tail to pass, a smaller one should be tried. V. Ulceration.—" Simple but fatal ulceration," as Mayo correctly called it; that is to say, phagedesnic or corroding ulceration, without the pre- existence of epithelioma or of cancer (compare pp. 95, 119, 133), is liable to affect the pharynx at the level of the cricoid cartilage, or the oesophagus lower down. If the finger or a bougie is passed, its point returns marked with bloody pus. The consequences are always the same ;—exhaustion trom the irritation of the disease, and from the inability to swallow ; or possibly a more speedy death from perforation of the aorta, or of the pleura. VI Epithelioma and Cancer also sometimes affect this part. 1 he symp- toms are alike: burning pain between the scapulae, and difficulty of swallowing Treatment—A deposit of hard cancer into the walls of the ™°Vhf™ will at first be scarcely distinguishable from stricture, and must be treated like it; but when burning pain indicates ulceration then nutrient enemata belladonna plasters to the back, opium, ice-cream, &c, should be usca o relieve the pain ; and a very careful diet, including eggs, meat beat to a pulp, and other nutriment of small bulk. A II Tumors pressing on the oesophagus, whether abscesses, polypi, aneu risms, bronchocele, or enlargement of the bronchial lymphatic glands, wu produce all the symptoms of organic stricture. Aneurisms and ab^e-ts have been burst by the passage of bougies-with, of course, instant death in the former case, and relief in the latter. Before performing this operatwn, therefore, the chest ought to be well scrutinized by auscultation, to ueteci This cut exhibits a stricture of the oesophagus. From the Museum of the Middlesex Hospital. 0ZS0PHAG0T0MY. 437 any unnatural pulsation or bruit; and any signs of embarrassed circulation or respiration should not be overlooked. Polypus.—Cases are recorded of polypous tumors projecting into the pharynx or oesophagus. If discovered, an ingenious surgeon might remove them somehow.1 VIII. Foreign Bodies, when fixed in the pharynx, or about the aperture of the larynx, or in the oesophagus, produce a sense of choking, and fits of suffocative cough. This accident, if unrelieved, may prove fatal in two manners. The patient may either be suffocated at once, by spasm of the glottis, or, if the foreign substance remains impacted, it may produce a fatal ulceration of the parts, attended with exhausting cough and dyspnoea, and profuse fetid expectoration. [The student should be warned that patients sometimes are deceived by their sensations, and that no foreign body has remained in the oesophagus, although they declare that they feel its presence. We know a case of the kind where so distinguished a surgeon as Nelaton, feeling deep in the pharynx a small resisting body, made numerous ineffectual efforts to remove what he afterwards discovered to be the great horn of the hyoid bone.] Treatment.—The patient should be seated in a chair, with the head thrown back, and the mouth wide open. The surgeon should then intro- duce his finger—regardless of attempts to vomit—and should pass it swiftly into the pharynx, and search the whole of it thoroughly. When the sub- stance is felt, it may perhaps be entangled in the point of the nail, or curved forceps may be guided to it by the finger. Pins and fish-bones are often entangled about the velum, or in the folds of mucous membrane between the epiglottis and tongue. If the body has passed into the oesophagus, and it is small and sharp (a fish bone, for instance), it may be got rid of by making the patient swallow a good mouthful of bread. If large and soft (as a lump of meat), it may be pushed down into the stomach with the probang. But large hard bodies, especially if rough and angular (such as pieces of bone or glass, &c), should be brought up if possible. A pair of long curved forceps, or a piece of whalebone armed with a flat blunt hook, or with a skein of thread, so as to form an infinite number of nooses, are convenient instruments. If the stomach is full, a dose of tartar emetic dissolved in a very small quantity of water may be administered, in the hope that when the contents of the stomach are vomited, they may bring up the offending substance with them. One case is on record in which a chicken-bone lodging in the oesophagus was dissolved by making the patient swallow large quantities of dilute acid. If all means fail, however, and the substance can neither be brought up nor down, and if it be lodged in the cervical portion of the tube, it must* be extracted by the operation of cesophagotomy in the following manner. IX. (Esophagotomy.—The operation should be performed on the side towards which the foreign subject projects. Its situation having been ascer- tained, an incision of sufficient length must be made through the skin and platysma between the sterno-mastoid muscle and trachea. The cervical fascia must next be divided on a director. The surgeon must then divide the cellular membrane with a blunt knife, or lacerate it with his fingers, avoiding the carotid and thyroid arteries and the recurrent nerve. A common silver catheter may then be passed down the throat, and be made to project in the 1 Vide Sir E. Home on Strictures, vols. i. and ii.; Monro on the Morbid Anatomy of the Gullet, &c; Brodie on Local Nervous Affections (spasmodic stricture); Mayo's Patho- logy ; Stokes in Cyclop. Prac. Med. vol. ii.; and Sir C. Bell's Institutes of Surgery, vol. i.; Arrowsmith's case of Polypus in (Esophagus, Med. Gaz., N. S. p. 165. There is a case of congenital imperforate oesophagus in the Musee Dupuytren, at Paris ; it was continuous with the trachea. 438 FOREIGN BODIES IN THE wound, so that the oesophagus may be opened by cutting on it. This small wound in the oesophagus should be dilated with forceps, in order to avoid hemorrhage, and the foreign body should then be extracted. This operation has occasionally been performed for the purpose of conveying food into the stomach in cases of stricture of the oesophagus, but with no very satisfactory results.1 X. Use of the Stomach-pump.—The tube of this instrument is to be introduced in the same manner as the oesophagus bougie. It is usual to place a gag in the patient's mouth, having a hole for the tube to pass through, in order that it may not be compressed by the teeth. Before pumping out the contents of the stomach, one or two pints of water should be injected into it, and care should be taken not to withdraw quite as much as was injected. More water should then be thrown in, and the process should be repeated till it returns colorless. The stomach-pump is by no means so universally efficacious as is popu- larly supposed. It ought only to be employed in those cases of poisoning by opium, of alcohol, or other narcotics, in which the stomach and nervous system are rendered so insensible that vomiting cannot be excited. For, in the first place, the operation is not free from danger. It is a well-established fact, that a tube may sometimes be passed into the trachea of a sensible per- son without creating any peculiar sensation, or exciting cough; but if the patient be insensible, that accident will be much more liable to happen. In fact, a case is on record in which a meddling surgeon, with more zeal than knowledge, did actually pass the tube down the trachea and inject the lungs with chalk mixture, which he had far better have permitted his luckless patient to have swallowed quietly; and Sir C. Bell tells us, that he has seen, on dissection, both lungs filled with broth, which was intended to have been injected into the stomach. Again, it is known that in one case the mucous membrane of the stomach was sucked into the holes of the tubes, and torn into strips—a thing likely to happen if the stomach is pumped too empty. Besides, this artificial evacuation of the stomach is by no means so efficacious as free vomiting, assisted by plenty of diluents. Lumps of arsenic were left in the stomach in the very case just cited, in which the mucous membrane was torn.3 SECTION III.—SURGICAL AFFECTIONS OF THE LARYNX AND TRACHEA, IN- CLUDING TRACHEOTOMY, AND THE VARIOUS CIRCUMSTANCES WHICH RE- QUIRE IT. I. Foreign Bodies in the Larynx and Trachea.—It sometimes hap- pens that a person who is busily laughing and talking during a meal, sud- denly rises from table, attempts to put his finger into his throat, speedily turns blue in the face, and then drops down dead. This arises from a piece of food getting into the rima glottidis; a thing liable to happen if a sudden inspiration be made through the mouth, as in laughing, when the mouth is filled with food. It rarely happens that the surgeon arrives in time to do any good ; but if he should be promptly on the spot, he ought to search the pharynx with his fingers, to ascertain whether the obstructing substance can 1 See Arnott on (Esophagotomy, Med.-Chir. Trans, vol. xx.; Report of a case in which it was performed unsuccesfully for the relief of stricture by Mr. Watson, of New York, and of two cases in which it was performed for the removal of a foreign body, in vols. ii. and iii. of Ranking's Abstract. [See Mr. Cock's case, Guy's Hospital Reports, third series, vol. iv. ; also the Amer. Journ. Med. Sci. April, 1859, p. 518 ; also the same, for a case of gastrotomy in stricture of the oesophagus.] 2 See an amusing Clinical Lecture on the abuse of the Stomach-pump, by Professor Watson, in Lond. Med. Gaz. vol. xvii.; and Roupell's Illustrations of the Effects of Poisons. LARYNX AND TRACHEA. 439 be removed ; and if not, he ought to perforin laryngotomy immediately; and to pass a probe up into the larynx through the wound, so as to push the foreign substance back into the mouth. When a foreign substance has passed the rima glottidis, and has got into the trachea, it will produce different symptoms according to different circum- stances. For, in the first place, it may be impacted in the ventricles of the larynx or upper part of the trachea; in which case it will probably produce violent spasmodic cough and difficulty of breathing, together with a fixed pain referred to one particular spot—a croupy sound during respiration, which may be heard by the stethoscope most distinctly at the seat of that pain ; and loss of voice. In the second place, the foreign substance may be loose in the trachea. In this case, the violent coughing and sense of suffocation produced by its first introduction generally subside for a time ; but every now and then there are violent fits of coughing, and of spasmodic difficulty of breathing, during which the substance may be heard by means of the stethoscope, or perhaps may be felt by the finger to be forcibly impelled against the upper part of the larynx. Thirdly, the foreign substance may have passed into one of the bronchi, where, perhaps, it may be detected by causing a whistling or murmuring sound ; and it will very probably be dislodged and driven upwards when the patient coughs. The right bronchus is that into which it generally falls, because it is a little anterior to the left, and encroaches a little on the middle line. It is sometimes difficult to distinguish the symptoms produced by a foreign body in the larynx or trachea from those of croup or laryngitis. But the surgeon may generally pretty confidently decide that a foreign body is pre- sent, if the symptoms came on suddenly during a meal;—or perhaps the history will be that the patient was playing with a button, or cherrystone, or some similar body in his mouth, and that he chanced to fall down, when the button disappeared, and the symptoms came on directly afterwards. Moreover, in these cases, expiration is generally more difficult than inspira- tion, whereas it is usually the reverse in the croup. Besides, when there suddenly occurs a fixed pain, and a fixed whistling sound in the larynx or bronchi, without any other symptoms of croup, the case must almost of ne- cessity arise from a foreign body.1 If there is any doubt, the pharynx and oesophagus should be well searched, by finger and probang, to make sure that the foreign body is not there. If any foreign body remains in either bronchus, it sets up more or less irritation : cough, pain, muco-purulent expectoration ; perhaps night-sweats, and other signs of hectic. Treatment.—When any foreign substance has entered the trachea, the in- dication plainly is, to get it out again; and the great point in the treatment is, to lull the vigilance of the muscles which guard the aperture of the glot- tis, so as to induce them to let it pass out by the way it entered. For it must be remarked that it is muscular spasm, excited by the contact of the foreign body, which not only hinders it from escaping when driven up to the glottis by the breath in expiration, but puts the patient in danger of suffoca- tion as well. In the first place, therefore, if the substance be movable, and round, and the symptoms not urgent, let the patient be kept quietly in bed and under 1 See an interesting paper by Mr. C. Hawkins, and another by Mr. Travers, jun., Med.-Chir. Trans, vol. xxiii. ; Sir B. Brodie on Mr. Brunei's Case, Med. Gaz., July 7th, 184:5 ; a Review of Gross on Foreign Bodies in the Air Passages, by Mr. Henry Lee, Brit, and For. Med.-Chir. Rev., Jan. 1856. [Also, the Work of Dr. Gross, entitled a Practical Treatise on Foreign Bodies in the Air Passages.] 440 LARYNGOTOMY AND TRACHEOTOMY. the influence of narcotics, in doses proportioned to the age; such as syrup of poppies with tincture of henbane and a little ipecacuanha. Then proba- bly the substance may become coated with mucus, and may be expectorated during an effort at coughing or vomiting. If the symptoms be more urgent, let the patient be put quickly under the influence of chloroform, with the same purpose of lulling the muscles of the larynx; when narcotized let him be turned upside down ; a child may be held with his head downwards, and be slapped on the back without cere- mony ; for a heavy person an apparatus will be necessary, in order to fasten him into a chair, such as was contrived by Mr. Brunei, when he had swal- lowed the half-sovereign. But if this proceeding does not answer, or if it seems to induce the risk of suffocating the patient, the air-tube must be opened; and this for two reasons: in order, first, to provide means for breathing; and secondly, to provide, if necessary, for the extraction of the intruding substances. For it must be remarked, that the irritability of the glottis subsides, so that the foreign body may pass through it, so soon as an artificial opening is pro- vided. II. Laryngotomy and Tracheotomy.—The air-tube may be opened either through the larynx, or through the rings of the trachea. The former operation is the more quickly and easily performed on an adult; it is fur- ther from the lungs, and less dangerous. Tracheotomy is more difficult and tedious ; but is necessary if there is any idea of introducing a forceps. Laryngotomy is performed by cutting longitudinally through the skin, then through the cricothyroid membrane, which may be felt as a soft de- pression, an inch below the pomum Adami. Tracheotomy is thus commonly directed to be performed:—The head being thrown back, an incision, an inch and a half to two inches long, must be made exactly in the middle line from below the cricoid cartilage to the top of the sternum. The skin, superficial fascia, and fat, are then divided; the sterno-hyoid muscles are separated with the point of the knife ; the loose cellular tissue and veins are cleared from the front of the trachea with the fingers or handle of the scalpel; the thyroid gland, if in the way, is pushed up ; a tenaculum is hooked into the trachea to draw it up slightly and steady it; then the surgeon seizes the moment, and whilst the trachea is stretched, sticks in his knife, with a slight jerk, at the bottom of the wound, and carries it upwards, so as to divide two or three of its rings. Various other methods of performing Tracheotomy.—There are several instruments and plans which have been devised, for the purpose of render- ing tracheotomy a more easy and safe operation. Amongst these we may mention first, Dr. Charles Edward's plan of operating above the isthmus of the thyroid gland, and immediately below the cricoid cartilage. The ope- rator should feel for the cricoid cartilage, and ink a perpendicular line, a quarter of an inch long, in the middle line below it. The skin should be Fig. 253. [Steel director with a hook, for tracheotomy.] drawn up over the thyroid, and then cut through in this line. Then the cricoid cartilage and first ring of the trachea being made out, the hook of LARYNGOTOMY AND TRACHEOTOMY. 441 the steel director is to be hooked in just below the cricoid, and made to hold the larynx well upwards and forwards. It will be seen that the groove of the director is open to the very end, and that on the opposite side to the groove the instrument finishes in a tenaculum hook. This hook then being fixed under the cricoid, and held up with the operator's left hand, a narrow stout scalpel is passed along the groove, with its edge downwards. " Should the thyroid isthmus," says Dr. Edwards, " or any pulsating vessel be in the way below, the puncture should barely admit the extremity of a probe-pointed bistoury;" in which case the bistoury being steadied against the end of the groove may be made to divide two or three rings of the trachea from within outwards in subcutaneous fashion; the soft parts over the trachea can be dilated enough afterwards to admit of the introduction of the tube. Of , course if the surgeon chooses to perform the operation below the thyroid gland, this instrument will be equally useful.1 Another ingenious modification is proposed by Mr. Henry Thompson,3 who has devised the instrument shown in Figure 254. This consists of two Fig. 254. [Henry Thompson's instrument for tracheotomy.] blades, united at one end by a hinge ; at the other bent downwards at an angle,'and furnished with cutting edges, nicely adapted together, so as when pressed together, to make as it were but one edge. There is a screw, by which the blades may be separated. The patient lying down, the surgeon feels with his left forefinger for the lower edge of the cricoid ; holding the instrument in his right, with the blades closed, he introduces the cutting point, transversely, in the middle line, about a quarter of an inch below the cricoid, so as to slip the point into the trachea, between the first and second rings. ' Then the blades are separated by the screw, sufficiently to admit a tube • the screw is then reversed and the instrument withdrawn. Trocars have been invented for tracheotomy, for which they are dangerous. They should never be used upon children, although they might be introduced between the cricoid and thyroid cartilages in the adult. The great danger and difficulty of the operation, is the bleeding from the numerous veins which lie in front of the air-tube, and which are kept filled by the embarrassment of the breathing. The instant the trachea is opened, blood rushes in with the air during inspiration, and the patient is very liable to be suffocated. In any such case, the surgeon should not hesitate to suck out the blood and mucus with his naked mouth, or through any catheter or tube or with a syringe. But in order to prevent this accident, he should use the knife most sparingly, and should be particularly careful not to cut downwards near the sternum. He should separate the tissue and clear the front of the trachea with a blunt hook, or the handle of the scalpel. Bleed- ing if arterial, should be checked by ligature; if venous, by iced water, compression with the fingers, the ligature, or actual cautery; and the trachea should not be opened till it is suppressed. So soon as an opening is made, the foreign body is sometimes expelled 1 Charles Edwards, M. D., Lancet, 1853, vol. i. p. 492. 2 Lancet, 1853, vol. i. p. 221. 142 LARYNGOTOMY AND TRACHEOTOMY. ivith a strong gust of air through the wound ; sometimes through the now tranquil glottis ; but if not, it may be gently searched for with a probe, and be removed by forceps or by a blunt hook; or the patient being chloroformed, may be turned upside down, and slapped on the back, as we have before said. If this proceeding is not successful, the patient must be sent back to bed, and be kept slightly narcotized ; and after a day or two the effort to remove the foreign body may be repeated. But in this case, and in any other in which the operation was performed for the relief of dyspnoea, a curved tube should be introduced for the patient to breathe through. It should fit tightly into the aperture, and prevent the entrance of blood into the trachea. It should be of such a size, as Trousseau has remarked, that the air may pass through it in respiration without any whistling noise.1 When the patient wishes to cough, or speak, or swallow, he must be taught to close its orifice with his finger. It should be double, as represented in the following figure, so that by withdrawing the innermost tube, it may be cleared of any mucus that may accumulate in it. It should have a hole in its convex surface, so that the patient may have the benefit of the air that enters by the larynx. The surgeon should have several sizes. Those indicated in the cut are the sizes made by Matthews. The tube depicted is the exact size of Xo. 4. The next drawing represents a double tube, the outer of which Fig. 256. [Double tube for insertion into the windpipe ] is reduced to two slips : by pressing these together its introduction is made easy. The tube should be secured by a tape round the neck, as shown in the adjoining drawing of a patient of Fig- 257. Mr. Partridge, in King's College Hospital: a boy aged five, whose trachea had been opened on account of the presence of a foreign body. The throat should be carefully wrapped in a woollen comforter, and the air be made moist. M. Trous- seau has pointed out the important fact, that a difficulty of swallowing is liable to come on about the fourth [Mode of securing the tube in the trachea.] or fifth day ; and that it is expedient 1 Trousseau de la Tracheotomie, L'Experience, Nov. 5, 1840; Clin. Lecture, Med. Times, Jan. 4, 1856. The writer begs to acknowledge the benefit and pleasure with which he has listened to Professor Trousseau's observations on this subject, in the wards of the Hopital des Enfans Malades. A series of papers on Tracheotomy by Dr. Turner, of Keith, are well worth reading, Prov. Med. Journal, 1854. Also Dr. Scrapie'* Memoirs of Diphtherite, New Sydenham Soc, 1859. [Curved tube for insertion into the windpipe.] LARYNGOTOMY AND TRACHEOTOMY. 443 Fig. 258. to give thickened soups, pounded meat, and other half-solid substances ; liquids are then apt to enter the larynx, because the epiglottis is out of gear. III. Tracheotomy or Laryngotomy is required for any disease or injury which causes mechanical impediment to respiration. 1. In acute laryngitis, croup, and diphtheria, when suffocation is immi- nent, tracheotomy should be performed. Some surgeons condemn it in croup, on the plea of its hopelessness. But we reply that it is the only remedy ; that it has un- doubtedly in many cases prolonged a life which was on the verge of extinction ; that it furnishes an exit for flakes of false membrane that cannot pass the rima glottidis ; and that it very likely would be more successful if it were done earlier, without waiting till the patient is exhausted by struggling for breath. Moreover, Mr. Henry Smith has well shown that in some fatal cases of croup, the obstruction has been seated in the larynx only, and that an opening below would have saved life. In the state called oedema glottidis, in which the submucous tissue about the glottis becomes infiltrated with serum in consequence of a low degree of inflammation, or of a general dropsical diathesis, a glance at the preceding figure will show that an artificial aperture must be often necessary to preserve life. This state may be suspected when intense dyspnoea, not referable to disease in the chest, and hoarseness arise, either during sore throat, or erysipelas; or after scarlet fever. [(Edema of the glottis.] Fis. 259. Fig. 2G0. Fig. 2.">f> —Warty excrescences within the larynx. Laryngotomy had been performed. From tho Middlesex Hospital Museum. Fig. 260.— Ulceratiou of the larynx. Both cases probably epithelioma. 2. In chronic inflammation or ulceration of the larynx the operation should also be performed before the disease has lasted long enough to ex- 444 POLYPUS of the epiglottis, etc. haust the patient by the spasmodic cough, dyspnoea, and purulent expectora- tion which attend it. This is an occasional consequence of secondary syphilis, as mentioned at p. 199, and more frequently of confirmed phthisis; but the operation should always be performed if there is imminent danger of suffocation, even though the patient's ultimate recovery may be quite hopeless. 3. The operation is sometimes required for tumors, warty excrescences, and epithelial growths within the larynx; cases that will generally be ob- scure, inasmuch as their symptoms must be nearly the same as those of the foregoing cases; beginning with hoarseness, tickling cough, and noisy breath- ing ; with purulent or bloody expectoration if ulceration occurs. 4. Tracheotomy was proposed nearly 20 years ago by Mr. Mayo, as a palliative in hydrophobia. It has since been proposed by Dr. Marshall Hall, in order to relieve or prevent the congestion within the head, which may precede the severer epileptic fits, from the spasmodic closure of the rima glottidis. Experience alone can determine the value of this proposal.1 But we may observe that hydrophobia does not kill by suffocation. 5. Cases that simulate Laryngeal Disease.—Some years since, the medi- cal journals made themselves merry at the expense of the house-surgeon to one of the largest hospitals in London, who, being summoned in the night to a patient apparently dying of dyspnoea, immediately performed tracheo- tomy, but without avail; for the man expired very soon afterwards; and on a post-mortem examination it was found that there was nothing the matter with the larynx, but that a large aneurism existed on the arch of the aorta. What was the use, it was said, of cutting the throat of a man who was dying of aneurism? The house-surgeon, however, was not to blame, be- cause, as is now very well known, tumors about the aortic arch may produce spasm of the glottis, by interfering with the recurrent nerves. But now that this fact is known, every surgeon should carefully scrutinize the chest in obscure cases of dyspnoea, to see whether it arise from this cause. No permanent good can then result from tracheotomy; yet the author heard of a case lately, at the Winchester Hospital, in which it certainly rescued a patient from immediate death, although he died shortly afterwards from other effects of the aneurism. But the operation is not admissible in that spasm of the glottis which often affects children during teething; nor yet in cases in which the symptoms of laryngitis are mimicked by hysteria.3 The application of a solution of nitrate of silver (gr. xx. ad ^i.) within the larynx is, on general principles, likely to be beneficial in cases of dis- ease of a prolonged asthenic or irritative character ;—obstinate cough, such as the latter stages of hooping-cough ; obstinate hoarseness or loss of voice; or ulceration from any cause, with copious expectoration. The tongue must be drawn downwards and forwards with the left forefinger, or with a curved spatula ; and then a curved probang carefully coated with sponge, a quarter of an inch in diameter, moistened with the solution, should be passed into the glottis. It must not be allowed to touch the pharynx, or it will cause efforts at vomiting. IV. Polypus op the Epiglottis, Larynx, and Trachea.—Professor Ehrman of Strasbourg has collected the histories of thirty-one cases of polypus of these parts in the human subject, three in the cow, and two in the horse, in an interesting monograph. The early symptoms are hoarse- 1 And experience, like reason, is strongly against it. See cases of failure, by Dr. Ogle and Dr. Ormerod, of Brighton, quoted in Ranking, vol. xxvii. 2 See papers by Dr. Horace Green, and Dr. S. Watson, in Ranking, vol. xvi.; Wag- staffe, Cotton, and others, at Lond. Med. Soc. ; Lancet for 1852. J. Hughes Bennett on Pulmonary Tuberculosis, Edinburgh, 1853. Coxeter's Laryngeal Syringe, for introducing a few drops of caustic solution into the larynx, is a good substitute for the probang. FRACTURES OF THE OS HYOIDES, ETC. 445 ness, and perhaps loss of voice, especially if the tumor be situated near the chordae vocales ; cough of a croupy, suffocative character ; sense of obstruc- tion in breathing, speaking, or swallowing; dyspnoea, gradually increasing with the growth of the tumor, next coming in terrific fits of suffocation, at last fatal: when the tumor, if within the trachea, is driven up between the chordae vocales by expiration ; or if attached to the epiglottis, is drawn down by inspiration. The most distinctive symptom is a valvular flapping sound heard or felt when the tumor moves during respiration. In more than one case the tumor, or a portion of it, has been torn off and coughed up : this of course decides the diagnosis. In a case by Mr. Stallard, the tumor was detached within the trachea, and the patient died suffocated. Polypi here, as elsewhere, are usually fibro-cellular, fibro-plastic, or epithe- lial. The symptoms above detailed are such as imperatively demand tra- cheotomy. But besides this, if the presence of a tumor is ascertained, or is highly probable, further measures may be adopted. If the tumor is attached to the epiglottis, it may be removed from above. If lower down, the larynx must be opened, an operation which will be easily added to the tracheotomy.1 In a case which occurred to Professor Ehrman, the patient, a healthy woman, set. 33, had lost her voice for three years ; when she began to expe- rience a sensation as of the opening and shutting of a valve in the larynx ; violent cough came on occasionally during swallowing, and caused expecto- ration of small portions of tissue. She was suddenly seized with a fit of suffocation, almost fatal, when Professor Ehrman performed tracheotomy, and the next day extended the incision upwards, through the junction of the alae of the thyroid cartilage, and removed a cauliflower excrescence from the left vocal cord. Recovery was complete, except of the voice. Seven months afterwards the patient unfortunately died of typhoid fever. The tumor was epithelioma, and had just begun to sprout again when the patient died. In another case, Dr. Brauers, of Louvain, laid open the larynx and cauterized a warty excrescence with acid nitrate of mercury and actual cautery. Final result not stated. These examples show that in any.case of laryngeal dis- ease requiring tracheotomy, the larynx itself may, if necessary, be opened, examined, and submitted to direct treatment. Y. Fractures of the Os Hyoides or of the Thyroid Cartilage are rare accidents, which may be produced by blows or falls on the front of the throat [or, as we have seen, after a quarrel, from the pressure of a cravat violently twisted around the neck]. The symptoms are pain ; displacement of the fragments, ascertained by examination ; difficulty of swallowing or of breathing ; and perhaps hemorrhage from the mucous membrane, which may be lacerated ; perhaps emphysema. The treatment must depend on the urgency of the case. In a case of perpendicular fracture of the thyroid cartilage, seen by Dr. Gibb, the two lateral portions of the cartilage were separated at the pomum Adami, but the only symptoms were loss of voice, and an "indescribable sensation" in the throat.2 In a case of fracture of the hyoid bone, the mouth was kept open by a gag, whilst the fragments, which had been displaced, and had even pierced the mucous membrane of the fauces, were restored to their proper position. Ice may be applied out- wardly if hemorrhage is very profuse, or inflammation violent. The trachea 1 Histoire des Polypes du Larynx. Strasburg, 1850 ; case by Mr. Stallard, Med. Gaz., 19th May, 1843. There is a preparation of it in the King's College Museum from Mr. Mayo's collection. 2 The author has to thank Dr. Gibb for the following references: Dr. Gibb's case, Brit. Amer. Med. Journ., Montreal, vol. vi., p. 306; Cases of Fracture of Hyoid Bone, Amer. Journ. Med. Sc, Philadelphia, vol. xiii., 1833, p. 250; Stethoscope, Richmond, Vir. U. S., June, 1S55 ; Pathological Trans., vol. i., p. 199 ; Fracture of Thyroid Car- tilage, Brit, and For. Med. Rev., N. S., vol. viii., p. 272. [See a very interesting case of Rupture of the Trachea in the Amer. Journ. Med. Sc. for January, 1858, p. 120.] 446 ARTIFICIAL BREATHINd must be opened if requisite to provide for breathing, and the stomach-pump if the patient cannot swallow. VI. Scalds of the Glottis, through swallowing boiling water or corro- sive fluids, produce the ordinary symptoms of laryngitis—suffocative cough, and dyspnoea. Treatment.—Leeches, ice to the throat, opiates to tranquillize, and tra- cheotomy if required. VII. Hanging may destroy life in three ways. 1. By dislocating the neck. 2. By compressing the trachea, and suspending respiration. 3. By compressing the jugular veins, and inducing apoplexy. Treatment—Artificial respiration, bleeding from the jugular vein if the face be turgid, dashing cold water on the face and chest, and a current of galvanism passed from the nape of the neck to the pit of the stomach, so as to excite the diaphragm.1 VIII. Drowning, Treatment of.—Let the head hang down for two sec- onds, to let any water run out of the mouth; then lay down the body with the head raised ; put two fingers into the mouth and draw the tongue well forwards ; wipe out the mouth and throat; strip off wet clothes ; wipe the face, nose, and eyes dry; and set people at work to rub the rest of the body dry. If breathing has nearly but not quite ceased, endeavor to rouse the circulation and the respiratory acts by friction of the entire surface, occa- sionally dashing cold water on the face, neck, and chest, and then wiping quite dry with a warm towel; and by tickling the nose and fauces, to excite sneezing, coughing, or vomiting. If breathing should not be thoroughly restored by these means, it should be set to work artificially. In some cases it maybe expedient to draw blood from the arm, or jugular vein, in order to lessen the load of the heart; and this operation (or leeches) may be required for congestion of the head or chest, after the immediate peril has passed away. Enemata of brandy may be of service in the early stage, whilst the heart's action is faltering. A case is related in which life was restored by the most persevering fric- tion, which was kept up for eight hours before the humanity of the surgeon, Dr. Douglas, of Havre, was rewarded by a return of respiration.3 IX. Artificial Breathing is required in all cases of suspended anima- tion, whether from drowning, injury, noxious gases, chloroform, or narcotic poisons. It may be performed by passing a pipe through the mouth, or a male catheter through the nostril, into the glottis ; or by simply putting a pipe into one nostril, and closing the mouth and the other nostril, and blow- ing through it. But it is a better plan to use a small pair of bellows, putting its muzzle into one nostril. The operator should be careful to force the air into the lungs with very great gentleness, and to press the larynx against the spine, so that the air may not go down the oesophagus. If the larynx has been crushed by a rope, or by a violent blow, it may be necessary to perform tracheotomy, so as to impel a current of air directly into the trachea. Or, instead of forcing air into the lungs, the operator may employ Dr. Sylvester's method, of imitating the natural expansion of the chest by mus- cular effort.3 The patient is laid on his back with the shoulders raised; the 1 For the manner of applying galvanism in these cases refer to Part V., Chap. II. 2 Med. Gaz., 23d December, 1846. 3 The True Physiological Method of restoring persons apparently drowned or dead, and of resuscitating still-born children, by H. Sylvester, M. D., Lond., 1859. There U a rolling method, invented by the late Dr. Marshall Hall, very ingenious, but coarse and inefficient by the side of Dr. Sylvester's. WOUNDS OF THE THROAT. 447 tongue brought forward, and retained, if necessary, by gently closing the patient's teeth in it. Then the operator raises the patient's arms by the side of his head, and extends them gently and steadily upwards and for- wards for a few minutes. This action imitates inspiration. Then the patient's arms are turned down, and gently and firmly pressed for a moment against the sides of the chest: this imitates a deep expiration. These ac- tions should be perseveringly repeated about fifteen times in a minute. SECTION IV.—SURGICAL AFFECTIONS OF THE EXTERNAL PARTS OF THE NECK AND THROAT. I. Wounds of the Throat are generally made with intention of suicide, and are extremely dangerous, no less from the importance of the parts in- jured, than from the despondency of the patient. Treatment.—The general indications are, 1st, to arrest hemorrhage; 2dly, to obviate difficulty of breathing ; 3dly, to prevent inflammation of the trachea or chest. In the first place, any arteries that are wounded must be tied, and hemor- rhage from large veins must be restrained by pressure with the finger, kept up as long as may be necessary. The patient should be put to bed in rather a warm room; and so soon as all oozing has ceased, but not before, his shoulders should be raised by pillows, and the head be bent forwards, and be confined by a bandage passing from each side of the nightcap to the shoulders. Plasters are inadmissible, and so are sutures, except in the cases that will be alluded to presently. If the wound penetrates the trachea or larynx, it should be covered with a loose woollen comforter, or a layer of cotton wool, or, after the first week, with one of Jeffreys' respirators, if it can be nicely adapted. The patient should not be kept too low ; and if the pharynx or oesophagus is wounded, a common, large-sized, elastic catheter may be passed, or the elastic tube of the stomach-pump, through which nu- tritive fluids can be injected by means of an elastic bottle. But if during the inflammatory stage the attempt causes great irritation, it may be neces- sary to employ nutrient enemata merely. At all events, no tube should be passed through the wound for that purpose. The great thirst and dryness of the fauces, experienced in these cases, may in some measure be mitigated by sucking a wet rag, or still better, a lump of Wenham Lake ice. If the patient finds great difficulty in expectorating through the wound, he must be taught to close it partially by leaning his head forwards, and placing his fingers on it, whilst he makes an expiratory effort, so that he may expel the air with a sudden gust. In every stage of the cure, difficulty of breathing should be viewed with suspicion. It may arise from several causes. 1. If the wound is above the larynx, it may be caused by the epiglottis being detached from the tongue, and hanging down upon or irritating the rima glottidis, or by clots of blood collecting in the pharnyx. 2. It may be caused by an irregular and jagged division of the larynx or trachea, so that some pieces of the cartilage hang into the tube; or supposing the trachea to have been completely cut through, it may be caused by the aperture of the lower portion being overlapped by the upper. In these cases it may be requisite to employ sutures, but they should be passed merely through the cellular tissue around the cartilage, and neither through the cartilage nor the skin. 3. It may be caused by swelling of the mucous membrane of the larynx and trachea in the acute inflammatory stage immediately after the injury; or by chronic thickening of that membrane from the continued irritation of cold air, if the wound is very slow in closing. In the former of these cases, free antiphlogistic mea- sures must be used ; the latter must be prevented by using a proper position, 448 BRONCHOCELE. so as to promote the approximation of the wound whilst it is healing. In either case it may be necessary to make a longitudinal division of the tra- chea to relieve the dyspnoea. 4. Another frequent cause of dyspnoea is the passage of blood into the trachea, if the wound is prematurely closed, and especially if it is sewn up or covered with plasters. Even supposing the trachea not to be opened, great danger may result from closing a wound of the throat before bleeding has ceased, for the blood may accumulate in the cellular tissue, and coagulate, and compress the trachea. II. Bronchocele (Goitre, Derbyshire neck) signifies an hypertrophy of the thyroid gland. Symptoms.—A soft, projecting, elastic tumor occupies the front of the neck, in the situation and of the shape of the thyroid gland. It is rarelv tender, and the skin is not discolored. Frequently one lateral lobe is larger than the other ; and occasionally the middle lobe or isthmus is solely or prin- cipally affected. Consequences.—When of moderate bulk, it rarely causes any inconve- nience, except occasional headache, and difficulty of breathing in a stooping posture. But when very large, it may pro- duce a most dangerous difficulty of swallow- ing and breathing, and congestion in the head by its pressure on the trachea, oesophagus, and jugular veins ;* or it may induce thickening and disease of the trachea, with most obsti- nate cough, which may end in consumption. Diagnosis.—It is to be distinguished from encysted and other tumors by its shape, by its want of fluctuation, and by its mostly affecting both sides. Prognosis.—If it be soft and recent, and occur in a young patient, it will most likely be cured ; but probably not if it be old, hard, and the patient advanced in life. Anatomy.—The disease begins, probably, with hypertrophy of the natural gland struc- ture, and concurrent formation of cysts. The gland structure nearly resembles that of the secretory glands ; that is to say, consists of pouches of pellucid membrane, containing nuclei and nucleated cells ; although not pro- vided, like the secretory glands, with ducts. The cysts are developed in the interstices of the gland structure, and often have growths of it sprouting from their walls. Some cysts attain large size, and are filled with glairy matter, more or less solid : in very old cases earthy deposit may be formed. Other cysts which contain blood, or a bloody liquid, are probably the remains of dilated veins.3 (See pp. 118, 316.) Causes.—Bronchocele is what is termed an endemic disease : that is, one extremely prevalent in certain localities ; amongst which may be mentioned Derbyshire, Nottingham, and the chalky parts of England generally; and various Alpine and mountainous districts, especially the Tyrol and valley of the Rhone. The use of melted snow; or of water impregnated with calcareous or earthy particles, to which the inhabitants of all those places are more or less habituated, although not perhaps the invariable cause, is 1 Mr. Howship gives a case of bronchocele with the jugular vein passing through its substance. The patient suffered greatly from congestion in the head. 2 Vide Baillie's Morbid Anatomy, by Wardrop, 2d ed. p. 84, and Turner's Art of Sur- gery, vol. i. p. 198. [Bronchocele.] The oesophagus is seen to be pushed to the right side by the tumor. From the King's College col- lection. BRONCHOCELE. 449 the most probable that can be assigned.1 In England it most frequently affects females about the age of puberty, and in many cases is obviously connected with uterine derangement. Patients so often refer its origin to some Flg* ' twist or strain of the neck, that there is some reason for believing that such an accident may be an exciting cause. The most practical point to be gathered from the consideration of its causes is this : that most persons who are sub- ject to it always find it increase at times when their health and strength are lowered by any circumstance ; and that in countries where it is endemic, it is closely associated with cretinism and Jn^i100^of]abronchocele*showing calcareous idiocy. Therefore it is to be looked on concre lonsJ as a disease of low degenerative type, and treated accordingly. Treatment.—The best remedy for this disease is iodine, combined with iodide of potassium to render it soluble, as in the compound tincture of the London Pharmacopoeia, and given in such doses as not to cause pain or dis- order of the stomach or the general health. (F. 88.) A lotion of iodine with iodide of potassium, may also be applied to the tumor; but it must be remembered that the swelling generally enlarges, instead of decreasing, if the skin be irritated. The patient, if possible, should remove from a district in which the malady is prevalent, and should drink boiled or distilled water. A residence on the coast, and warm sea-bathing, are mostly advantageous. Any disorder in the digestive or uterine organs should be carefully removed, for bronchocele seems often to be connected with uterine disorder. Steel, iodide of potassium with bark, and aloetic purgatives : in some cases anti- hysteric remedies are of service. Other remedies which were in vogue before the discovery of iodine, and which may be resorted to if that fails, are as follows : bromine; the bromides of potassium and of iron; chlorides of barium and calcium ; mercury ; iron ; potass ; soda ; digitalis, hyoscyamus, and belladonna ; and sea-water. If medicine proves ineffectual, and the tumor enlarges rapidly, so as to threaten suffocation or apoplexy, surgical operations must be resorted to. There are three which have been proposed and practised : viz., the intro- duction of setons ; ligature of the arteries which supply the gland ; and extirpation. The general results of these operations may be stated thus : All three of them have at different times succeeded ; all of them are haz- ardous to life, and have proved fatal; and the first two have, in some instan- ces, failed to remove the disease, although the patient has recovered with his life. If a seton be passed, it should be of silk, and large enough to fill the wound made by the needle, so that there may be no fear of bleeding. The needle should be long and narrow. If after the seton has remained for some time, it ceases to produce a diminution of the gland, it should be with- drawn, and be reintroduced in another place. Extirpation of the gland is performed by making an incision in the mid- dle line of the neck ; the skin and muscles must then be dissected from the tumor • and every artery be tied as soon as it is divided. Then (as it is mostly enlargement of the isthmus, or middle lobe, that requires this opera- 1 Capt. Alexander Gerard, in his account of Korrawur in the Himmalayas, says, that "although the Korrawurrees can get nothing but snow for some months in the year, they are not so subject to goitres as the people that live in the damp grounds in the forest at the foot of the hills, where there can never be any snow water." 29 450 TUMORS IN THE SIDE OF THE NECK. tion), a strong double ligature should be passed through it, and should be firmly tied on each side of it, before it is cut out. Encysted Tumors.—The cysts, which are formed in this gland, and which contain a glairy matter or blood, often require treatment. If necessary, they may be punctured, when they will most likely inflame, suppurate, or lose their lining membrane by sloughing, and contract. If this does not answer a se- ton should be passed. They are apt, after puncture, to give exit to a great quantity of arterial blood ; if this prove troublesome, the wound must be filled with lint, when it will readily cease. In a case of cyst in the thyroid gland, which occurred to Mr. Fergusson, he could distinctly feel something of atheromatous consistence within it. An incision having been made, this turned out to be a cauliflower intracystic growth, so extremely vascular, that the wound was obliged to be closed. Similar cysts are liable to form in other parts of the neck, not connected with the thyroid gland. Their treat- ment is the same.1 This gland may further be affected with acute and chronic inflammation, and tubercular deposit; either of which may lead to abscess. Their treat- ment must be conducted on general principles. It has also been affected with cancer, although rarely. Some cases of it are recorded in the Med.-Chir. Trans, vol. xxvii., by Mr. Caesar Hawkins, and by Mr. Brown, of Bath. The patients presented solid tumors in the situation of the gland, not having the characters of ordinary bronchocele; and one distinctive feature was the fixity of the parts. III. Hernia Bronchialis (Bronchocele vera, Goitre aerien) is a very rare tumor, formed by a protrusion of the mucous membrane through the cartilages of the larynx or the rings of the trachea, and caused by violent exertions of the voice. Larry met with sundry instances of it in French officers, and in the muezzins or priests that call the people to prayer from the minarets in Mohammedan countries. The tumor is soft and elastic, can often be made to disappear by pressure, and is increased by any exertion. The only available treatment is moderate support.2 IV. Parotid Tumors.—This name may be assigned to those tumors which occur in front of the ear, over the parotid gland. Cysts of various sorts, filled with glairy matter, or with blood; enchondromatous tumors, pure, or mixed with newly-developed gland tissue, and enlarged lymphatic glands, are the commonest; cancer may also be met with. Such tumors may of course involve the facial nerve ; the facial artery, or the external ca- rotid ; or may extend inwards to the pterygoid and styloid processes. " If there be reason to suspect," says Mr. Listen, " that the disease is of a malig- nant nature, and not thoroughly limited by a cellular cyst, no interference is admissible. If, on the contrary, it be at all movable, has advanced slowly, possesses a smooth surface, and is firm (neither of stony hardness, nor pulpy), then an operation may be contemplated." If slowness of growth and capa- bility of being moved freely concur, the surgeon should remove such tumors; keeping his knife close to the tumor, especially at its deep part, so that he may not divide the nerve or artery, if possible. Sometimes, however, they may be so involved, that their division is unavoidable. The patient should always therefore be warned of the possibility of facial paralysis after removal of one of these tumors. V. Tumors in the side of the Neck.—Every variety of tumor may be found in this locality ; enlarged lymphatic glands ; cysts serous and sanguino- lent; tumors composed of gland structure, like that of the thyroid gland; !.Vide a paper by Mr. B. Phillips in Med.-Chir. Trans, vol. xxv., on Tumors in the Neck not involving the Thvroid Gland; Paget, Lectures, vol ii. ; Fergusson, Pract. Surg., 3d edit. p. 655; [4th*Am. edit. p. 422.] 2 Larry, Clinique Chirurgicale. torn. ii. p. 81. Paris, 1829. WRYNECK. 451 fibro-plastic tumors, and cancer; the last possibly involving the great vessels, or attached to the vertebrae. If subjacent to the skin merely, and freely movable on the subjacent tissues, they may readily be removed ; but if they lie deep, and are bound down by the platysma and fascia, they require some consideration. If a tumor be of slow growth, defined in its outline, and movable, so that it is probably not cancer, or if it interfere with deglutition or respiration, its extirpation may be attempted. If any suspicious tumor is of recent origin, the surgeon should wait, to see whether rapidity of growth and implication of adjacent parts give reason for believing it to be cancer- ous. See the remarks on the removal of tumors in Part V. VI. Wryneck is a peculiar distortion in which the head is bent down toward one shoulder (generally the right), and the face is turned to the op- posite. The right eyebrow and right corner of the mouth generally become elevated, so as to preserve their horizontal position, notwithstanding the distortion of the neck. Varieties.—This affection presents many varieties. It may perhaps be only a part of general lateral curvature of the spine. Or, 2, it may depend on caries of the cervical vertebrae. 3. It may be caused by contraction of the cicatrix of a burn or ulcer. Or, 4, by glandular enlargement on one side of the neck; the treatment of which cases requires no observation in this place. But the genuine wryneck is produced by contraction of one sterno-mastoid muscle, which may depend, 1, on inflammatory or rheumatic spasm of that muscle. This form generally occurs somewhat suddenly to weakly children with disordered digestive organs. The muscle is often hot and tender, and any motion causes pain. Treatment—Perfect rest in the horizontal posture, leeches, and poultices, or hot fomentations, so as to keep the skin constantly moist and perspirable, with purgatives and alteratives, followed by quinine.1 [Ironing the part with a hot smoothing-iron, a layer of flannel being placed over the skin, affords great relief.] 2. It may depend on rigidity and atrophy of the muscle, which may be a sequel of the state of inflammatory spasm last described, or may be con- genital. Treatment—A long-continued course of bark, with iodide of potassium, Scott's ointment (F. 160) worn as a plaster, blisters behind the ears and to the nape of the neck, and the use of a machine to keep up extension, may be of service in cases that are of no very long duration. If they fail, as they probably will, or if the case is congenital, division of the sternal origin of the muscle (or perhaps of the clavicular also) is the last resource. It is best performed thus : The skin covering the muscle at about an inch from the sternum is to be pinched up between the left forefinger and thumb. A narrow curved bistoury is then to be thrust under the muscle, and is to be made to divide it as it is being withdrawn ; but the wound in the skin must only be large enough to admit the instrument. The aperture may be made at the anterior border of the right muscle, and between the sternal and clavicular portions of the left. So soon as the division is complete, the ends of the muscle retract with a dull snap, and the thumb should be pressed on the part, to prevent effusion of blood under the skin. When the wound is healed, but not before, an apparatus should be applied to elongate the callus, and restore the neck to its proper position. Dr. Little finds that the best way of getting a purchase on the head, so as to keep it in a proper position, is by encircling it round the forehead and occiput with a broad ' For further information respecting this form of wryneck, consult Abernethy, Lecture xxxii.; James on Inflammation, 2d ed. p. 484; Brodie on Local Nervous Affections ; and Co'ley, Med. Gaz. N. S. vol. iv. p. 148. 452 PNEUMOTHORAX. strip of adhesive plaster, and with a bandage over this. Another strip of plaster is put round the waist. A tape is then sewn firmly to the bandage and plaster which encircle the head, either in front of or behind the ear, ac- cording to circumstances, and should be made to pass diagonally across the neck and chest, and be fastened to the waistband on the opposite side, with the requisite degree of tightness to insure proper rotation of the head. In cases of voluntary retention of the head on one side, Dr. Little has resorted, with advantage, to painful counter-irritation on the other.1 3. Lastly, this distortion may be caused by palsy of one sterno-mastoid muscle, in consequence of which the other muscle, being uncontrolled, drags the neck permanently to its own side. If the administration of remedies calculated to remove any existing disease in the head or back, and to im- prove the health, and if strychnine, blisters, and electricity fail, division of the sound muscle has been recommended.3 CHAPTER XVI. SURGICAL DISEASES AND INJURIES OF THE CHEST. I. Pneumothorax signifies a distension of the cavity of the pleura with air, and collapse of the lung. It is known by the following symptoms: On the affected side there is an absence of the respiratory murmur, with an exceedingly clear sound on percussion, and immobility of the ribs; and there is puerile respiration on the other side. It may be caused, 1, by a frac- tured rib which has lacerated the lung—and in this case it is attended with emphysema, as has been detailed at p. 241. 2. It may be caused by the bursting of an abscess of the lung into the cavity of the pleura. This case will be indicated by succussion and by metallic tinkling, in addition to the signs mentioned above. Succussion simply consists in shaking the patient, when (inasmuch as both air and fluid have escaped from the lung into the pleural cavity) the fluid will be heard to splash, if the ear is applied to the chest at the level of the fluid. If there is fluid in the cavity of the pleura and air besides, the clearest parts on percussion will always be uppermost, in whatever posture the patient may be. The metallic tinkling is a clear sound, like the dropping of water into a cask. It is produced when the patent coughs, by which means a drop of fluid is shaken from the orifice in the lung, and made to fall to the bottom of the chest. 3. It may be a con- sequence of the escape of air from a wounded lung, after the external wound through the parietes of the chest has been closed. Treatment—So far as the mere surgical treatment of this symptom is concerned, if the breathing become very difficult, with a distended and tym- panitic condition of the diseased or injured side of the chest, a small trocar may be introduced between the fifth and sixth ribs, to let the air escape. II. Hemothorax, which signifies the presence of blood in the pleural cavity, may be suspected if great dyspnoea and dulness on percussion follow a fractured rib, or if it come on rapidly after closure of a wound in the chest. The blood may proceed either from the intercostal artery, or from the lung. 1 Little on Deformities, Lond. 1853. 2 Vide cases of Wryneck, &c, by Dieffenbach, in the Lancet for Sept. 1838. Goocli gives a case of wryneck and distortion of the jaw caused by contraction of the platysma myoides, and cured by division of that muscle, in the year 1759. WOUNDS OF THE CHEST. 453 Treatment—If the difficulty of breathing be very urgent, an incision must be made to let the blood escape. III. Hydrothorax, or water on the chest, is indicated by great difficulty of breathing, especially on lying down—livid countenance—disturbed sleep —dulness on percussion—and if the effusion be confined to one side of the chest, there is very great difficulty in lying upon the other. Treatment.—If the hydrothorax were merely an inflammatory effusion from pleurisy, a local affection, paracentesis might be advisable for the dyspnoea; but if (as it is generally) it is an effect of organic disease of the heart or lungs, the operation would do no good. At all events, both sides of the chest must not be punctured. IV. Empyema signifies abscess of the chest, or suppuration ot the pleura. It is an effect of acute inflammation, whether idiopathic, or caused by injury; or else of the bursting of abscesses into the chest, or of the irritation of carious ribs. It is known by dulness on percussion, gradually increasing enlargement of the side of the chest—separation of the ribs—dyspnoea— difficulty of lying on the sound side—more or less oedema of the parietes of the chest—shivering and hectic, and the other signs of deep-seated sup- puration. If left to itself, the abscess may point and burst between the ribs. Paracentesis is decidedly required, if the case be clear; if it be not, two or three punctures may be* made with a grooved needle, or a small ex- ploring trocar, and a cupping-glass be applied over them to extract some fluid. V. Paracentesis Thoracis, or puncture of the chest, is an operation sometimes required for the foregoing affections, and especially for empyema. Wherever there is an indication of decided pointing, that is the place for an operation ; otherwise the place usually chosen is between the fifth and sixth ribs, a little behind their middle. An incision, an inch and a half long, is made through skin and muscles, and the point of the bistoury to be passed through the pleura. If fluid escapes from this puncture, a trocar may be plunged in, or if there is no doubt in the diagnosis, a trocar may be em- ployed at once. It may be advantageous to employ the drainage tube which M. Chassaig- nac1 has adopted for large abscesses in general, and which has been used in empyema by Dr. Goodfellow and Mr. De Morgan. This is a small India- rubber tube, with many perforations, passed through the cavity of the abscess, pleuritic or other, in order that there may be absolutely no accumulation, and that every drop of pus may be discharged, so soon as it is formed, and before it has had time to be decomposed. The first puncture or aperture is made as above described. A long bent iron probe is passed through it, into the cavity, and made to project at one of the intercostal spaces, as far back and as low down as possible. Here it is to be felt and cut down upon, and made to project; and then a piece of silk to be attached to an eye in it which is to be drawn through the wound, and by means of the silk, an India-rubber tube; the ends of the tube are tied together, and the pus allowed to drain away. VI Hydrops Pericardii may occur under the same conditions as hydro- thorax and may be combined with it. Its diagnosis is obscure. It may be suspected to exist if the patient complain of constant weight in the prsecor- dia great dyspnoea, especially when lying on the back, and faintness upon exertion • if there is great dulness on percussion, and manifest fulness over the region of the heart—if its pulsations are tremulous—and the circula- tion embarrassed. The operation of paracentesis pericardii has been 1 «„* Ppnf,rt of Paper by Dr. Goodfellow and Mr. De Morgan, Medical Times and Gazette, 1859 vol. i ?p" 659. [Also in Med.-Chirurg. Trans, vol. xiii., and Amer. Journ. Med. Sci. for April, 18(30.] 454 WOUNDS OF THE CHEST. practised, although it can rarely be of much benefit, and ought not to be dreamed of until blisters and diuretics have failed entirely. It has been attempted in sundry cases of hydrothorax, which were mistaken for hydrops pericardii; but by a second lucky mistake the pleura was opened instead. It may be performed either by making an incision opposite the heart's apex, and dividing the muscles and pericardium with the same precautions as in paracentesis thoracis, or by first making an opening into the pleura, opposite the junction of the fifth or sixth rib with its cartilage—and then introducing the finger, feeling for the distended pericardium, and cutting into it with curved scissors ; but it is an operation which we by no means recommend. VII. Wounds and Contusions of the Parietes of the chest require the same treatment, whether the ribs are fractured or not. A bandage may be applied to prevent motion of the ribs,- if the patient express himself re- lieved by it; but sometimes it adds to the distress, and must not be used. The bowels must be opened, the diet moderately low, cough and irritation be allayed by full opiates, and bleeding or leeches be employed, if necessary, to prevent inflammation. VIII. Penetrating Wounds of the thorax, such as stabs from a sword, are usually attended with wound of the lung, of which we shall speak directly. In the dead body, when air is admitted to the cavity of the pleura, the lung collapses at once : this is certainly not the case in the living body, unless the external wound be very extensive indeed ;—on the contrary, the lung con- tinues to discharge its functions, although less perfectly in proportion to the amount of air passing in and out of the wouud in the chest. The writer has had the opportunity of ascertaining that the respiratory murmur may be perfect throughout the lung, just after a wound into the pleural cavity has been closed. Hernia of the Lung.—If the lung protrudes, the rule generally given is, to return it as quickly as possible, unless it is injured or beginning to mor- tify ; but Mr. Guthrie recommends that it should be permitted to remain, as it closes the aperture into the pleura, and speedily granulates and heals over. Hernia of the lung, without external wound, protruding through the pleura amongst the muscles, is excessively rare, and must be treated by bandage or truss. IX. Wounds of the Lung, if extensive, are probably quickly fatal. If not, they will probably present the following symptoms : Great dyspncea and sense of suffocation; the countenance pallid and extremely anxious— and expectoration of blood, which is coughed up in florid arterial mouth- fuls, mixed with occasional clots. If the wound is not extensive, there may be only a certain amount of oozing into the pleural cavity, and no cough nor bloody expectoration at, all. The dangers of wounds of the chest are three- fold. 1st. Hemorrhage, which may destroy the patient by exhaustion, or may fill up the air-passages and induce suffocation. 2dly. Inflammation, which may supervene, and will be aggravated by the irritation of clots of blood, splintered bone, or of other extraneous bodies. 3dly. Profuse and exhausting suppuration, with cough, debility, hectic, and all the symptoms of phthisis. Treatment.—The first indication is to check the hemorrhage. If this proceed from the intercostal, or any other artery of the parietes (although these do not often give trouble), the wound must be enlarged, and the bleed- ing orifice be seized with forceps, or tenaculum, or be secured by torsion.1 If hemorrhage proceed from the wounded lung, the remedies are ice or cold 1 Mr. Lawson says that the intercostal artery was not once secured in the Crimean campaign. WOUNDS OF THE CHEST. 455 drinks, perfect quietude, opium to insure sleep and diminish the respiration, astringents, as gallic acid, or alum, administered internally, and lastly, the abstraction of blood from the arm in such a way as to induce speedy syn- cope, if no other remedy suffices.1 Secondly, the wound should be examined, and if it be of large size, or a gunshot wound, the finger should be introduced into it, to remove clots of blood, splinters of broken ribs, or any other foreign substances that it may find. If it is not sufficiently large for this purpose, it may be dilated by a probe-pointed bistoury. At the same time, an intercostal artery, if wounded, should be secured. Thirdly, the wound should then be accurately closed with lint and plaster, or sutures, and the patient should be suffered to lie as quietly as possible. He should have plenty of cool air, and a very light covering. The rule is generally given, in all injuries of the thorax and abdomen, to place him on the wounded side ; but he must decide for himself what position is the most comfortable. The closing of the wound is of necessity a great relief to dyspnoea. Fourthly, inflammation must be combated ; and if, in spite of the opium, the pulse rises, and the pain and cough and spitting of blood return, vene- section must be repeated. The diet must be proportioned to the patient's condition ; beef-tea, meat and port wine in one case; iced lemonade, barley- water, or milk and water in another. But, as Mr. Lawson observes, the in- flammation which follows an injury is a totally different thing from idiopathic pneumonia, and a certain exudation of healthy lymph is necessary, and should not be checked by antimony and mercury. Fifthly, if there should be evidence that the side of the chest has become filled, and the lung compressed, by air, by extravasated blood, or by inflam- matory effusion, serous or purulent, either the wound must be opened, or another incision should be made into the pleural cavity lower down. Secondary hemorrhage, after wounds of the lung, may, 1, be caused by inflammatory excitement; or, 2 (if the wound be gunshot), by the separa- tion of sloughs from the lung ; or, 3, by the sloughing of an intercostal artery that may have been brushed by the ball. Venesection is the remedy for the first case, and the ligature, pressure, or styptics, such as gallic acid internally, for the latter two. Foreign Bodies in the chest add greatly to the danger of exhausting sup- puration, although patients have recovered for years with balls, or pieces of cloth, encysted in the lung or pleural cavity. In some cases, a ball has re- mained rolling loosely about in the pleural cavity. If any foreign body is detected, it should, if possible, be removed, and part of the upper border of a rib may be sawn away with Hey's saw, if necessary, in order to get at it. Some surgeons direct penetrating wounds of the chest not to be closed ; or they even recommend tents or canula? to be inserted, to provide for the escape of blood or matter. But it must be evident that there will be much less liability to severe inflammation if the wound is closed, just as in wounds of joints and compound fractures. Besides, " if the patient," says Hennen, " is placed with the wound in a dependent posture, the exit of effused fluids is not necessarily impeded. If they exist in large quantity, the wound is effectually prevented from closing; if the flow is so minute as to admit of the union of the wound, the quantity effused is within the power of the absorbents to remove." X. Abscess behind the sternum, and caries of that bone, sometimes re- quire a perforation to be made in it with a trephine.3 ' See also Dr. Fraser on Penetrating Wounds of the Chest. * For cases, references, &c, see G. Borlase Childs, Lancet, 24th August, 1850 ; Caesar Hawkins, Med. Gaz. N. S. vol. v. p. 62. 456 PARACENTESIS ABDOMINIS. XL Wounds of the Heart generally prove fatal from hemorrhage. Numerous instances, however, are on record, in which stabs or musket- wounds of this organ have healed, both in man and animals, without any ill effects remaining. The diagnosis and prognosis will of course be ex- tremely doubtful. The only available remedy is opium, in order to prevent hemorrhage and keep the circulation as quiet as possible, so that the blood may coagulate in the wound, and the coagulum become adherent and or- ganized.1 XII. Deformity of the chest and spine is an almost inevitable conse- quence of severe pleurisy, or of empyema. The lung, compressed by pleu- ritic fluid, or bound down by adhesions, cannot expand again in the act of respiration, and the side of the chest falls in to accommodate itself to the crippled lung. These cases will be known by their history ; by the fact that the deformity was preceded by enlargement; and by the deficient respira- tory sounds which will be detected by auscultation. Mechanical appliances are of very questionable utility ; but the writer has seen abundance of cases, in which, if the patient were young, and the disease not too severe and long- continued, great flattening and deformity have been completely recovered from by the unaided efforts of nature. CHAPTER XVII. injuries of the abdomen, and surgical operations. I. Paracentesis Abdominis, an operation much better called by the Anglo-Saxon term tapping, is required in ascites, and in ovarian dropsy, when the abdomen has become so distended that the breathing and the cir- culation of the lower extremities are seriously impeded. Diagnosis.—In the first place, ascites may be known by the abdomen being equably enlarged and fluctuating, not feeling harder at one part than at another, whilst in ovarian dropsy, the swelling probably fluctuates less distinctly, for it may be composed of distinct cysts, some of which feel more distended than others. If, however, the ovarian tumor consists of a single thin-walled cyst, this diagnostic mark will be absent. A second means of distinguishing the two affections is afforded by percussion. In ascites, the bowels, as they contain air, float up through the fluid ; and, in whatever po- sition the patient may be placed, they tend to occupy the uppermost part, and the fluid thj lowest; and a clear sound may be elicited by percussion over the bowels, but a dull sound over the fluid. Thus, if the patient be placed on his back, a clear sound will be produced over the anterior sur- face of the abdominal parietes, but a dull sound towards the sides and back. In ovarian dropsy, on the contrary, the abdomen is distended by a tumor, which occupies its front part, the bowels being behind and on either side of it. Consequently, when the patient lies on her back, percussion of the an- terior surface produces a dull sound ; whilst a clear sound may be produced towards the back part and sides. Yet if the quantity of ascitic fluid be very large, and the abdomen be so distended that the mesentery does not allow the bowels to float up and entirely reach the anterior wall, it must be evident that this diagnostic mark may be far less palpable. Even in this case, however, the croaking of air in the bowels may be perhaps felt; and as Dr. 1 For full information on the subject of this chapter, see Guthrie's Commentaries on Military Surgery, Lond. 1855. OVARIOTOMY. 457 Tanner remarks, in some MS. notes with which he has favored the author, it is more likely that ascites will be taken for ovarian dropsy than the con- verse. In any case of doubtful diagnosis, therefore, the probabilities are in favor of ascites. Some degree of ascites is frequently present with ovarian dropsy. Moreover, fluid may escape into the peritoneal cavity from the ova- rian tumor, as stated by Hughes Bennett. Thirdly. A microscopic exami- nation of the fluid which is removed will, in ovarian dropsy, most probably reveal the old disintegrated blood-globules, the epithelial cells, the large compound granular masses, and heaps of granules, oil-cells, and crystals of Fig- 263, cholesterine, which abound in the liquid of old ovarian cysts. Lastly, there are the history and ge- neral symptoms, the uterine derange- ment, and pelvic tumor felt in the early stage of the ovarian disease ; the im- • lii.i j /• j.i_ -, i TFluid from ovarian tumor, microscopical paired health, oedema of the legs, and ex^ination of] enlargement of the liver, which proba- bly precede ascites. Into these it is not our province to enter. Operation.—The rule generally given is, that the patient must be seated in a chair—that a broad towel must be passed round the lower part of the abdomen, its ends to be crossed behind and intrusted to two assistants, who are to be instructed to draw it tight and support the belly as the fluid es- capes. These precautions are taken, because of the risk that the removal of the compression to which the abdominal veins have been habituated, might cause the blood to gravitate into them from the heart and induce syncope, or that perhaps they might burst, and occasion a fatal hemorrhage. But this risk is entirely avoided if the plan be adopted of placing the patient in the recumbent posture on her side, at the edge of the bed, and turning L:r over as the fluid escapes ; and this plan is not only safer and more convenient, but more effectual for getting rid of the fluid. But be this as it may, the sur- geon, holding a trocar in a canula in his right hand, with the end of his fore- finger about two inches from the point of the instrument, plunges it through the linea alba, two inches below the umbilicus ; then holding in the canula with his left hand, he pulls out the trocar with his right. Modern instru- ments are provided with an India-rubber tube at right- angles ; so that the fluid may pass into a convenient receptacle, without noise or splashing. If the trocar is a large one, which is expedient in ovarian dropsy, it will be as well, before introducing it, to puncture the skin with a common lancet, or to make an incision with a scalpel. The aperture is afterwards to be closed with lint and plaster, and a broad bandage with napkins as a compress, to be applied with comfortable tightness. (See Bandages.) If a patieut with ascites happens also to have an old irreducible hernia, and the sac is much distended, and preserves a free communication with the abdomen, it is a good plan to puncture the sac instead of the linea alba. II. Ovariotomy.—The ovary, which, in a healthy condition, is about 1^ inch in its long diameter, and composed of peritoneal and fibrous coat, en- closing a vascular stroma filled with minute cysts, is liable to many diseases. Sometimes a solid tumor is developed in it, or a cutaneous cyst containing hair, teeth, and bone. But the disease to which the name ovarian tumor, or ovarian or encysted dropsy is given, may be described as an exaggeration of the entire organ, or of one or more of the individual cysts contained in it, into an enormous tumor, which may weigh from 50 to 100 lbs., or even more. This tumor may be simple or cancerous. In the simple, the parts composing the tumor are natural structures, only 458 OVARIOTOMY. greatly hypertrophied ; in the cancerous, the solid intra-cystic parts are composed of cancer tissue. In some cases a cancerous growth may be superadded to a previously-existing simple tumor. The number of cysts may be one, or almost infinite, there being in the latter case a vast number of smaller ones developed in the interstices, and projecting into the cavities, of the larger ones. They may be thin and flex- ible like bladder, or thick and semicartilaginous. The contained fluid may be clear and transparent as pure water, or thick and ropy, from the presence of a peculiar extractive matter; or may be of a deep coffee color from the presence of broken-down coloring matter of the blood ; or opaque, from the presence of the matters shown in the preceding page. The ovarian fluid contains much less albumen than blood serum does, and no phosphate of soda, or but very little.1 The diagnosis from ascites has been spoken of already. From pregnancy it must be distinguished by its history and duration, and especially by the physical condition of the uterus, as ascertained by examination. For a more detailed history, and its diagnosis from other growths within the abdomen and pelvis, we must refer to obstetric writers, our concern being only with the treatment by operation. Once in existence, three courses are open to this disease. 1. It may sub- side after tapping, or after accidental rupture of the cyst into the peritoneal cavity. The latter event, however, has proved fatal through peritonitis in some of the instances in which it has been noticed. In some cases relief, more or less great, has followed the ulceration of the tumor, and the dis- charge of its contents through the navel or into some part of the bowels. But each of these cases is rare. 2. The disease, although incurable, may remain stationary, the system become habituated to it, and life go on almost as though the burden existed not. The writer, in former editions, mentioned the case of a lady, aged about 60, of tall commanding figure, in whom an ovarian tumor, of immense size, has existed for more than thirty years. Her health had been for years pretty good, although when the disease first made its appearance, before the diag- nosis was fully made out, she suffered for three years from all the remedies that the physicians of George the Fourth's time could devise for the dis- persion of the swelling. Since the last edition she died of suppuration of the cyst. 3. But unhappily such cases as these are the exceptions. In by far the greater number the tumor continues to increase ; fills up the abdomen; interferes with the breathing ; makes the patient's existence a misery ; and at last wears her out from pain and irritation. This fatal issue will be, of course, much quicker if the malady is of a cancerous nature ; in which case, instead of remaining free and unattached in the peritoneal cavity, or even instead of being bound down by more or less numerous bands of adhesion, the tumor becomes amalgamated with the abdominal wall, with the liver, and with other viscera, and communicates a cancerous infiltration to every part that it adheres to. The question then is, what can our art do to cure the patient, or to mitigate her sufferings; and there are three things that re- quire mention, viz., lstly, tapping ; 2dly, various medical and surgical mea- sures adopted in the hope of producing atrophy of the tumor; and 3dly, extirpation, or ovariotomy. 1. Tapping.—This is the simplest mode of procuring relief; and in some few cases the tumor, emptied by this means, continues quiescent for years or 1 Analysis by Dr. G. 0. Rees, quoted in Dr. A. Farre's article Uterus, in Todd's Cyclopaedia. OVARIOTOMY. 459 for life. But far more commonly the operation requires to be soon repeated. Cases are extant, in one of which the patient lived to be tapped 66 times at intervals of about a month; and, in another, 128 times at intervals of six weeks; but taken as a general rule, it may be affirmed that few patients survive more than four years after the first tapping, a period passed in the greatest misery and suffering. We may add, that in order to relieve the patient effectually, it may be necessary to use a very long trocar, and to plunge it quite deeply, so as to reach the more deeply-seated cysts; and that the puncture had better be made wherever fluctuation is most evident. Tap- ping per vaginam, when a fluctuating portion of tumor projects much in that situation, may be worth adopting. 2. Under the second head may be enumerated an immense variety of plans for producing atrophy or absorption of the tumor; such as (a) the admi- nistration of the iodide of potassium, with tonics, and the iodide of iron : these should have a fair trial in incipient cases, and after tapping ; in cases in which the author has been consulted, he has always found a tonic plan of treatment the most effectual. Considering the enormous amount of blood- cells, albumen, and other blood-stuff in the fluid contents of the tumor, the writer has suggested the administration of gallic acid and the other vege- table astringents. As for mercury and remedies whose object it is to pro- mote absorption by creating great evacuations, or by lowering the system, the writer can only say that he believes the less they are resorted to the longer the patient will live. (6) Mr. Isaac Baker Brown's plan of first emptying the cyst by tapping, then applying firm pressure and administering mercury, (c) Operations for opening the cyst into the cavity of the peri- toneum by subcutaneous section, thus imitating the cases in which the cyst has been ruptured by violent action of the abdominal muscles, and the fluid has been absorbed, and the patient cured. But of course, for the success of such operations, it is requisite that the active growth of the tumor be at an end. (d) Operations for causing the tumor to waste and suppurate by passing setons. (e) Procuring adhesion of the cyst to the abdominal pa- rietes, and establishing an ulcerated opening into the cyst at the adherent spot; or cutting into the cyst, and stitching the edges of the opening into it to those of the wound through the abdominal parietes ; thus establishing an artificial oviduct, through which the contents of the cyst may be evacu- ated. Most of these plans were originated by Mr. I. B. Brown. (/) The iodine injection has been tried by Dr. Simpson with good results ; and by Mr. Spencer Wells. The latter gentleman prefers a solution of 20 grains of iodine and 30 of iodide of potassium, in an ounce of distilled water, to the strong tincture of the Edinburgh Pharmacopoeia, which Dr. Simpson employs. About two fluid ounces of this solution are injected after the cyst has been completely emptied. The same precautions are necessary as in the injection of the tunica vaginalis, not to let the point of the trocar slip out of the cyst, so as to run the risk of injecting the fluid into the peritoneum. For this purpose a catheter may be passed through the canula of the trocar, deep into the cyst, before the fluid is let out, and be held there. The iodine is injected, or allowed to run in through a glass syringe, and is suffered to remain. If it answers the desired end, it will destroy or modify the inner surface of the sac, take away its secreting power, and cause the cyst to wither. The pain which follows the injection may be relieved by opium, and fomentations. But it stands to reason that this is not a radical remedy, and that it is not a safe remedy, unless there be but one cyst. To ascertain the last point, Dr. Graily Hewitt uses an exploring sound, which may be passed into the interior of the cyst, through the canula of a trocar; which is provided with an India-rubber diaphragm to prevent the escape of the 460 OVARIOTOMY. liquid, till the whole interior of the cyst has been explored.1 (g) There is another operation of fair promise which has been proposed by Dr. Tanner, for cases in which the presence of extensive adhesions renders it impossible to remove the cyst. This consists in tying tightly the pedicle of the tumor after the fluid has been removed by tapping. Thus it may be hoped, that whilst the supply of blood furnished to the cyst by its adhesions will be suffi- cient to prevent gangrene, the obstruction of the main arterial channel might prevent the fluid from being secreted anew. 3. Ovariotomy.—The remaining remedy is extirpation. Against which may be adduced, 1st, the difficulty of diagnosis, insomuch that out of eighty- one cases collected by Mr. B. Phillips in 1844, in which it had been at- tempted, no tumor whatever was found in five, and in six others the tumor was not ovarian; 2d, the fact that in fifteen out of the eighty-one cases, after the abdomen was opened, extirpation of the tumor was found imprac- ticable, in consequence of the numerous adhesions which bound it to neigh- boring parts ;3 3dly, the mortality. Of the eighty-one cases, forty-nine recovered,'thirty-two died. Of the sixty-one in which the tumor was ex- tracted, thirty-five recovered, twenty-six died. Of the fifteen in which the tumor could not be extracted, nine recovered, and six died. Dr. Robert Lee, in 1853, enumerates one hundred and sixty-two cases, out of which the tumor could not be removed in sixty ; of these nineteen were fatal; of one hundred and two cases in which the tumor was removed, there were forty-two deaths. On the other hand, in favor of the operation, it may be argued—1st, that the mortality arising from this is not larger than that from many other surgical operations ; and, to use the words of Mr. Southam, the statistical argument is singularly inconsistent when used by surgeons who do not hesi- tate to recommend operations still more dangerous, for the removal of dis- eases not immediately fatal; as, for example, ligature of the innominata artery for aneurism ; an operation that has always proved fatal. Out of seven cases, Mr. Spencer Wells has preserved the lives of five. 2dly, that no other plan of treatment can effect a radical cure, but that by this, women, relieved of a burden which made life miserable, have married and borne child- ren. 3dly, that if favorable cases only were submitted to operation, the mortality would be very small, and that increase of experience will lead to the selection and discrimination of favorable cases, and to improvements in the operation; such, for example, as the bringing of the peduncle out of the wound, instead of leaving it to slough within the abdomen. 4thly, that if the surgeon, in order to complete his diagnosis, makes a small incision, to ascertain the existence of adhesions, and closes it again with suture if he finds this to be the case, no great harm is likely to result; in fact, this, 1 See remarks by Dr. Simpson, quoted in Prov. Med. Journ., 1854, p. 1067; case by Spencer Wells, and description of Dr. Graily Hewitt's instrument, Med. Times, 1859, vol. i. p. 549. 2 Out of four patients operated on by Mr. Lizars some years ago, one died ; one re- covered ; in one, after the abdomen was laid open, there was found to be no tumor at all; and in the fourth there was discovered an enormous mass of convoluted vessels looking like a placenta, which proceeded from the omentum to the tumor, and of course rendered extirpation quite out of the question, so that the incision was closed again. Mr. Solly, in a Lecture in the Med. Gaz. vol. xxxviii., states that the deaths from ovari- otomy up to 1846 were only one in three and a half. Dr. Tilt, Lancet, 1848, vol. ii. p. 626, gives sixty-one cases, which occurred in the practice of five individuals. Of these, it was impossible to remove the tumor in eleven ; of which eleven, seven recovered and four died. Of fifty cases in which the ovary was removed, thirty-seven recovered and thirteen died. In a series of interesting and important papers on the subject in the Med. Times for 1859, vol. i., it is stated that, out of twelve cases operated on in London in 1858, the tumor was not removed in two; of which one was fatal in a fortnight, the other in four months ; of the ten patients from whom the tumor was removed, seven were living, and six in excellent health, at the end of the year. OVARIOTOMY. 461 which is sometimes raked up as an opprobrium against operators, is a pru- dent and legitimate measure. Lastly, that it is by far the most merciful plan of treatment, if adopted early, in patients otherwise healthy, with a still growing but non-adherent tumor. In a field where so many have distinguished themselves, it would be im- possible to mention all, and unfair to select a few of those who have ac- quired celebrity for their skill and success in this operation; yet the writer cannot refrain from adducing the names of Mr. Lane, Dr. Clay, Mr. Southam, Mr. Walne, Dr. Frederic Bird, Mr. Jeaffreson, of Framlingham, Mr. West, Mr. Crouch, of Bruton, now of Mitcham, Mr. I. B. Brown, Dr. Tanner, and Mr. Spencer Wells. The surgeon who proposes to himself to perform this operation, should make certain, 1st, that a tumor exists, and that it is ovarian ; 2dly, that the tumor is increasing, and likely to destroy life, if allowed to remain. Xo one would interfere with a stationary tumor. 3dly, that the increase of the tumor is not arrested by tapping, moderate pressure, and iodine or iron. One tapping is always expedient, as a means of diagnosis, because if the empty sac subsides into the pelvis, it is a guarantee against extensive adhe- sions. 4thly, that the disease is not cancerous. Cancer may be suspected if the tumor has begun early in life, is increasing very fast, and is adherent, and if there is great pain, and decay of health and strength. 5thly, that the general health is such as would be desired in any patient who was to undergo a capital operation ; lastly, he should ascertain whether there are extensive adhesions to the abdominal parietes or viscera. This he may do in some measure by noticing whether the tumor shifts its place as the patient rolls herself from side to side, and also by a very ingenious test which the author has seen used by Dr. F. Bird; namely, by putting the abdominal muscles in action, and noticing whether they rise much from the surface of the tumor. Thus, if the patient whilst lying on her back be told to raise herself up in her bed without using her arms, the recti muscle will start up into a prominent band, if their sheath is not bound down by adhesions on its peritoneal surface, but not if it is. By observing also, as Dr. Sibson sug- gests, whether the tumor descends during inspiration; and by grasping and endeavoring to slide the abdominal parietes over the tumor, or to grasp them and lift them from the tumor, much valuable information will be derived ; but the decisive test is a short incision, and exploration with the finger. The reasons for running the risk will be much the strongest in the case of a young healthy person, whose life, if spared, might be long and valuable. The operation comprises the following steps. The patient ought to have the bowels and bladder empty, and to have taken food three hours previously. The temperature of the operation room should be raised to about 10°, and the air should be moistened by the vapor of water. The patient's position should be easy, and chloroform should be administered. The most happy method of operating, supposing that the circumstances admit of it, is, to make a short incision, say from four to six inches, between the umbilicus and the pubes, along the linea alba, through the peritoneum. Next to puncture the cyst, and empty it; and for this purpose to employ a very large trocar devised by Mr. Hutchinson, so as to get through the pro- cess as quickly as possible. Then to drag out the emptied and collapsed cyst, seizing it with hooked forceps, or running a ligature through it. In the next place, to separate the tumor from its pedicle, and secure the divided tissues, so that there shall be no internal bleeding, which is one great source of danger after the operation. At the same time it is one of the greatest modern improvements that the divided pedicle shall not be put back within the abdomen, where it may possibly bleed, and certainly suppurate before the ligatures separate; whilst the ligatures themselves keep the wound open, 4C2 OVARIOTOMY. and favor the spread of inflammation ; but that it shall be brought out of the wound and be fixed there. This improvement is due to Mr. Duffin. For this purpose the pedicle may be compressed by a clamp, originally devised by Mr. Hutchinson, consisting of two parallel plates of steel, which in the most improved form of the instrument are gilded, and are capable of being screwed together at either end, so as to compress the pedicle equally.1 The inner surface of each plate is jagged, so that the pedicle can scarcely slip. It should, as Mr. Spencer Wells observes, be so placed as not to drag the uterus, and consequently should be as far from that organ as possible; and if the pedicle be very short, a portion of cyst may be cut off, sufficient to make a pedicle long enough to project through the wound. Lastly, the wound is closed accurately (leaving the stump of the pedicle secured by the clamp just protruding from it), and so the operation is finished. The method of closing the wound recommended by Mr. Spencer Wells, is by a sufficient number of harelip pins with twisted suture, or by silver wires; and the wires or pins should be passed through the entire thickness of the wound, including the peritoneum, so as to bring two surfaces of that membrane into contact, and produce adhesion of them, and exclude the contact of the purulent matter which may be secreted by the other struc- tures. But there are cases in which the steps of the operation do not follow so smoothly as we have just described them. The abdomen may contain a large quantity of ascitic fluid, most of which must be allowed to escape before beginning upon the ovary. It may not be possible to extract the tumor through a small incision, either because its contents are too viscid to run out, or because it is solid and cannot be emptied (of course any lesser contained cysts may be punctured), or because of adhesions. These, if old, firm, and extensive, may cause the operation to be abandoned ; if slighter, they may be gently torn through, or, if need be, divided with the knife, and any arteries or veins of sufficient consequence must be tied. If it be im- possible to apply the clamp, a stout whipcord ligature may be made to en- circle the whole pedicle ; and even then, some single vessels may require to be tied. The remaining ovary should be examined, and if diseased may be removed ; but the patient should not needlessly be spayed. One steady as- sistant should take charge of the edges of the wound, holding them close to the cyst, so that the bowels shall not protrude between ; flannels steeped in water at 98°, should be at hand to protect them if need be. The patient should be kept thoroughly warm during the operation, by flannel stockings, and bottles of hot water to the feet; and the abdomen be afterwards padded with the softest cotton wool, and supported by a many- tailed or Indian bandage. Morphia may be administered in regular small doses, to procure sleep by night and ease by day. Sickness and thirst may be allayed by sucking ice. The diet should be good, consisting of soup, light pudding, and wine or brandy and soda water, according to the patient's taste. The bowels should be regulated as they are after a confinement; that is, having been well emptied before the operation, they need not be disturbed till they begin to feel uncomfortable ; then a lavement may be administered. The catheter should be introduced regularly. If great pain and tenderness tome on, a common warm linseed poultice may be applied, as suggested by Mr. Wells ; and if serous effusion should be produced by peritonitis, he very rationally recommends that the wound should be partially opened to let it escape, as he did iu one case, with the best possible results; for, as he ob- serves, the serum in this case was so acrid that it scalded the fingers; and there is no doubt but that it would have been capable by inoculation of 1 Described in Medical Times and Gazette, Dec. 11, 1858. WOUNDS OF THE ABDOMEN. 463 producing puerperal fever ; what mischief, then, must it not cause within the peritoneal cavity ?' III. Violent blows on the Abdomen from obtuse substances, the pas- sage of cart-wheels, spent shot, and so forth, may produce various results. 1. They may cause severe concussion and collapse, which may either speed- ily prove fatal, or may pass off without further ill consequences, or may be succeeded by inflammation. 2. They may produce laceration of the bowels, or of the solid viscera; with effusion of blood or of their secretions into the peritoneal cavity. This may be suspected if the patient complains of excruciating pain radiating over the whole belly ; if the features are pinched, the belly soon swells, and the pulse is very small and tremulous. Treatment.—The patient must be suffered to lie quietly during the stage of collapse, without any officious administration of stimulants; and as soon as pain or vomiting comes on, he should be bled. Subsequently bleeding, or leeches, and fomentations to the belly, to abate inflammation ; and large doses of opium to support the system under the irritation, are the only avail- able remedies. The bowels should not be disturbed either with purgatives or enemata for the first three days, nor should any nutriment be taken, save very small quantities of the mildest fluids at intervals.3 IV. Abscesses between the abdominal parietes occasionally result from contusions or punctured wounds, and sometimes occur idiopathically. Ac- cording to the principles laid down in the chapter on Abscess, they should be opened early, both because of the tendinous structures by which they are covered, and of the possibility that they might burst into the peritoneum. V. Penetrating Wounds of the abdomen may be divided into four species : namely, 1st, simple wounds of the parietes; 2dly, wounds of the viscera; 3dly, wounds of the parietes with protrusion of the viscera; and, 4thly, wounds in which some of the viscera are protruded and wounded like- wise. 1. In the case of a simple wound of the parietes, the surgeon must first (if it be large enough) gently introduce his finger, to ascertain that no part of the intestines is beginning to protrude ; then the wound must be closed by sticking-plaster; or by suture, if it is extensive. If the epigastric artery is divided, it must be cut down upon and tied. The surgeon must recollect that when any part of the abdominal parietes has been wounded or severely bruised, it is almost certain afterwards to become the seat of hernial pro- trusion. 2. Wounds of the Viscera.—In the case of small wounds of the abdomen without protrusion, it will be often impossible to say whether the bowels are wounded or not, but the treatment must be altogether the same, whether they are or not. (a) Wounds of the stomach may be known by the situation and depth of the wound, by vomiting of blood, by the very great depression and collapse, and by the nature of the matters (if any) that escape from the wound. (b) Wounds of the bowels may perhaps be known by the passage of blood with the stools, or by fecal matter escaping from the wound, or by the symp- ' See Lizars on the Extirpation of Diseased Ovaria, Edinburgh, 1825 ; J. Hughes Bennett, Ed. Med. and Surg. Jour. April, 1846 ; B. Phillips, Med.-Chir. Trans, vol. xxvii.; Dr. R. Lee, on Ovarian and Uterine Diseases, Lond. 1853; Dr. Tilt, Lancet, 1849 and 1850; Mr. I. B. Brown, on Diseases of Women, Lond. 1854; Southam on Ovariotomy, Prov. Jour. 1845, and Transactions, 1847 ; Dr. Tanner, in the Lancet for 1852, vol. 'ii.. and Med. Times for 1853, vol. i.; C. R. Thompson of Westerham (describes the improved trocar mentioned at p. 457), Med. Times, 1858, vol. i. p. 329 ; Spencer Wells in Med. Times and Gaz. for 1853 and 1859; [Gross, op. cit. vol. ii. p. 1023.] 2 [See the paper of Mr. Poland in Guy's Hospital Reports, Third Series, vol. iv., and the Amer. Journ. Med. Sci. April, 1859, p. 515.] 464 WOUNDS OF THE ABDOMEN. toms of extravasation of their contents into the abdominal cavity—that is to say, excruciating pain, radiating over the whole belly from the seat of the injury, and attended with signs of great collapse. Fortunately, however, as Mr. Travers has shown, wounds of the stomach and intestines, unless very large, are not so liable to be attended with extravasation as was formerly thought. For, in the first place, the mucous membrane protrudes through the muscular, so as to fill up a small aperture ; and, secondly, any tendency to extravasation is counteracted by the constant equable pressure of all the abdominal viscera against each other. Moreover, lymph is soon effused, and glues the neighboring parts together, and thus the aperture is circumscribed, and any future extravasation is prevented. (c) Wounds of the liver, if extensive, are, from its great vascularity, nearly as fatal as those of the heart. Small wounds may be recovered from. There will at first be symptoms of great collapse, which, if the patient sur- vive, will be succeeded by severe sickness, pain in the liver, yellowness of the skin and urine, great itching, and a glairy, bilious discharge from the wound. (d) Wounds or rupture of the gall-bladder are almost invariably fatal, al- though there are one or two instances of recovery on record. (e) Wounds of the spleen, if deep, are also fatal, from the great hemor- rhage that follows, although the whole organ has been removed from animals, and from man, without much consequent evil. (/) Wounds of the kidneys are attended with bloody urine. They are exceedingly dangerous, first from hemorrhage, next from violent inflamma- tion with excessive vomiting ; and, lastly, from profuse suppuration, kept up by the passage of urine through the wound. Venesection, very mild laxatives, the warm bath, very light dressings, so as to admit of the flow of urine through the wound, and some unctuous application to prevent excoria- tion of the surrounding skin, are the necessary measures. (g) Wounds of the bladder, if communicating with the peritoneum, are extremely dangerous, owing to extravasation of urine. In fact, unless there is an external wound through which it can escape, they are almost uniformly mortal. The catheter must be worn constantly. Mr. Syme (in his "Con- tributions ") gives a case of rupture of the bladder below the line of reflec- tion of the peritoneum, in which the patient recovered, free incisions having been made to give exit to the urine which was extravasated between the abdominal muscles and skin. 3. If the intestines protrude, and are neither wounded nor gangrenous, they should be first freed from any foreign particles that stick to them, and then be returned as soon as possible. The patient should be placed on his back, with his shoulders raised, and his knees drawn up. If absolutely necessary, the wound must be a little dilated with a probe-pointed bistoury. Then the surgeon should return the bowel portion by portion, passing it back with his right forefinger and thumb, and keeping his left forefinger on that which is already replaced, to prevent it from protruding again. He should be careful to replace intestine before omentum, and the part that pro- truded last should be returned first. 4. If the stomach and intestines, when protruded, are found to be wounded, it is usually directed that the wound shall be sewn up. (See p. 153.) Then it is hoped that the aperture in the bowel will be united by the adhesion of contiguous surfaces ; and the silk employed in the suture will be detached by ulceration, and fall into its cavity. If, however, any part of the bowel that is protruded be very much lacerated, or be gangrenous, it should not be returned, but left hanging out, that an artificial anus may be formed. The symptoms of inflammation of the peritoneum or abdominal viscera, which is of. course exceedingly likely to follow these wounds and injuries, may readily be recognized. The patient lies on his back, with his knees ARTIFICIAL ANUS. 465 drawn up ; he breathes solely with the thorax, and not with the diaphragm or abdominal muscles; the countenance is anxious; the pulse small, wiry, and resisting, but becomes fuller after bleeding; there is severe throbbing pain, with great tenderness, more or less widely diffused ; a dry tongue, con- stant nausea, or vomiting, and obstinate constipation, complete the catalogue. If the case proceeds to a fatal termination, the belly swells, partly from serous effusion, partly from tympanites ; and the pulse becomes more frequent and weak, the patient retaining his senses to the last. The treatment comprises rest; opium or morphia, which may be given as enema ; fomentations ; leeches if necessary ; ice to allay sickness ; and cold beef-tea by spoonfuls. It is quite unnecessary to give purgatives in cases of inflammation of the bowels. It is true that the bowels will be obstinately costive ; but this cos- tiveness arises from their being inflamed, and unable to propel their contents onwards; and the proper remedies for it are such as will relieve the inflam- mation—that is, bleeding, leeches, fomentations, and calomel and opium. But if, in spite of common sense, the surgeon attempts to overcome the cos- tiveness by colocynth pills and black draughts, he will soon induce obstinate vomiting, that will render all his other remedies nugatory. If in any case of inflammation of the bowels it is probable that they are loaded with feces, the proper remedy is the repeated injection of warm water as an enema.1 VI. Artificial Anus signifies a preternatural communication between the intestine and skin. It may be a consequence of penetrating wounds, of abscess or ulceration of the intestines, or of mortification of intestine in strangulated hernia, and it is sometimes purposely made by the surgeon in case of imperforate anus, in order to afford an exit for the feces. The ex- ternal opening is irregular, everted, and red, and the surrounding skin excoriated. The aperture in the intestines adheres by its margin to the peritoneum, so that extravasation into the abdomen is prevented. That portion of intestines which is immediately above the aperture, and that portion which is immediately below it, meet at the artificial anus at a more or less acute angle, and present two orifices; one by which matters descend from the stomach, and another which leads down to the rectum. These two orifices, are separated by a sort of crescent-shaped septum, formed by a pro- jection of the mesenteric side of the bowel opposite to the aperture. Now it may readily be understood that the greater the aperture in the bowel, the more acute will be the angle at which the upper and lower portions meet, and the greater will the septum also be ; and that, if the septum is large, it will act as a valve, and close up the orifice of the lower portion of bowel, causing any matters that come down through the upper portion to escape externally, instead of passing into the lower.3 The consequences of this affection may be, 1st, that the patient may die of starvation, from the escape of the chyle, if the aperture is near the duo- denum. 2dly, that a portion of the intestine may protrude and form a hernia ; besides the constant disgusting annoyance occasioned by the escape of fecal matter and flatus. Treatment.—If the affection is of recent origin, and especially if it is consequent upon strangulated hernia, the patient should remain in bed, and great care should be taken to keep the parts clean ; and then, perhaps, the external aperture may contract and cicatrize. If the latter is very small, and if the passage between it and the bowel is of some length (a state of 1 See Travers on Wounds of the Intestines, Lond. 1812 ; Hennen's Military Surgery: the observations on the treatment of Enteritis in Ferguson on Puerperal Fever; Grif- fin's Medical Problems; Holland's Notes and Reflections ; and Dr. Watson's Lectures. 2 See the Chapter on Artificial Anus in Lawrence on Hernia, and Dupuytren in Diet. de Med. torn. iii. 30 466 ABDOMINAL SECTION. parts termed fecal fistula), something may perhaps be done by compression, or by engrafting a piece of skin over the aperture ; or by making an oval incision in the skin on each side of the aperture, and bringing the outer edges of the incision together by means of needles and the twisted suture; or by applying the actual cautery to the margin of the wound. But if the loss of substance in the bowel is considerable, and the project- ing septum large, the chance of recovery is not great. A pad of simple linen or lint may be worn to compress the aperture, and prevent discharge from it, or sometimes a hollow truss with a leathern or horn receptacle, may be used with advantage. Enemata are useful in all cases. Moreover, a tent may be thrust into both internal orifices, in order to enlarge the lower one, and repress the septum, as proposed by Desault. As a last resource, a small portion of the septum may be nipped and strangulated by the forceps invented by Dupuytren for that purpose. VII. Abdominal Section.—There is a class of cases of obstruction of the intestines, in which it is found, after death, that the mischief has been done by some one little band, and that if this could have been found and severed, the patient might have had at least a chance of recovery. Intestinal obstruction may, however, arise from many other causes; such as, 1st, ileus, or obstinate spasm; 2dly, impaction of accumulated feces, or, perhaps, of a large gall-stone; 3dly, solid growths within the intestine; 4thly, tumors pressing upon it from without; 5thly, stricture of the intes- tine ; 6thly, invagination, or the slipping of one portion into, and constric- tion by, another. This condition is rarely recognized in time, and is often mistaken for dysentery, and the writer believes that many children die of it, without the true cause being known. The child is ill, probably vomits; is evidently in pain in the bowels, and usually passes the contents of the bowels mixed with more or less blood ; afterwards blood alone. Most probably the parents send for medicine, and possibly get a powder containing some strong purgative, which makes the case worse or hopeless. The symptoms of strangulation continue; and if the patient survive long enough, there is a discharge of fetid bloody serum oozed out by the strangled bowel, and pos- sibly a portion of bowel may be passed down to, and protrude from, the anus. In some desperate cases, the strangled part has bodily sloughed off, and been Fig. 264. Invagination of the intestine, from nature, by Dr. Westmacott. A large coil of the small intestines, including the caput coli, has been engulfed within the ascending colon. The vermiform appendage is seen projecting out; and through an aperture, made artificially, the black and almost gangrenous intes- tine is seen strangled within. voided; the continuity of the canal has been established again, and the pa- tient has recovered. The best remedy is opium. Lastly, constriction by artificial anus. 46V bands of lymph ; or by rents in the mesentery through which the bowel has slipped ; besides internal hernia ; obturator hernia, for example. Moreover, from whatever cause arising, the symptoms are usually much the same—viz., obstinate constipation; a vomiting first of a yellowish or greenish liquid, then of a feculent or stercoraceous matter; and occasional fits of colicky pain—arising from the efforts of the intestine to overcome the obstacle, during which the coils of the distended guts can be seen through the abdo- minal parietes. To these essential symptoms, tenderness, and other signs of inflammation are added in greater or less degree. Now the practical question arises—suppose there were to be a case of evident mechanical obstruction of the bowels; that injections have been used as largely as they safely can ; and that purgatives have been given till they do but add to the distressing vomiting; that leeches and opium and hip-baths have been resorted to for the relief of tenderness; and that some space has been given, if the symptoms are not very urgent, to see what na- ture unaided can do, and that the case remains unimproved—shall the patient be left to die ? or shall surgical means be resorted to, to give him a chance ? The author would say, let the patient settle his affairs, worldly and spiritual, and let an operation be resorted to. The most favorable circumstances which such a case can present are, if the patient is not too much exhausted by a long continuance of pain and vomiting; if he can point to any one spot as the seat of uneasiness, and, probably, of stricture, and if an examination of the distended coils of intes- tine seems to confirm this suspicion ; and if he has been known to suffer on former occasions from an attack of inflammation in the abdomen, thus making it probable that the obstruction is caused by bands of lymph, rather than by either of the other causes; and if the present attack have come on suddenly. If the operation is determined on, the air of the apartment should be raised to about '70°; flannels dipped in warm water should be ready to pro- tect the bowels if they protrude ; chloroform should be administered, and the bladder emptied. Then an incision should be made through the linea alba below the umbilicus ; the peritoneum be carefully opened, and the finger at once passed to the probable seat of obstruction. If a band is found, the finger must be passed under it, and a probe-pointed bistoury used to sever it, the wound should be closed with abundance of sutures, and a compress and bandage be placed over it. In one of the cases in which the author has operated, the patient pointed beforehand with perfect accuracy to the spot where the obstruction was found. Should the operator either fail in finding an obstruction, or in relieving it, the desperate resource remains of opening the bowel, as low down as possi- ble, and stitching the opened part to the edge of the wound in the parietes so as to establish an artificial anus.1 VIII. Artificial Anus for the Relief of Obstruction.—When an obstruction of the bowels is situated in the rectum or colon, and the passage of fecal matter is entirely prevented, so that life is in imminent danger, it is the surgeon's duty to propose an operation for the patient's relief. The class of cases referred to, comprise, 1, cases of congenital deficiency of the rectum in new-born children, in which an attempt has been made un- 1 See a most able and comprehensive paper by B. Phillips, Med.-Chir. Trans, vol. xxxi., containina: copious bibliographical notices, and a catena of opinions ; an account of a case by R. Druitt, in the same vol. ; and of others by Dr. Golding Bird and Mr. Hilton in vol. xxx. ; by Fergusson, Lancet, 1850, vol. i. p. 128. Also a most practical paper on complications of hernia, and obstruction of the bowels, with numerous engrav- ings and cases, by R. R. Robinson of Camberwell, from whom the author is glad to ac- knowledge that he has received much valuable information. Lond. Journ. of Med. 1S51. 468 artificial anus. successfully to open the bowel from the perineum ; 2, cases of impassable stricture of the rectum, or of some part of the colon; 3, of obstruction by cancerous and other growths within, or tumors without; or, in fact, by any other conceivable cause. Before resorting to such an operation, the surgeon must first explore the rectum thoroughly by finger and bougie, inject water by the long tube, and take every other method of establishing an accurate diagnosis, since, of course, to make an opening below the point of stricture would be useless. Then there are two places in which the operation may be performed :— (1.) The sigmoid flexure of the colon may be opened by an incision in the left iliac region. This operation was proposed by Littre in 1720. In- stead of opening the sigmoid Fig. 265. flexure on the left, the caecum on the right side may, if deemed expedient, be opened by an oblique incision, near the anterior superior spine of the ilium. (2.) The colon may be opened in the lumbar region by a vertical incision along the outer edge of the quadra- tus lumborum, just above the crest of the ilium, as was pro- posed by Callisen in 1817, or by the horizontal section pro- posed by Amussat in 1832. This is generally called Amus- sat's operation. An incision through skin and fat may be made horizontally above, and parallel to, the crest of the ilium, commencing near the spine, and carried outwards for from two to five or six inches, according to the age [Formation of an artificial anus in the lumbar region.] and DUlK Ot the patient, lad- ing the interval between the external oblique and latissimus dorsi muscles as a guide—perhaps meeting the musculo-cutaneous lumbar nerves—the surgeon carries his incision through muscles and fascia, so as to come on the bowel at its posterior part, where not covered by peritoneum. When the loose renal fat which is usually found here has been divided (or portions of it removed), so as fairly to bring the bowel into view, two ligatures must be passed through it, above and below, so as to steady it when opened, and to attach the edges of the open- ing in the bowel to that in the skin when the operation is completed. This must be done likewise when the sigmoid flexure is opened in front; and par- ticular care should be taken to secure the edges of the wound into the bowel, so that no effusion can take place into the peritoneum. The right or left lumbar region must of course be selected, according to the situation of the stricture. If the patient recovers, he should be provided with a smooth ivory plug, attached to a metallic or India-rubber plate, and secured by a truss or bandage, for the double purpose of preventing the escape of feces at incon- venient times, and of preventing the aperture from contracting, and so re- fusing a free vent to their discharge. hernia. 469 The ultimate fate of the patient will depend in great measure on the nature of the disease which required the operation, and on the effects which this may have already caused. Out of forty-eight cases collected by Mr. Haw- kins, there is scarcely one in which death can fairly be said to have been caused by the operation itself.1 IX. Gastrotomy for the relief of Starvation.—In a case of cancer of the oesophagus, in which life was at the point of extinction by starvation from utter impossibility of swallowing ; in which the trachea even had been opened for the relief of the breathing, and in which the rectum, as it always will in time, ejected the materials introduced as nutritious enemata, Dr. Habershon caused an aperture to be made into the stomach, through the left linea semilunaris, which was skilfully effected by Mr. Cooper Forster. Eggs, milk, and other articles of nourishment were introduced, and the man lived till the third day after the operation, with his sense of starvation re- lieved, and then expired in comparative comfort.3 [This operation has now been performed five times, and always with an unfavorable result.] X. In a case of acute inflammatory disease of the Appendix Cmci arising apparently from the impaction of a small mass of feculent matter, Mr. Han- cock made an incision close above Poupart's ligament into the abdominal cavity, and gave issue to some offensive serum, to the great relief of the patient, who was moribund, but recovered. He proposes a similar opera- tion for the purpose of letting acrid effusions drain away, in cases of un- healthy peritonitis, and the hint is a valuable one.3 CHAPTER XVIII. HERNIA. SECTION I.—NATURE AND CAUSES OF HERNIA GENERALLY. Definition.—Hernia signifies a protrusion of any viscus from its natural cavity. But the word, used by itself, is restricted to signify protrusion of the abdominal viscera. Causes.—The formation of hernia may be readily understood by consider- ing that the abdominal viscera are subject to frequent and violent pressure from the diaphragm and other muscles by which they are surrounded, a pressure which tends to force them outwardly against the parietes of the abdomen. If any point of the parietes be not strong enough to resist this pressure, some por- tion of the viscera may be forced through it, and form a hernial tumor externally. The predisposing cause of hernia, therefore, is a weakness of the parietes of the abdomen, which may be produced by various circumstances. Thus, 1. Some parts of the parietes are naturally weaker than others, especially the inguinal and crural rings, and the umbilicus; and it is at these parts that hernia most frequently occurs. 2. The abdominal parietes may be weak 1 Almost all that is known of these operations is summed up in a paper by Mr. Caesar Hawkins, Med.-Chir. Trans, vol. xxxv., which contains copious references to the original memoirs of Amussat, Pring, Maitland, Teale of Leeds, Evans of Derby, Clement of Shrewsbury, Baker of Birmingham, and other English and Continental operators. Notes of a good case in which it was performed by Mr. Hutchinson, for obstruction by cancerous tumor following ovariotomy, Med. Times, 1859, vol. i. p. 11. 2 Quoted in Ranking, vol. xxviii., from Guy's Hosp. Rep. vol. iv. 3d Series [or Amer. Journ. Med. Sci., April, 1859, p. 518]. 3 A short account of disease of the Appendix Caeci, cured by operation ; by Henry Hancock. Lond. 1S43. 4T0 REDUCIBLE HERNIA. from malformation, or congenital deficiency. 3. They may be weakened by injury or disease, such as abscesses, wounds, and bruises, or by distension by the pregnant uterus, or by dropsy. The exciting cause is compression of the viscera by the action of the muscles that surround them, and especially of the diaphragm. Hence hernia is so frequent a result of violent bodily exertion—lifting heavy weights and the like—especially if the patient have been previously weakened by illness. Moreover, it is not uncommon in persons afflicted with stone or stricture, from the immoderate straining that they employ in passing their urine. The viscera most liable to hernial protrusion are the small intestines, omentum, and arch of the colon. But every one of them has occasionally been found protruded, partially or entirely—especially in cases of congenital deficiency of the abdominal parietes. The Sac of a hernia is a portion of the parietal or reflected layer of peritoneum which the protruding viscera push before them in their escape, and which forms a pouch containing them. It very soon contracts adhesion to the surrounding cellular tissue, and consequently does not return into the abdomen when the viscera are replaced, although it must be observed, that a hernia may be pushed back en masse, sac and all, when great force is used in reducing a strangulated hernia. As the hernia increases in size, the sac also increases ; partly by growth, partly by distension, and slight laceration or unravelling; partly by fresh protrusion of peritoneum. Sometimes it diminishes in thickness whilst increasing in capacity ; sometimes, on the contrary, it becomes thick, indurated, and divisible into layers. Its neck (the narrow part which communicates with the abdomen) always becomes thickened, rigid, and more or less puckered, in consequence of the pressure of the muscular or ligamentous fibres which surround it. Sometimes the sac has two constricted portions, or necks—either because (as in oblique inguinal hernia) it passes through two tendinous apertures—(the external and internal abdominal rings)—or because the original neck has been pushed down by a fresh protrusion. Some hernias, however, are destitute of a sac, or at least of a complete one. This may happen,—1. If the protruded viscus is not naturally covered by peritoneum; as the caecum. 2. If the hernia occur in consequence of a penetrating wound. 3. In some cases of conge- nital umbilical hernia. 4. Hernia may be considered virtually without a sac, if the sac has been burst by a blow, or if it has become entirely adhe- rent to its contents. Instances, again, are known in which two peritoneal sacs have protruded through one and the same aperture in the abdominal parietes; and in which one sac has come down within a previously-existing one. Division.—Hernia is divided into several species : 1st, according to its situation—as the inguinal, femoral, and so forth ; 2dly, according to the condition of the protruded viscera; which may be (a) reducible, or return- able into the abdomen ; (b) irreducible, that is, not returnable into the ab- domen ; or (c) strangulated, that is, subject to some constriction, which not only prevents their return into the abdomen, but also interferes with the pas- sage of their contents, and with their circulation. SECTION II.—REDUCIBLE HERNIA. Symptoms.—A soft compressible swelling appears at some part of the abdominal parietes. It increases in size when the patient stands up; if grasped, it is found to dilate when he coughs or makes any exertion; and it diminishes or disappears when he lies down, or when properly-directed pres- sure is made upon it. If the sac contains intestine (enterocele), the tumor is smooth, rounded, and elastic ; borborygmi (or flatulent croakiugs) are oc- REDUCIBLE HERNIA. 471 casionally heard in it, and when pressed upon, the bowel returns into the abdomen with a sudden jerk and gurgling noise. [It is moreover resonant on percussion.] If, however, it contains omentum (epiplocele), the tumor is flattened, inelastic, flabby, and unequal to the touch, and when pressed, it returns without noise, and very slowly, the pressure requiring to be continued till it has nearly disappeared. But very often one hernial sac contains both intestine and omentum (entero-epiplocele);1 and very frequently it is per- fectly impossible to ascertain which it contains by any external examination. Treatment.—This may be palliative or radical. The usual plan is, to em- ploy a truss, an instrument consisting of a pad placed on the seat of pro- trusion, aud of a steel spring which passes round the body, and causes the pad to press with the requisite degree of force. In writing for a truss it is usual to give the circumference of the body at the hips, midway between the spine of the ilium and the trochanter. The patient must expect to find the truss rather irksome for the first week. It should be constantly worn by day; and if the patient will submit to wear it at night, also, so much the better If he will not do this, he should, at all events, apply it in the morn- ing, before he rises from the recumbent posture. The skin of the part which it presses upon should be regularly washed, and bathed with Eau de Cologne or spirit, else large boils are apt to form on it. There are some cases in which the common truss fails to keep up a rup- ture comfortably, and for these the surgeon should be prepared to recom- mend other instruments, which are, for the most part, the property of various individuals, and each of which has some peculiarity adapting it to particular Cases. Cole's truss has a spiral spring acting on the pad. The MocMain lever truss has a simple belt passing round the body, thus dispensing with the usual circular spring ; and the pressure on the pad is effected by means of a strap passing under the thigh, and acting on a spring lever attached to the pad. Salmon and Ody's self-adjusting truss has a pad revolving on a ball and socket. The Maidstone truss allows the pad to slide on the spring, so that the circumference of the instrument may be adapted to the varying size or movements of the body. Egg's truss is said to be made of old sword-blades : it is very strong, though not irksome, and requires no fasten- ing. Adams's graduated pressure truss has two springs of different curves, by sliding which on one another the amount of pressure may be varied. In Tod's truss the spring goes round the waist,, and curves downwards to com- press a pad at the internal abdominal ring. Newson's wire truss has a round wire, instead of a flat steel spring," which renders it less likely to be displaced. Trusses may have French pads, which are of an oblong-triangular shape, instead of oval, like the English ; or pads filled with air ; or with sand, which will retain any shape given to it; or may have springs going entirely round the body. Instead of a steel spring an elastic India-rubber belt may be used, such as are constructed by Bourjeaud. Dr. Arnott has devised a truss, in which, by means of a wire, external to the steel spring, and capable of being tightened or slackened by a nut and screw, the amount of pressure can be regulated with the greatest possible nicety. Dr. Charles Edwards has invented one, in which the pad is capable both of revolving and of slid- ing on the spring. For children the India-rubber band and pad generally answer without a spring. A pad of hard polished wood is recommended by Mr. Dartnell. He also uses flannel instead of leather as a covering for the spring, as it can be washed.9 1 From xriXn, tumor; hrtpov, intestinum; and ImirXon, omentum. The word x^Xn is fre- quently used in the older surgical terminology ; ex. gr., hydrocele, a tumor containing water; hematocele, a tumor containing blood ; bubonocele, a hernial tumor in the groin. 2 It is made by Spratt, of Brook-street, Hanover-square. Dr. Charles Edwards's (of Cheltenham) is made by Weiss. Dartnell, Lancet, 1841, vol. ii. 472 IRREDUCIBLE HERNIA. Radical cure.—If the patient is below the age of puberty, or not much above it, and if the hernia has not existed very long, the truss, if constantly worn, may effect a permanent cure. The herniary aperture, no longer sub- ject to distension, then becomes firmly closed, and the neck of the sac ob- literated. This cure may perhaps occur in two or three years ; but, as a measure of precaution, the truss should be worn for two or three years more. This is constantly the case with the umbilical and other hernias of infants. But the hernias of adults have commonly till of late in this country been considered as admitting of palliative treatment by truss only; and the patient has been doomed to wear the instrument for the rest of his days. Modern surgery promises, however, that some means of radical cure shall be placed at our disposal, which we shall describe more conveniently under the head of reducible inguinal hernia. SECTION III.—IRREDUCIBLE HERNIA. Definition.—Hernia is said to be irreducible, simply, when the protruded viscera cannot be returned into the abdomen ; although there is no impedi- ment to the passage of their contents, or to their circulation. Causes.—Hernia may be rendered irreducible, 1, by an adhesion of the sac to its contents, or of the latter to each other, or by membranous bands formed across the sac. 2 By enlargement of the omentum or mesentery— whether from simple deposition of fat, or from sarcomatous or other organic change. 3. Omental hernia may be rendered irreducible by a contraction of that portion which lies in the neck of the sac, so that it is not stiff enough to stand against the pressure intended to push it back into the abdomen, but doubles up under it. Consequences.—Irreducible hernia may produce sundry inconveniences. In the first place, the patient is often liable to dragging pains in the abdo- men, or perhaps attacks of vomiting, which come on after food, or when he assumes the erect posture, because the protruded omentum or intestines being fixed, resist all distension or upward movement of the stomach. These inconveniences will be greatly aggravated, if the patient increase in corpu- lency, or become pregnant. Moreover, the protruded bowels being de- prived of the support naturally afforded them by the abdominal muscles, their feculent contents are apt to lodge in them, and frequently cause colic or constipation. Lastly, the bowel is greatly exposed to external injury, and in constant hazard'of strangulation. Treatment.—This may be either palliative or radical. I. The palliative treatment consists in applying a hollow bag truss, or else a truss with a hollow pad that shall firmly embrace the hernia, and prevent any additional protrusion. The patient should avoid all violent exertion or excess in diet, and should never let his bowels be confined. 2. Radical cure.—It has occasionally happened, after confinement to bed for several weeks with fever or some other emaciating ailment, that a hernia, irreducible before, has been replaced with ease, owing to an absorp- tion of the fat of the omentum or mesentery and relaxation of the abdo- minal apertures. The same result has also in some cases been effected by art—by keeping the patient in the recumbent posture and on very low diet for six weeks or two months, and by the frequent use of glysters and laxa- tives, and at the same time by keeping up a constant equable pressure on the tumor by means of a bag truss made to lace over it. This plan is very uncertain as to its results, and will be effectually defeated if there are any adhesions; and, besides, there are not many patients who will submit to it. It will be more likely to succeed if the hernia is omental, than if it contains intestines. But several instances are known, in which, after the contents of STRANGULATED HERNIA. 473 old hernias had been replaced, they produced so much irritation in the abdo- men, that the patients were glad to compound for their life by keeping the hernia. Any surgical operation with the view of opening the sac, dividing adhesions, and returning the parts into the abdomen, is scarcely justifiable, as it would be exposing life to too great a hazard.1 SECTION IV.—STRANGULATED HERNIA. Definition.—Hernia is said to be strangulated, when it is constricted in such a way, that the contents of the protruded bowel cannot be propelled onwards, and the return of its venous blood is impeded. The causes of strangulation may be, 1. A sudden protrusion of bowel or omentum through a narrow aperture, in consequence of violent exertion;— a thing not unlikely to happen if a truss has been worn for some time, and then is carelessly left off. 2. Distension of the protruded intestines by flatus or feces, or tumefaction and congestion of the omentum or mesentery. 3. Swelling of the neck of the sac may be a cause; and spasm was formerly considered so. The seat of stricture is either the thickened portion of peritoneum which forms the neck of the sac, or tendinous bands external to it. In some cases the bowel has been constricted by membranous bands, or by fissures in the omentum within the sac itself. But it must be recollected that the mem- branous aperture, through which the displaced bowel passes, does not exert any active force upon it;—on the contrary, it is the ruptured part which has been squeezed into a narrow aperture, and is pressing outwardly against that aperture. Yet the effect is the same in either case. The symptoms of strangulated hernia are, first, those of obstruction of the bowels; secondly, those of inflammation. The patient first complains of flatulence, colicky pains, a sense of tightness across the belly, desire to go to stool, and inability to evacuate. It is true that stools may be passed if there be any fecal matter in the bowel below the hernia, or if the hernia be entirely omental, but with very transient relief. To these symptoms suc- ceed vomiting of the contents of the stomach, then of mucus and bile, and, lastly, of matters which have acquired a stercoraceous appearance by being delayed in the small intestines. On examination the surgeon finds a rup- ture, which he cannot put back, and which is uneasy, tense, and incompressi- ble. The communication between the abdomen and the misplaced bowel is almost, or, if the stricture be tight, is quite interrupted ; and therefore the impulse felt on coughing is either diminished or altogether lost. More- over, as Mr. Luke2 very clearly pointed out, if the hernial tumor is examined with both hands, and if one hand is employed in grasping the body of the tumor, and two fingers of the other in feeling near the neck of the tumor for the impulse created by each act of compression, it will be found that the sensation of impulse will cease to be felt at the part where the stricture exists; and will not be felt all along the neck of the hernia, as it would if no stricture existed. If this state of things continue, the inflammatory stage comes on. The neck of the sac becomes tender, and tenderness diffuses itself over the tumor and over the abdomen, both of which become very painful and much more swelled. The countenance is anxious ; the vomit- ing constant; the patient restless and despondent; and the pulse small, hard, and wiry. After a variable time, the constricted parts begin to mortify. 1 See B. Cooper, quoted in Ranking, vol. xvi. A case in which Velpeau practised subcutaneous incisions for the relief of an irreducible hernia is related in Bull. Gen. de Therap. 15th and 30th Aug. 1840. 2 Quoted in Mr. Ward's very able Memoir on Strangulated Hernia, Lond. 1854. See also Med. Times, Dec. 1854. 4 74 STRANGULATED HERNIA. The skin becomes cold, the pulse very rapid and tremulous, and the tumor dusky red and emphysematous; but the pain ceases, and the patient having perhaps expressed himself altogether relieved, soon afterwards dies. Varieties.—There is often considerable diversity in the rapidity and vio- lence of these symptoms. If the patient is a strong adult, and the strangu- lation has commenced suddenly with a fresh protrusion during some forcible exertion, the inflammatory stage may come on instantly, and be followed by death in a very few hours. On the other hand, if the patient is old, if the hernia has been long irreducible, and has a large neck, and if the strangula- tion is produced by distension of the protruded bowel with flatus or feces— the symptoms of mere obstruction may last many days before those of in- flammation come on. To this latter class of cases the term incarcerated is applicable.1 Again, if the hernia be omental, the symptoms will probably be less acute than if it be intestinal; but not much less. Even if a portion of the calibre of the bowel is constricted, and not the whole—so that a pas- sage may be left—the symptoms will be the same. Morbid Appearances.—After death from strangulated hernia, the bowels are found reddened, the upper portion of them much distended, and there are effusions of turbid serum and lymph. Around the sac the tissues are cedema- tous or emphysematous. The strangulated intestine is dark, claret-colored, and turgid with blood, roughened in patches by a coating of lymph ;—or displaying patches of gangrene, in the form of greenish or ash-colored spots, which break down under the finger. The mucous and muscular coats, where they have been subjected to the pressure of the stricture, are liable to be ulcerated. The omentum is dark red ; if gangrenous, it feels crispy and emphysematous, and the blood in its veins is coagulated. The sac also con- tains bloody serum. Treatment.—The indications are, to return the intestine, or such portion of it as may be reducible ; and for this purpose to divide any constricting part, if necessary. The Taxis.—This is a Greek word, absurdly and pedantically used to signify the acts of gentle pressure with the hands, by which hernias are re- duced. The bladder having been emptied, the patient should lie down in an attitude of complete repose, and be put under the influence of chloroform; if this be not used, he may be made to lie in a warm bath, with his shoulders raised ; and both his thighs should be bent towards the belly, and be placed close to each other, so that every muscle and ligament connected with the abdomen may be relaxed. If not narcotized, he should be engaged in con- versation, to prevent him from straining with his respiratory muscles. In order effectually to remove the expulsive force of the diaphragm, Dr. Bu- chanan, of Glasgow, directs the patient to make a deep expiration, and to abstain from drawing in the breath as long as possible.2 Then the surgeon, if the tumor be large, grasps it with the palms of both hands, gently com- presses it, so as to squeeze out a little flatus and venous blood, and occa- sionally with his fingers gently moves the parts at the neck of the tumor, or perhaps tries to pull them very gently downwards, in order if possible to dislodge them.3 This operation may be continued for a quarter or half an hour, or longer, if the tumor is indolent, but not so long if it is tender ; and 1 There is great confusion in the use of these terms, as some surgeons employ the term incarcerated to signify what is generally known as irreducible hernia. 2 Quoted from Glasgow Medical Journal, July, 1856, in Ranking, vol. xxiv. 3 Mr. T. Hunt, late of Heme Bay, now of Alfred Place, in a communication with which he has favored the author, condemns all kneading and pushing, and says that he believes that gentle, long-continued, and equable pressure will reduce every hernia, provided time and gentleness are allowed for the operation. Mr. Hunt's opinion is grounded upon numerous cases during a practice of thirty years. STRANGULATED HERNIA. 47 5 at last, perhaps, the surgeon will be delighted to hear a gurgling sound ac- companying the return of a portion of intestine. The operator should recol- lect that too much force may bruise or rupture the viscera, or drive sac and all into the abdomen, or push them between the layers of abdominal muscles, and that he must not be satisfied with a partial reduction of the volume and tension of the tumor, if the vomiting remains unrelieved; because, as Mr. Mayo has shown, such a diminution might be caused by merely forcing the serum contained in the sac into the abdominal cavity. If the taxis do not succeed, certain auxiliary measures are commonly re- sorted to. (a) The first to be mentioned is chloroform, inhaled till it produces com- plete relaxation and unconsciousness. (b) Bleeding to the approach of syncope may be tried if the patient is robust, the hernia small and of recent date, and if there is much tenderness of the sac or of the abdomen, in which latter case it may be employed before trying the taxis. (c) The hot bath (96°—100° F.) continued long enough to produce great relaxation is useful in similar cases ; but it must be recollected that a deli- cate person will not be very likely to bear the shock of an operation, if bled or boiled to death's door first of all. (d) A large dose of opium, or morphia, is a remedy most useful in cases of acute strangulation, if for any reason chloroform be not given ; and espe- cially if the pain and vomiting are violent. (e) The tobacco enema (3j and Oj aq. ferv. allowed to stand ten minutes, and half to be used at a time) has certainly been successful in many cases, especially of inguinal hernia; but it is a most dangerous remedy. It has proved immediately fatal to some patients, and has rendered others incapable of surviving the shock of the operation. (/) Cold applied to the tumor by means of pounded ice or a freezing mixture (F. 114) in a bladder, is a remedy commonly enumerated ; and is said to be most applicable to large scrotal hernias when the symptoms are not very urgent. But it is not without its hazards ; for it may cause gan- grene of the skin if applied too long, or if hot applications are incautiously used after it; and above all, it may be the excuse for injurious delay. Cer- tainly it should not be used if painful. (g) Purgatives and enemata are irritating and mischievous in sudden acute strangulation, but vastly beneficial if the patient is aged, the hernia large and long irreducible, and if the attack has been preceded and caused by constipation. Large doses of calomel and colocynth are the best purga- tives, and the enemata should consist of as much gruel or water as can be injected without causing very much pain or distension. Moreover, Dr. O'Beirne has fully shown that greater benefit is to be derived in cases of incarcerated hernia and obstinate constipation from passing up a long tube (the tube of a stomach-pump answers very well) into the colon, than from the use of the ordinary short enema-pipe. The long tube relieves the bowels of their flatus ; and of course by diminishing the bulk of the contents of the abdomen, renders the return of the hernia more easy.1 Operation not to be delayed.—In old standing cases, occurring to aged people with large hernias, the surgeon may be justified in waiting some time to try the effect of his remedies ; but in acute cases occurring to young people, we would earnestly inculcate the rule that if the taxis, aided by chloroform or opium, do not very speedily succeed, it is the safest plan to perform an operation for dividing the stricture without further delay. It is 1 Vide Lancet, July 6 and 27,1839 ; also James's Retrospective Address, in Prov. Med. Trans. 1840 ; and O'Beirne on Defecation. 476 STRANGULATED HERNIA. very well remarked by James, of Exeter,1 that time is of the most extreme value in the treatment of strangulated hernia. The earlier the taxis is tried, the more likely it is to succeed ; before the bowel has been long and strongly nipped, and thickened hy congestion. The same may be said of an operation. The operation that may be performed may be either the old one of open- ing the sac, dividing the stricture, and returning the intestine ; or secondly, the plan of division of the stricture, without opening the sac ; or thirdly, Mr. Gay's operation for limiting the incisions to the neck of the sac. The manner of operating for each variety of hernia will be found in the follow- ing sections. Here we make a few observations applicable to the subject generally. 1. Supposing the sac to be opened, the intestine should be well examined, and especially that part of it which has been actually compressed by the stricture, and which should be gently drawn down for that purpose. If it be merely dark claret-colored from congestion, or slightly roughened with lymph, or if it exhibit a few black patches of ecchymosis, it should be re- turned—the operator being careful to replace it bit by bit-—intestine before omentum—and those parts first which protruded last. The wound may then be closed with sutures, and a firm compress be placed upon it. 2. If the hernia were irreducible long before it was strangulated, and if its contents are united to the sac by firm and broad adhesions, they should not be disturbed. But if the adhesions are recent, or very thin and slight, they may be divided and the bowel be returned. 3. If the intestine is mortified, which will be known by the softened green or ashy spots, the mortified parts should be slit open, the stricture be divided, and the patient left to recover with an artificial anus. Again, if a large portion of intestine, which has been long irreducible in an elderly person, appear extremely dark and advanced towards sphacelus, so as to render it doubtful whether it would be capable of performing its functions when re- turned, it has been advised to make an opening into it, and so afford an outlet for its contents through an artificial anus; but such a proceeding must not be rashly resorted to. 4. If the omentum is gangrenous, or if it is thickened and indurated, it would, if returned, excite dangerous irritation of the peritoneum. In this case some surgeons advise it to be left to granulate in the sac, or to cut it off close to the neck of the sac, and leave it there as a plug to prevent further pro- trusion. Macfarlane and others, on the contrary, recommend it to be cut cleanly off, and all the vessels to be tied with fine silk ligatures, and the end to be then passed quite into the abdomen, breaking up any adhesions about the neck of the sac, if necessary; thus avoiding the dragging pains and colic which are liable to occur if a portion of the omentum or intestine is fixed. 5. But it may happen that there may be a portion of intestine concealed within the omentum, and completely enveloped in a kind of sac formed by it. This is especially liable to be the case in the umbilical hernia. Therefore, to use the words of Mr. Prescott Hewett, "when the hernial sac appears to contain thickened omentum only, the omentum ought to be drawn out and carefully examined, to see that it does not form a sac containing a portion of intestine."2 If it is thickened and firmly united to the neck of the hernial sac, throughout its whole circumference, an incision should be carefully made through it; bearing in mind that it is often extremely thick, and that the intestine may be firmly adherent to its inner surface. In fact, as Mr. Hewett says, the surgeon ought carefully to " examine every portion of omentum which is in a hernial sac, so as to ascertain that no knuckle of intestine is 1 On the operations for Strangulated Hernia. Lond. 1859. 2 Med.-Chir. Trans, vol. xxvii. STRANGULATED HERNIA. 477 contained within its folds, before it is returned into the abdomen, left in the sac, or removed altogether." Division of the Stricture external to the Sac.—Petit, Aston Key, Luke, and other eminent surgeons have recommended that the stricture should be released without opening the sac itself. The argument in favor of this pro- ceeding is, that less injury is inflicted ; that there is no rough handling and exposure of the intestine ; and that the case is brought nearer, as regards safety, on a level with one in which no operation has been performed. The argument is confirmed by experience ; and this mode of operating should always be adopted, unless there is some reason to the contrary. It is espe- cially advisable, when the hernia is of very great size, and has been long irreducible, so that the idea of returning its contents could not be enter- tained ; and when the hernia is small and of quite recent date. In a similar case, M. Guerin has divided the stricture by means of a subcutaneous in- cision.1 Mr. Gay's modification of this operation consists in making a small incis- ion, near the neck of the sac, and carrying the tip of the forefinger to feel for the seat of stricture, and dividing it by a bistouri cache. We shall allude to this operation again when speaking of femoral hernia, to which it is chiefly applicable ; and may remark that the advantages claimed for it are, that it meddles only with healthy parts, is slight, comparatively safe, and easily performed, and that there is no long convalescence. Seutin's Plan.—Baron Seutin has described a method of dilating the stricture, which he has employed so successfully that he rarely has had occa- sion to use the knife for strangulated hernia. It consists in insinuating the tip of the forefinger into the constricting orifice, and dilating it forcibly. There is a germ of good sense and reason in this which makes it well worthy of trial.3 Hernia reduced en masse.—When the taxis is used forcibly for the reduc- tion of a strangulated hernia, the tumor, sac and all, may be forced back through the herniary aperture, and lie between the abdominal muscles and the peritoneum; or between the muscles and the fascia transversalis. Or, according to Mr. Birkett, the neck of the sac may be burst, " so that the in- testine escapes into the loose connective tissue between the peritoneum and internal abdominal fascia." In such a case, the symptoms of strangulation continue, and although the tumor disappears outwardly, yet there will be symptoms of fulness and tenderness above Poupart's ligament, in the situa- tion of the internal ring. The first thing to be done is to make the patient stand up and cough, in order if possible to bring the hernia down again, when it should be operated on without delay ; but if this does not succeed, a cautious incision should be made through the abdominal parietes, over the suspected seat of the disease ; the tendon of the external oblique should be divided, so as to lay open the internal abdominal ring ; and the sac if found should be drawn down, the stricture divided, and the case be then treated according to the ordinary rules.3 1 Vide Fergusson's Practical Surgery, p. 526. Guerin, Gaz. Med. de Paris, 7th Aug. 1841; Mr. Key's Memoir, on dividing the stricture external to the sac ; Luke, Med.- Chir. Trans, vol. xxxi. 2 The surgeon seeks with his forefinger for the aperture that has given issue to the hernia, pushing up the skin sufficiently from below; then with the pulp of the finger towards the bowel or omentum, he insinuates it between the viscus and the aperture. This proceeding demands perseverance. When introduced, the finger is to be hooked, and made to stretch the ring till a sensible dilatation or tearing is produced. The plan appears to have been most successful in femoral hernia ; and when stricture was seated at the external abdominal ring. Quoted in Ranking, vol. xxiv. p. 164. 3 Luke, Med.-Chir. Trans., and Med. Gaz., 5th May, 1843 ; Report of discussion on a paper by Mr. Birkett, at Med.-Chir. Soc, Med. Times, June 25, 1859. [See Mr. Birkett's paper in the xiii. vol. of Med.-Chir. Trans., or Amer. Journ. Med. Sci., April, I860.] 478 REMARKS ON HERNIA. After-treatment—After the hernia has been returned, a compress—a towel, for instance—should be put on the site of the tumor, and be retained with a bandage, so as to prevent any protrusion from coughing, sneezing, or any other accidental exertion, and the patient should have a full opiate. The surgeon should not be in haste to get the bowels to act, and should abstain from giving salts and other purgatives; for as the intestine that was constricted remains for some time inflamed, weakened, and incapable of pro- pelling its contents, they would but irritate it uselessly. Castor-oil and laudanum may be resorted to after twelve or twenty-four hours. Tender- ness, pain, and other inflammatory symptoms may be allayed by leeching, fomentations, and by calomel and opium. Free exit should be afforded to pus. A truss should be applied before the patient gets up again. SECTION V.—REMARKS UPON THE DIAGNOSIS AND COMPLICATIONS OF HERNIA. We may remark that hernia is a malady extremely common in every rank of life, and one for which the practitioner should never fail to make inquiry, in cases of disturbance of the abdominal viscera. 1. The patient may not be aware that he has a hernia, or if aware of it, may think it of no consequence, or may be deterred by mauvaise honte from mentioning it. For example, an elderly clergyman of eminence consulted the writer a few years since, respecting various dyspeptic symptoms ; nausea, loss of appetite, and painful sensation of dragging at the stomach, and irregularity of the bowels. When asked if he was ruptured, he said, that he had never thought it worth mentioning, but that whilst preaching, some time ago, he had felt something come down into the scrotum. He had in reality a large double scrotal rupture, which was the cause of his dyspepsia. But it is more particularly when a patient is affected with vomiting and constipation, especially if the face is pinched and anxious, that the surgeon should inquire for, or rather should examine for himself, the ordinary seats of hernia, such as the inguinal and femoral rings and the umbilicus, and the extraordinary, such as the linea alba, and the thyroid and ischiatic foramina. It would be a terrible thing to be treating a patient for enteritis, and let him die of strangulated intestine. 2. The patient may have a tumor, at one of the common seats of hernia, ichich yet is no hernia. The commonest example of this is an enlarged gland at the bend of the thigh. Yet if, with such a tumor, a patient should have symptoms of strangulation, the surgeon should not hesitate to cut down upon it. There often has been found a small hernia behind such a tumor; and in any such case the rule is, if in doubt, operate. 3. The patient may have a hernia, reducible, or irreducible, which yet is not the cause of the symptoms. There are numberless causes of internal strangulation, which may exist along with a hernia. First, the bowel may be strangulated within itself; a condition known as intussusception, and described at page 466. Secondly, it may be strangulated by an awkward twist on its own axis. TJiirdly, it may be tied down by some accidental band, the result of previous inflammation; a thing that should always be inquired for. In women, bands of adhesion not seldom exist between one ovary and some adjoining part: and this should be borne in mind. Fourthly, the bowels may be simply matted together by recent adhesions, the result of subacute inflammation. Fifthly, they may be thrust through an aperture in the diaphragm. (See Diaphragmatic hernia.) So that in any case, if the condition of a hernia does not account for the symptoms of strangu- lation, the possibility of some other cause should be looked for. The following cases may be examples. The author was sent for to see a stout elderly man, whom he found in bed, with vomiting, and intense pain of eight INGUINAL HERNIA. 479 hours' duration. On inquiry, it was discovered that he had an umbilical hernia; but this was reduced and not tender, although there was great tenderness and fulness in the vicinity. The bowels had been open the day before. Two grains of opium were administered. At the next visit, the writer was shown a large quantity of bloody serous fluid which had passed from the bowels. Another dose of opium was given, and the patient kept under its influence. Late at night some bilious matter passed, and the patient gradually recovered. These were symptoms of intussusception. While the author is correcting these pages, he is sent for to see a patient aet. 57, ill for a week, with pain in the bowels and vomiting. The man's countenance exhibits severe suffering; he is constantly vomiting a white frothy liquid, and says he has burning pain in his stomach. Has had double- scrotal rupture from infancy. On examination both ruptures were thoroughly reduced ; and the forefinger, pushing the flabby scrotum before it, could be passed up through tendinous apertures an inch in diameter, into the abdo- men. Everything was soft in the neighborhood. But in the left iliac fossa was a large swelling, somewhat nodulated. There was great tenderness in the right hypochondrium. Repeated enemata brought away enormous quantities of small pale brown lumps, and the swelling in the sigmoid flexure disappeared; but it took two days to bring down dark-green bile from above. If a patient with irreducible hernia be attacked by colic, or enteritis, or peritonitis, the case will present many of the features of strangulation. Yet it may perhaps be distinguished by noticing that the pain and tenderness did not begin at the neck of the sac, and are not more intense there than elsewhere. The diagnosis will be very obscure if the inflammation com- mences on the omentum or intestine in the sac. But the general rule is, when in doubt, operate. 4. " Strangulation may occur in a person the subject of double hernia, and a doubt may arise as to which is the hernia requiring operation. In such a case, the hernia that has existed the longest, and is the most tense, should be the one first subjected to the knife."1 5. Reduction en masse.—Lastly, the possibility of this accident should be remembered. (See page 477.) SECTION VI.—INGUINAL HERNIA. Definition.—Inguinal hernia is that which protrudes through one or both abdominal rings. Varieties.—There are four varieties. The oblique, direct, congenital, and encysted. 1. The oblique inguinal hernia is the most common. It takes precisely the same route as the testicle takes in its passage from the abdomen into the scrotum. It commences as a fulness or swelling at the situation of the internal abdominal ring, that is to say, a little above the centre of Poupart's ligament, next passes into the inguinal canal (and in this stage is called bubonocele), and if the protrusion increase, it projects through the external ring, and descends into the scrotum of the male, or labium of the female. The coverings of this hernia are, 1, Skin. 2, A strong layer of condensed cellular tissue derived from the superficial fascia of the abdomen, in which the external epigastric artery ramifies. With this is mostly incorporated, 3, the fascia spermatica, a tendinous layer, derived from the inter-columnar bands, a set of semicircular fibres, which connect the two margins of the external ring. Under this lies, 4, the cremaster muscle, sometimes called 1 R. R. Robinson, on Complication of Hernia, Loud. Journ. Med. 1851. 480 INGUINAL HERNIA. tunica communis. 5. Xext comes the fascia propria, a cellular layer continuous with the fascia transversalis of the abdomen ; and lastly, 6, the sac. The internal epigastric Fig. 266. artery is always internal to the neck of the sac. The spermatic cord is generally behind the sac; but, in old cases, the parts which compose the spermatic cord are separated by the tu- mor, so that the vas deferens and spermatic artery lie some- times in front, sometimes on either side of it. 2. The direct inguinal hernia bursts through the conjoined tendon of the internal oblique and transversalis muscles, just behind the external ring. Its coverings are the same as those of the oblique variety, except the cre- master, for it has no connection with the cord. The epigastric artery runs external to the neck of the sac. This hernia may, however, push the conjoined tendons before it, instead of bursting through it. The spermatic cord gene- rally lies on its outer side. 3. The congenital hernia is a variety of the oblique, and is so called be- This diagram, copied from Tiedemann, gives an internal view of the parts concerned in the formation of hernia; and on the left side shows the usual place at which direct inguinal hernia protrudes. Fig. 267. Fig. 268. Fig. 267 exhibits a congenital omental hernia of the right side. Fig. 268, an encysted hernia; a kind of which was first described by Hey, of Leeds, ina.letterto Gooch (Vide Gooch's Chir. Works, vol. ii. p. 217.) He says: "The intestine in this case had forced its way into the scrotum before the tunica vaginalis had formed its adhesion to the cord, but after its abdominal orifice was closed: under which circumstance it brought the peritoneum down with it, form- ing the hernial sac ; contrary to what happens in the hernia congenita, where the intestine deif ends be- fove the orifice in the tunica vaginalis has closed, and consequently has no hernial sac but thtft tunic. From the King's College Muaeum. INGUINAL HERNIA. 481 cause the state of parts which permits of it only exists at or soon after birth. A portion of omentum or intestine accompanies the testicle in its descent, and passes down with it into the very pouch of peritoneum which forms the tunica vaginalis reflexa, before its communication with the general perito- neal cavity has become obliterated. The sac of this hernia is consequently formed by the tunica vaginalis; its coverings in other respects are the same as those of the oblique variety, and the protruded bowel lies in immediate contact with the testicle, and if not replaced generally adheres to it. 4. The encysted (or hernia infantilis) is a sub-variety of the congenital. The protruding bowel pushes before it a sac of peritoneum either into or close behind the tunica vaginalis, and this tunic and the sac adhere very closely together. This hernia, therefore, has, as it were, two sacs : viz., one proper sac, and another anterior, composed of the tunica vaginalis, which in these cases is very liable to be the seat of hydrocele. Fig. 268 shows another variety of the encysted hernia, in which the sac is apparently formed of tunica vaginalis, but its communication with the testicle is closed. Diagnosis.—1. The difference between the oblique and direct inguinal hernia, and their relations to the epigastric artery, are shown in the follow- ing figure, which is taken from Tiedemann. In the oblique, the neck of the tumor inclines upwards and outwards, and causes a fulness extending up to the middle of Poupart's ligament. In the direct it inclines (if at all) rather inwards ; and when the hernia is reduced, the finger, Fig. 269. carrying integument before it, can be passed straight back into the abdominal cavity. But in old cases of oblique hernia, the neck of the sac is dragged down towards the middle line, so that all distinction is lost. 2. Hydrocele may be distin- guished from hernia by its be- ginning at the bottom of the scrotum; by its being semi- transparent and fluctuating, and preventing the testicle from be- ing clearly felt (whilst the cord can be distinctly felt above it); and by not dilating on cough- ing. Whereas hernia begins at the top of the scrotum ; it is not transparent; does not fluctuate; does not prevent the testicle from being clearly felt, although it obscures the cord ; and dilates on coughing. But hernia may and does often coexist with hydrocele, the former beginning from above, the latter from below. More- over, a hernia, consisting of intestine greatly distended with flatus, has been known to be as transparent as a hydrocele. 3. Hydrocele of the Cord, if low down, may be distinguished by its trans- parency and fluctuation; but if high up, it may extend into the abdominal ring, and receive an impulse on coughing, and the diagnosis be very difficult. But as a hernia may be concealed behind this kind of tumor, the rule, when in doubt, operate, should be acted upon in case of symptoms of strangulation. 4. Varicocele (or cirsocele), which signifies a varicose enlargement of the spermatic veins, resembles hernia, inasmuch as it increases in the erect pos- ture, and perhaps dilates on coughing; but it maybe distinguished from hernia by its feeling like a bundle of tightly-distended veins ; and although, 31 [Difference between direct and oblique inguinal hernia.] 482 RADICAL CURE. like hernia, it disappears when the patient lies down, and the scrotom is raised, still it quickly appears again, if pressure be made upon the external ring, though that pressure would effectually prevent a hernia from coining down again. 5. Lastly, a testicle that has not come down through the external abdo- minal ring into the scrotum, has been frequently confounded with a bubono- cele, or small hernia in the inguinal canal; and has been compressed with a truss, to the great pain and detriment of the patient. A little care and attention will prevent this mistake. Treatment.—1. Inguinal hernia, if reducible, must be kept up with a truss. Care must be taken not to let the pad bear against the spinous pro- cess of the pubes, or the spermatic cord. Radical Cure.—From the earliest times attempts have been made to pro- duce a radical cure of this kind of hernia, especially by measures calculated to obliterate the sac. Thus excision of the sac, and of the testicle with it; —ligature of the sac ;—pressure by hard trusses ; injection of iodine ; the use of caustics, so as to produce a slough and subsequent firm cicatrix; the introduction of isinglass, blood, and goldbeaters' skin, have been practised with much danger and little success. At present there are operations, of established repute, which act by plugging up and closing the herniary aper- tures. Gerdy's Operation.—More than twenty years since, M. Gerdy proposed a method of pushing a fold of integument up as far as possible into the neck of the sac, securing it in this inverted or invaginated position by means of two sutures (both ends of a ligature being passed from within the inva- ginated skin), and then denuding the pouch of invaginated skin of its cuticle by means of liquor ammonias, so that the surfaces of skin and peritoneum thus opposed to each other respectively may adhere, and the neck of the sac be effectually plugged. This operation was practised by Mr. Bransby Cooper with some benefit. For the herniary aperture in Mr. Cooper's patient was so large before the operation that the bowel could hot be kept up by a truss ; whereas, after the operation, a common truss enabled the patient to pursue a laborious occupation with safety and comfort.1 Wutzer's Operation.—But Gerdy's operation is not always safe, nor always effectual, and is very much inferior to that which Professor Wiitzer, of Bonn, has performed since 1838, and which was introduced into England by Mr. Spencer Wells in 1854. The essential parts of it consist in the invagina- tion of a portion of the coverings of the hernia—including skin of the scrotum, fascia, and sac—which are introduced into the inguinal canal; in the use of a wooden plug which shall retain the invaginated tissues there, and which shall be of such a size as to fill the canal as nearly as possible ; and in the use of an outward wooden pad, of corresponding size and shape to the plug, which shall be so applied, that by means of equable pressure the opposed surfaces of the invaginated portion of sac shall adhere, so that the neck of the sac shall be plugged up, and obliterated. The original instrument of Wiitzer consisted of a roundish plug, with cover to match. The following drawing represents an instrument enlarged and improved by Professor Rothmund of Munich, and subsequently by Mr. Spencer Wells. Mr. Redfern Davies has since suggested that the plug should be made to expand like a glove-stretcher, so that it may fill out the internal ring. The structure and application of it will be readily learned from the following description of the operation.2 1 Bransby Cooper, Guy's Hosp. Rep. Oct. 1840. 2 See Spencer Wells, first paper, Med.-Chir. Trans, vol. xxvii. 1854; also his Lecture in Med. Times, 1858, vol. i. p. 79 ; and paper in the Dublin Quar. Journ. Med. Sc, May, 1858. Redfern Davies, Med. Times, 6th August, 1859. INGUINAL HERNIA. 483 The patient's bowels should have been well cleansed by castor-oil a day or two previously, and the rectum be emptied by enema on the morning of [Instrument for radical cure of hernia, Wiitzer's modified. the operation. The bladder should be empty, the hair of the affected side removed, and the hernia carefully reduced. The patient should be in the same position as for the taxis. The surgeon stands on the side on which he operates. The first step consists in invaginating the sac and its coverings. The surgeon using the left forefinger for the left side " places it," says Mr. Wells, "on the scrotum, about an inch below the external ring, and then pushes a fold of the scrotum before his finger, with a little rotary movement slowly and steadily into the canal, keeping the palmar surface of the finger turned forwards and a little outwards, until it is well under the tendon of the ex- ternal oblique, and the plug of scrotum is well pressed up to, or through, the external ring." He must make sure that his finger is within the inguinal canal, beneath the tendon of the external oblique, and that it has not merely slipped up under the skin, outside the tendon. The next step is, to introduce the wooden plug; which should have the needle or needles passed within it, so far as may be, without permitting their points to project. The surgeon taking it in his disengaged hand, is directed by Mr. Wells to bend the finger which is in the canal, and slip the plug along its dorsal surface, so as to introduce the plug adroitly, whilst with- drawing the finger. Here, again, the operator must be on his guard, both that the invaginated sac and skin do not come down with the finger, and likewise that the wooden plug be introduced into the inguinal canal, and not merely slipped up under the integument; and following Mr. Wells's authority, must feel that the external oblique tendon lies over, and rolls over it; which fact ought also to be ascertained with regard to the preliminary introduction of the finger. The next point is, to push the needle or needles onwards, till their points come through the skin. Then the cover must be adjusted, and fixed by the screws—the needles also, be fixed in their places by screws; their steel points removed and knobs put on, and the handle of the instrument be taken off. Thus it will be evident that two surfaces of sac are pressed together, whilst the inguinal canal is filled with invaginated tissue ; and now the object is to get the opposed surfaces of sac to adhere. The means thereto is the pressure which may be produced by the screw. The part should be examined every day, by raising the cover, and the pressure equalized, if need be, by a little cotton wool. The patient must be kept in bed, with his knee's and scrotum supported. About the fourth or fifth day, inflamma- tory redness and swelling are seen around the needle punctures; in another day or two, suppuration follows, and serous fluid begins to ooze from the invao-inated skin. Xow the instrument may be removed, and it will probably be found, by pulling at the skin of the scrotum, that adhesion has taken place 4 84 RADICAL CURE. firmly ; if not, the instrument may be replaced for two or three days longer. If the pressure is too severe, or unequal, or continued, of course sloughing may occur. f "About six or seven days may be allowed," says Mr. Wells, "from the period the instrument is applied, and from seven to fourteen more, till cica- trization is complete ; so that the patient must be prepared for a three weeks' confinement to his room. After this, a light truss with a weak spring, and large, well-stuffed pad must be worn for about three months, during which time the patient must abstain from violent exercise." Professor Rothmund lays stress on the expediency of smearing the wooden plug with cantharides ointment, to cause the inner surface of the invaginated skin to suppurate and adhere ; but this seems not to be absolutely necessary, and the cavity soon disappears, leaving a dimple to mark its place. This operation has now been performed in a large number of cases in England, with complete success in most, with incomplete success or failure in some, and without mischievous results in any. Even when it has failed of complete success, it has enabled a truss, heretofore useless, to be worn with benefit. Moreover, it seems that there is no case, unless of extreme age and de- crepitude, in which it may not be adopted. Treatment by metallic stitch.—Yet the invagination of the sac and of its coverings, and the adhesion of them within the herniary aperture, can be produced by simpler methods than the apparatus of Wiitzer. Thus Mr. Spencer Wells, in August, 1858, in a case in which Wutzer's operation had been performed, and had been followed by some bulging, and a threatening of a return of the hernia, pushed a fold of scrotum up to the external ab- dominal ring, and passed a handled needle along his finger, and for an inch behind the external oblique tendon. The needle was made to penetrate the skin, and draw back an iron wire, each end of which was secured by a skein of cotton. After seven days the wire was withdrawn, and it was found that some amount of thickness had been produced : the truss was applied again, and a perfect cure followed. But to Mr. Redfern Davies, of Birmingham, is due the credit of applying a simple form of operation to the femoral and ventral hernia. For instance, in a case of femoral hernia, after it has been returned, the finger or fingers are made to carry a plug of invaginated skin and sac as far as possible into the femoral ring. Then a curved tube, containing a needle, is carried on the finger well through the ring; the needle is made to pierce the doubled integuments, and to bring through a silver wire suture ; one, two, or more such sutures are passed, according to the size of the rupture ; the ends are passed through small pieces of vulcanized India-rubber, and are secured by split shot clamped upon them after they have been drawn tight. In about eight days the wires are removed ; in eight days more the patient may get up and wear a light truss, till the invaginated plug is firmly secured. The application of this method to ventral hernia will be evident.1 Wood's Operation.—In the last place, we come to the operation devised by Mr. John Wood, of King's College, which the author has seen him exe- cute with the most consummate skill, and the good effects of which he has witnessed in a case in which Wiitzer's operation had failed. It is performed thus :—An incision about half an inch in length is made through the skin of the scrotum, over the spermatic cord, an inch and a half below the pubic spine. The skin is then separated, by means of a small tenotomy knife, from the subjacent fascia in a circle around this incision, about two inches 1 See Femoral and Ventral Hernia radically cured, by Redfern Davies, Med. Times, Feb. 12, 1859 (four cases of femoral and two of ventral hernia) ; Mr. Spencer Wells's case, ib., Feb. 5, 1859. f STRANGULATED INGUINAL HERNIA. 485 in diameter. Next, the finger is introduced into the wound and made to pass into the inguinal canal. The finger then searches for the arched border of the internal oblique muscle, and is carried behind it towards the linea alba. Then a curved needle, represented in the cut, with its point protected [Instrument for radical cure of hernia, Wood's.] by a tube, is carried up along the concavity of the finger, and made to per- forate the conjoined tendon close to the internal ring, and to perforate the skin ; but the skin, before perforation, is to be drawn upwards and inwards, so that the outward puncture will be, when the skin is restored to its natural situation, lower and more external than the point where the conjoined ten- don is perforated. A thread is now put through the eye of the needle, and the needle withdrawn, leaving one end of the thread projecting. The finger next is made to feel for the external pillar of the ring, and to push the cord downwards out of the way; and the needle is carried along it, and made to pierce Poupart's ligament; meanwhile the skin is moved downwards, so that the needle-point comes out at the first puncture. A loop of thread is left there and held, whilst the needle is withdrawn. The finger is next made to feel for the internal pillar, and the needle made to pierce the conjoined ten- don, the internal pillar, and triangular ligament, half an inch above the pubes. The point is brought out at the same aperture as before, the end of thread is pulled out, and the needle withdrawn. The two separate ends of thread which have perforated the internal pillar, and the loop which has perforated Pou- part's ligament, are pulled tight, and are passed through a hole in a boxwood pad, and tied over the bar represented above. Thus the inguinal canal is first filled with invaginated fascia and sac; and then its sides are brought together by this subcutaneous suture, so that it is contracted and made to adhere to the invaginated tissues. A pad and bandage are applied, and- the ligatures allowed to remain three or four days. After-treatment as before. In this operation, the skin is not invaginated ; consequently it has no ten- dency to drag down the other invaginated tissues; on the contrary, it tends to keep them in their place. The time required is shorter ; and although some degree of varicocele is apt to follow, yet this cure is more speedy, more certain, and less painful on the whole than Wutzer's operation.1 2. The irreducible inguinal hernia must be supported with a bag-truss. If it contain only omentum, a common truss may perhaps be applied in the usual manner, so as to make the omentum adhere to and plug the neck of the sac. But this cannot often be borne, and is liable to induce swelled testicle 3 In attempting the reduction of strangulated oblique inguinal hernia, the patient should be placed in the position described in a foregoing page (474), with his thighs as close together as possible (although the surgeon > See a description of it, Med. Times and Gaz., June 25, 1859. 48 6 STRANGULATED INGUINAL HERNIA. must put one arm between them), and the pressure must be made upwards and outwards. The operation for this hernia is performed thus :—The parts being shaved, and the skin made tense, an incision three or four inches long must be made through the skin, along the axis of the tumor, beginning from above its neck. This will be quite long enough, even for the largest hernia; because the object is to "bring the seat of stricture fully into view, without exposing too much of the sac. Then the successive coverings, before enumerated, are usually divided in the following manner:—a little bit of each is pinched up with forceps, and cut into with the knife held horizontally; a director is passed into this little aperture, and the layer is then divided on it to the extent of the incision in the skin. Cautious operators will find (or make) many more layers than those usually enumerated, which are, in fact, easily subdivisible, especially in old hernias. But the practised surgeon, who knows that he is operating on the living body, and that his object is to cut through everything till he reaches the sac, will dispense with these dissect- ing-room formalities. When at last the sac is reached, which will be known by its bluish transparency, it is to be opened sufficiently to admit the finger, a little bit of it being first pinched up and cut through, so as to admit the director. Then the left forefinger should be passed up into the neck of the sac to seek for the stricture, which will generally be at the internal ring. It may be at the external ring (or at both) ; but whatever it may be, it must be dilated so as to allow the finger to pass into the abdomen. A curved blunt-pointed bistoury or hernia-knife—not cutting quite up to the point— should be passed up flat on the finger through the stricture, and its edge be then turned up so as to divide it; and in every case the division should be made directly upwards, parallel to the linea alba; and then whether the hernia be direct or oblique, the epigastric artery will not be wounded. If no stricture be discovered in the neck, it must be sought for in the body of the sac. The subsequent proceedings—the return or otherwise of the intestine, and the after-treatment—are detailed in the preceding section. If the surgeon performs the operation without opening the sac, the first point, says Mr. Luke, is to ascertain the exact seat of the stricture. Now, since the stricture prevents the communication of impulse from any one part of the tumor to any other part beyond the stricture, all that is required is, to press the tumor firmly between the fingers of one hand so as to cause impulse, whilst with the fingers of the other hand at the neck of the sac, • the precise point where impulse ceases is ascertained. At that point will be found the seat of stricture. " The next step is, to incise the integuments so that the centre of the incision shall be directly over the stricture; a pro- ceeding easily accomplished by causing a transverse fold to be pinched up between the fingers and divided by transfixing it with a straight bistoury, in a direction parallel with the long axis of the tumor. The various fascias are subsequently divided, until the neck of the tumor is fairly exposed. If this be carefully and completely done, a depression will usually be observed at the seat of stricture, presenting a more contracted appearance at that part than at others. To the touch this contracted part feels thick, while into it thin layers of fascia dip, which may be mistaken for the stricture itself, but which may be divided wholly independent of it, and no relief arise from the division. When these layers are turned back, the real stricture is exposed to view." Then the next step is, to scarify the thickened peri- toneum forming the stricture, so as to render it dilatable, without actually cutting through it, and then the taxis is to be used for the return of the hernia. When the stricture is caused by the margin of the external ring, it is easily divided by the hernia director and bistoury; when at the internal FEMORAL HERNIA. 487 ring, it must be done by tne same means, although the operation is more difficult,1 SECTION VII.—FEMORAL OR CRURAL HERNIA. Definition.—Femoral hernia is that which escapes behind Poupart's ligament. It passes first through the crural ring—an aperture bounded internally by Gtmbernat's ligament—externally by the femoral vein—before, by Pou- part's ligament—and behind by the bone. It next descends behind the falciform process of the fascia lata ; thirdly, it comes forward through the saphenic opening of that fascia ; and lastly, as its size increases it does not descend down on the thigh, but turns up over the falciform process, and lies on the anterior surface of Poupart's ligament. The coverings of this hernia are—1. Skin. 2. The superficial fascia of the thigh, loaded with fat, and divisible into an uncertain number of layers. 3. Fascia propria, a layer of cellular tissue derived from the sheath of the femoral vessels, or, according to others, from the fascia cribriformis which closes the saphenic aperture. It is in general pretty dense about the neck of the hernia, but thin, or even deficient on its fundus. 4. The sac. Between the last two there is often found a considerable layer of fat, which might be mistaken for omentum. Femoral hernia rarely attains a very large size. It is much more frequent in the female than in the male, obviously from the greater breadth of the pelvis.2 Diagnosis.—1. Femoral hernia may be distinguished from the inguinal by observing that Poupart's ligament can be traced over the neck of the sac, and that the spinous process of the pubes lies internal to it; whereas it is the re- verse in the inguinal hernia. Besides, the femoral is generally much smaller. Supposing that a large femoral hernia is so fixed that it will not allow the course of Poupart's ligament to be traced, the diagnostic mark pointed out by James, of Exeter, may be at- tended to, to wit, that an inguinal hernia descends towards the labium, a femoral may mount up to near the spi- nous process of the ilium.3 2. Psoas abscess resembles this her- nia in its situation, in dilating on coughing, and diminishing when the patient lies down. The points of dis- tinction are, that it is generally more external, that it fluctuates, but does not feel tympanitic, and that it is at- tended with symptoms of disease of the spine. ' Luke, Med.-Chir. Trans, vol. xxxi. p. 108. 2 Mr. Partridge informed the author that he had met with a case of femoral hernia, protruding below Poupart's ligament, external to the vessels. 3 James, On Operations for Strangulated Hernia, &c. Lond. 1859, p. 10. The cut, taken from a preparation of Mr. Fer- gusson's in the King's College Museum, shows a femoral hernia with its relation to the other parts which pass under Poupart's ligament. Exter- nally are seen sections of the iliacus and psoas muscles, with the crural nerve between them ; then the femoral artery and vein ; next the her- nia, which passes through a small aperture oc- cupied by an absorbent gland in the normal state, and is bounded by Gimbernat's ligament on its inner side. The hernia passes downwards in the sheath of the femoral vessels, separated, however, from the vein, as that is from the arte- ry, by a process of cellular tissue. The sheath of the vessels is continuous above with the fascia transversalis. a, artery; v, vein. 488 FEMORAL OR CRURAL HERNIA. 3. Varix of the femoral vein also resembles this hernia, inasmuch as it dilates somewhat on coughing, and diminishes when the patient lies down ; but then if pressure be made below Poupart's ligament, the swelling quickly reappears, although it must be evident that under such circumstances a her- nia could not come down. 4. Bubo and other tumors of the groin may in most cases be recognized by their general character and history, and by their being unattended with symptoms of inflammation or obstruction of the bowels. But if there be any such swelling, and symptoms of strangulation as well, an incision should certainly be made to examine it; for there may be a tumor that may be satisfactorily proved to be an enlarged gland, and yet there may be a small knuckle of intestine strangulated behind it. 5. Lastly, the possibility of there being a strangulated obturator hernia behind the femoral hernia should not be lost sight of. Treatment.—1. The reducible femoral hernia should be supported by a truss, the pad of which should tell against the hollow which is just inferior and external to the spinous process of the pubes. This hernia is very sel- dom, if ever, cured radically. 2. The irreducible should be supported by a truss with a hollow pad ; or perhaps (if it be omental) the pressure of a common pad may be borne. 3. The femoral hernia, when strangulated, gives rise to much severer symptoms than the inguinal does, because of the denser and more unyielding nature of the parts which surround the neck of the sac. In performing the taxis, the patient should be placed in the usual position, with the thigh of the affected side much rolled inwards, and crossed over towards the other side. The tumor should first be drawn downwards, from the anterior part of Poupart's ligament, and then be pressed with the points of the fingers backwards and upwards. If, however, the taxis and chloroform do not soon succeed, the operation should be resorted to. The old operation.—In the first place, the skin must be divided. Some surgeons make one simple perpendicular incision. Sir A. Cooper directs one like an inverted j,; Mr. Liston prefers making one incision along Pou- part's ligament, and another falling perpendicular from its centre over the tumor, thus: \^ The skin may be very safely and expeditiously divided by pinching it ^"^ up into a fold, and running the knife through it with its back towards the sac. Mr. Fergusson sometimes makes one like an inverted j^, so that the skin can be turned back in three flaps; after which the succeeding layers may be divided by a simple longitudinal incision. Then the different cellular layers down to the sac must be divided by the bistoury and director, as in the inguinal hernia, and the sac must be opened with very great care, because it is generally very small, and embraces the bowel tightly, and seldom contains any serum or omentum. Then the finger should be passed up to seek for the stricture, which, according to Sir A. Cooper and Mr. Liston, will be generally found to be the inner edge of the falciform process. This must be gently divided for a line or two, the incision being directed upwards and a little inwards, towards the spinous process of the pubes. It must be recollected, that if this incision were carried too far, the spermatic cord in the male, or round ligament in the female, would be injured. If, however, the stricture is not released by that incision, a few fibres of Gimbernat's ligament must be divided. 2. The operation without opening the sac is described by Mr. Luke thus. After premising that the seat of stricture is sure to be at or near the femoral ring, and that it is sometimes caused by bands of fascia propria, half or three- quarters of an inch below the ring ; and that the upper boundary of the tumor on the abdominal surface is often marked by a visible depression, or FEMORAL OR CRURAL HERNIA. 489 at least that it can be felt by the fingers ; " a fold of integuments," he con tinues, " is to be pinched up at that part, and divided by transfixing it with a narrow knife, so that the incision, when the skin is replaced, shall fall per- pendicularly to the body, with its centre opposite to the depression referred to. By a few strokes of the scalpel the tendinous expansion of the abdo- minal muscle is to be laid bare ; after which a finger should be introduced as far as Poupart's ligament, between the tendinous expansion and the tumor, where the latter rises upon the former. The ligament being thus exposed, a hernia-director is guided under it by the finger into the femoral ring, the margin of which may be safely and easily divided in an upward direction with a common probed bistoury, and the taxis applied in the usual way. Should the margin of the ring have formed the stricture, the taxis for the most part succeeds very readily, and the operation is completed in a very short time. But should the stricture be caused by the bands of fascia pro- pria referred to, the director will have passed over them as it entered the femoral ring, in which case any amount of division in an upward direction will be of no avail. When the taxis does not succeed readily, these bands of fascia may generally be suspected to be the cause of failure. The fact may be made sufficiently clear by introducing the finger upon the neck of the sac, under Poupart's ligament, while the body of the sac is pressed be- tween the fingers and thumb of the other hand, when it will be discovered that no impulse is communicated to it by such pressure. By a little atten- tion the bands may be detected crossing the neck of the sac from half to three-quarters of an inch below the ring, and may be divided by insinuating the nail of the forefinger of the left hand under them from above, and by carrying the point of a probed bistoury along the nail, with its blunt edge towards the sac. The division is made by the surgeon drawing the bistoury away from the sac towards himself, a proceeding which, if properly per- formed, avoids all danger of wounding the sac or its contents."1 3. Mr. Gay's Operation, respecting which Mr. Fergusson says emphati- cally that he scarcely ever performs any other for crural hernia, and that, "if the sac is not opened, it is the nearest reasonable approach to the taxis that surgery has yet made," is thus performed : An incision, rather more than an inch long, is made near the inner side of the neck of the tumor. The superficial fascia having been divided, the forefinger (of the left hand if the hernial tumor is on the right side, and vice versa) is to be passed through this wound, along and close to the side of the hernial tumor, to its neck. On the finger, a bistouri cache is to be passed through the cribriform fascia, and through the crural canal to the ring. " By the least amount of force, and with the aid of a little gentle compression of the inner side of the tu- mor by the finger, the point of the bistoury may be insinuated between the sac and the pubic margin of the ring; the edge of the knife is then to be turned towards the pubes, and by projecting the blade the seat of stricture in that direction may be effectively divided." If, after this, and after the division of any other stricture that may be felt around the neck of the sac, the hernia cannot be reduced, the incision can be enlarged, and the opera- tion of opening the sac, as usually directed, be performed.2 1 Med.-Chir. Trans, vol. xxxi. p. 112. 2 On Femoral Ruptures, with a new mode of operating, &c, by John Gay, Lond. 1848. 490 OBTURATOR HERNIA. SECTION VIII.--THE UMBILICAL, VENTRAL, AND OTHER REMAINING SPECIES OF HERNIA. I. Umbilical Hernia—(exomphalos)—is, for obvious reasons, most fre- quent in children soon after birth. It is also not uncommon in women who have frequently been pregnant, although, in many of the so-called umbilical herniae in adults, the hernial aperture is really not at the umbilicus, but a little on one side of it. The coverings of this hernia are skin, superficial fascia, and sac ; they are always very thin, and not unfrequently the sac is adherent to its contents. Treatment—If reducible, and the patient an infant, the best plan is to place a hemisphere of ivory with its convex surface on the aperture, and retain it there with cross strips of plaster, and a bandage round the belly. A pad of linen, covered with sheet lead, will do as well. An adult should wear a truss or elastic belt, with some contrivance to prevent it from slipping down below the proper level. For the irreducible umbilical hernia a large hollow pad should be worn. If it becomes strangulated, and the patient is aged, and the strangulation was preceded by constipation, purgatives and copious enemata should have a fair trial. If the operation is necessary, an incision should be made over the neck of the tumor through the skin (which is very thin), and the tendinous parts be divided, and the bowels returned without opening the sac, if possible. II. Yentral Hernia is that which protrudes through the linea alba, or through the linees semilunares or transversee, or in fact through any other parts of the abdominal parietes, save those which are the ordinary seats of hernia. It may be a consequence of wounds or bruises. Its treatment re- quires no distinct observations ; but if it should ever be necessary to operate for the relief of strangulation, care must be taken to avoid the epigastric artery.1 III. Perineal Hernia descends between the bladder and rectum, forcing its way through the pelvic fascia and levator ani, and forming a tumor in the perineum. IY. Yaginal Hernia is a variety of the preceding, in which the tumor projects into and blocks up the vagina, instead of descending to the peri- neum. Y. Labial or Pudendal Hernia descends between the vagina and ramus of the ischium, and forms a tumor in one of the labia. It is to be distinguished from inguinal hernia by the absence of swelling at the abdo- minal rings. These three herniae must be replaced by pressure with the fingers, and be kept up by pads made to bear against the perineum, and perhaps by hollow caoutchouc pessaries worn in the vagina. YI. Obturator or Thyroid Hernia projects through that aperture in the obturator ligament which gives exit to the artery and nerve. In a fatal case related by Mr. Howship, in which a very small piece of intestine was strangulated in this opening, the patient complained of great pain down the leg in the course of the obturator nerve. This might be an aid in the diag- nosis. In a case in which Mr. Hilton laid open the abdominal cavity, and disengaged a knuckle of intestine from the obturator foramen, there were no symptoms that indicated the kind of obstruction met with.3 In a case suc- 1 Mention is made in the Lond. Med. Gaz., 21st October, 1842, of an adipose tumor, situated between the peritoneum and abdominal muscles, and projecting through an aperture in the linea alba, through which it could be pushed back, so that it com- pletely simulated a hernia. Such a case, if complicated with peritonitis, might render the diagnosis very obscure ; but an incision would clear up the mystery. 2 This case, like many others, was unfortunately operated upon too late. The ob- struction existed from the 20th of January to the 1st of February. Hilton, Med.-Chir. HERXIA. 491 [Obturator Hernia.] From a preparation of Mr. Fergusson's in the King's College Museum. cessfully operated upon by Mr. Obre there were symptoms of strangulation, and a slight degree of fulness in the triangular space at the upper part of the right thigh compared with the left; and a distinct hardness in the neigh- borhood of the femoral artery behind the saphenous opening. Mr. Obre made a straight incision, as in the operation of tying the common femoral artery, beginning three inches below Poupart's ligament, hoping to find in- testine low in the crural canal. When the cribriform fascia was opened, and the saphenous opening exposed, no hernia] sac was found, but a hard something could be felt lying deep on the inside of this opening. The dissection was continued downwards; the fascia lata divided ; the pecti- naeus exposed and divided trans- versely for about an inch and a half, when a hernial sac was exposed, which rose up into the wound to the size of a pigeon's egg. The finger was passed into the obturator open- ing ; the sac opened, and found to contain small intestine ; the edge of the aperture slightly divided (iu do- ing which the saphenic vein was wounded, and was tied), the intes- tine was returned, and the patient did well. VII. Ischiatic Hernia protrudes through the sciatic notch. This and the preceding are exceedingly rare ; and the tumors are of necessity small. If discovered to exist during life, they must be returned and supported by proper apparatus—and if strangulated, the stricture must be divided by operation. YIII. Diaphragmatic Hernia is generally a result of congenital de- ficiency, or accidental separation of the fibres of the diaphragm. But it may also be caused by violent falls on the abdomen, or by violent pressure of any kind, capable of lacerating the diaphragm, and driving some of the bowels into the thorax.1 It may also be a consequence of gunshot wounds. This form of hernia, if strangulated, will produce the ordinary symptoms— vomiting, constipation, and pain ; and the distinction from the symptoms of ileus or intussusception—or from those produced when a fold of bowel is entangled in a rent in the omentum, or mesentery; or when the bowel is constricted by membranous bands resulting from previous inflammation of the peritoneum, will be very difficult, if possible. In a case recorded by Dr. Copeman, of Norwich, the patient had umbilical hernia, which was quite free from strangulation, but a portion of the stomach and omentum had escaped, through a rent in the diaphragm, into the left pleural cavity. This patient complained of pain in the left shoulder, and below the heart, and dyspnoea. Mr. Guthrie had predicted, in his Commentaries,8 the possibility of hernia through the diaphragm, after a gunshot wound, and had described the opera- tion which might be attempted for its reduction: that is, an incision through the walls of the abdomen, large enough to admit the hand to draw back the Trans, vol. xxxi. p. 323 ; Obre, Ranking, vol. xiv. ; Report of cases in Lancet, for 1851, vol. i. p. 513 ; Wilkins, Lancet, 1853, vol. i. 1 Reid on Diaphragmatic Hernia, Edin. Med. and Surg. Journ., Jan. and July, 1840; Copeman, Prov. Med. Journ., 1855. 2 Sixth ed., 1856, p. 505. 492 DISEASES OF THE RECTUM AND ANUS. stomach into its proper place. He informs the writer (Jan. 1856) that he has received from the Crimea an interesting account of a gunshot wound, in which the greater part of the stomach and duodenum protruded into the chest through a wound of the diaphragm caused by a Minie ball. CHAPTER XIX. SURGICAL DISEASES AND INJURIES OF THE RECTUM AND ANUS. I. Foreign Bodies in the rectum sometimes require to be removed by surgical art. They may consist either of small bones or the like that have descended from above, or of pins, glyster-pipes, or other bodies introduced from below. Substances of very extraordinary dimensions (a blacking- bottle, for instance), have been forced into the anus. The grand point is first to dilate the bowel well, by passing in several fingers coated with lard, or by means of a speculum, and then a proper forceps, or a lithotomy scoop, may generally be used with success. Several specula have been invented for the purpose of enabling the sur- geon to see into the anus ; to remove substances from within, or to make medicinal applications, or to perform operations. The simplest is a glass tube, silvered and covered with caoutchouc, of various sizes, and having various kinds of apertures to allow of the inspection of the mucous mem- brane. This was invented by Mr. W. Fergusson. A very complete three- valve speculum has been devised by Mr. Lane, and is made by Savigny. Others are made by Coxeter, and other mechanicians. [Fig. 274. Fig. 275. Fig. 274. Fergusson's speculum for the rectum. Fig. 275. Imperforate anus and rectum; the rectum descending to half an inch of the surface of the integuments.] II. Imperforate Anus (Atresia ani) signifies a congenital closure of the rectum, and may occur in various degrees. The anus may be merely IMPERFORATE anus. 493 closed by thin, fine skin, which soon becomes distended with meconium ; or the gut may ter- minate in a blind pouch at any point from the sigmoid flexure downwards, and the anal aper- ture being altogether wanting; or the anus may be open for an inch or two, with an obstruction beyond ; or the rectum may ter- minate in the bladder, or urethra, which will be known by the escape of urine tinged with me- conium ; or, although the anus may be closed, there may be a fistulous track leading from the rectum just above it, and open- ing somewhere in the perineum.1 Treatment.—If the end of the intestine can be felt protruding when the child cries, a free cru- cial incision may be made into it without delay : if it cannot be felt, a day or two should be waited, so that it may become distended with meconium, and then a cautious incision should be made with a double-edged bistoury, in the direction of the Fig. 277. Imperforate anus. From the King's College Museum. curve of the sacrum. If it succeed in reaching the bowel, the aperture should be kept open by a bougie. But if this operation should fail in reaching the bowel, or if the rectum 1 Case in South's Chelius, vol. ii. p. 329. [Fig. 276. Intestine terminating in a dilated pouch on right side of abdomen.] 494 DISEASES of the rectum and anus. appears to be altogether deficient, the only resource is the formation of an artificial anus in the left loin (p. 465). When the rectum opens into the bladder or urethra, an aperture must be made into the neck of the bladder for the free discharge of the feces,1 if the natural orifice cannot be restored. III. Spasm of the Sphincter Ani is known by violent pain of the anus, with difficulty of evacuating the feces. On examination, the muscle feels hard, and resists the introduction of the finger. This affection may be caused by constipation of the bowels, or disorder of the health. It may occur in sudden paroxysms which soon go off; or may last permanently, and lead to organic thickening and stricture of the anus. It is very frequently connected with piles, or with fissure of the anus, or ulcer just within it. Proctalgia, or neuralgia of the anus, is a very common disorder of chil- dren and of gouty adults, and in either case is best treated by purgatives. IV. Fissure of the Anus is a small chap or crack giving intense pain during the passage of the motions, frequently continuing two, four, or even eight hours after the evacuation. Introduction of the finger causes greater suffering in this than in any other affection of the rectum ; and if unrelieved, fissures often enlarge and assume the character of ulcers. A piece of hyper- trophied skin, probably the remains of an external pile, and generally situ- ated behind, leads, in many instances, to the fissure. Immense relief is produced by free purgation. If, after a fair trial of purgatives, and the local use of sulphate of copper, nitrate of silver, or of tannin lotion, or oint- ment of galls with lead, the symptoms continue unabated, recourse must be had to the knife. Y. Ulcer of the Rectum, if influenced by the sphincter muscle, is seldom cured without the use of the knife. If, however, it be situated at a distance, and out of reach of the action of the muscle, it may heal up by the local application of stimulants, and attentive regulation of the bowels. In the first place, probably a dose or two of calomel, followed by castor- oil, should be administered, and after this blue pill, dandelion, nitro-muriatic acid, and such other remedies as may be necessary to bring the secretions into a healthy condition. 2. Meanwhile, an attempt may be made to soothe the local irritation by washing out the rectum with a pint of thin arrowroot and water after a motion ; or by injecting, by means of a glass syringe, about two fluid drachms of glycerine ; or by using a lotion of borax and extract of poppies, F. 122, or belladonna liniment, F. 149. 3. Stimulating appli- cations, such as nitrate of silver and citrine ointment, may be tried to the fissure or ulcer. 4. Other means failing, an incision should be resorted to. The left forefinger should be introduced, and a straight, narrow, blunt-ended bistoury by its side ; with the latter, an incision should be made through the fissure, or ulcer, so as to divide the mucous membrane, and in severe cases, part of the sphincter. A little flake Fig. 278. of cotton wool should then be laid in the wound, so that it may heal by granulation.3 VI. Haemorrhoids, or Piles, are small tumors situated near, usually within, the anus. They consist of folds of mucous and submucous tissue in various stages of in- ,.,,.,, flammatory swelling, congestion, infiltra- Piles after excision, showing the dilated ,. J °' , ° \ -, veins, of which they are in a great measure tlon> or permanent hypertrophy, and composed. usually contain enlarged veins. Sometimes there is a little varicose knot with the cellular tissue around thickened. Sometimes the blood in a dilated 1 Case in Fergusson's Pract. Surg., 3d ed. p. 720. [4th Amer. ed. p. 54(!.] 2 See observations by Richard Quain, F. R. S., quoted in Ranking's Abstract, vol. xvi. haemorrhoids. 495 [Fie vein coagulates, forming a solid tumor with the thickened cellular tissue around. Again, the mucous membrane of the whole circumference of the bowel becomes swollen and hypertrophied, with its surface extremely vascular and sensitive. This swollen membrane is apt to become pro- lapsed, or, in plain English, to come out at every evacuation of the bowels ; causing great pain from being compressed by the sphincter until fairly put back into its place, and bleed- ing freely from the straining and pressure. Lastly, there may be one or more distinct pen- dulous tumors, varying in size from that of a pea to that of a walnut, of a pale or reddish- brown color when indolent, but dark or bright red when congested or inflamed. These add greatly to the discomfort and tendency to pro- lapse. External Piles may be met with, 1, in the form of round hard tumors just at the margin of the anus, and covered half with skin and half with mucous membrane ; or, 2, of oblong ridges of skin external to the sphincter, com- monly called blind piles. Symptoms.—Piles may be met with in two states—indolent or inflamed. When indolent, they produce the inconveniences that neces- oid internal ha;morrhoids.] [Fig. 280. Aggravated case of internal ha;inorrhoids in an ulcerated condition] 496 DISEASES of the rectum and anus. sarily result from their bulk and situation, and from getting within the gripe of the sphincter; more or less pain in defecation ; prolapse ; and if not pain, yet a sense of weight and discomfort that is excessively annoying, and that renders the mind inapt for matters requiring deep thought. Sometimes, too, the bowel is apt to come down when the patient is taking exercise or exerting himself. When inflamed, they occasion the following symptoms : Pain, heat, itching, fulness, and throbbing about the anus—a sensation as if there were a foreign body in the rectum—pain and straining in passing evacuations. These symptoms may, in violent cases, be complicated with irritation of the bladder, frequency of micturition, pain in the back, pain and aching down the thighs. The young surgeon should remember, that a patient with piles may not be aware of the nature of his complaint, or through delicacy may abstain from mentioning it. Whenever, therefore, a patient complains of unusual irritation of the bladder, or of symptoms of dysentery—that is to say, frequent, painful, and unsatisfactory efforts to pass motion—the surgeon should always make inquiries after piles. In women, piles may cause aching of the back, uterine irritation, with mucous discharge, and many anomalous symptoms, which the surgeon will in vain endeavor to cure until he finds out the real cause. The hemorrhage from piles will be treated of more particularly at page 499. Causes.—The predisposing causes are any circumstances that produce fulness of the abdominal vessels, or that impede the return of blood from the rectum—such as luxurious and sedentary habits of life—pregnancy, consti- pation, and disease of the liver. The exciting causes may be anything that irritates the lower bowels—particularly straining at stool—and violent doses of purgative medicines; among which aloes is blamed more than it deserves to be. Since this medicine is so valuable and in such common use, and yet so little understood, the writer will, for the sake of his younger readers, state briefly what the use of aloes is, and in what its misuse consists. Aloes is what was formerly called an eccoprotic; that is, an expeller of feces. When taken into the stomach it is readily dissolved and absorbed, and is eliminated through the colon and rectum, which latter parts it stimulates to unload themselves of their contents ; and if they contain fecal matter, which from torpidity they do not expel, aloes is an effectual and unirritating remedy. But if these parts are already active and empty, aloes can but irritate them fruitlessly, causing straining and tenesmus, and also probably piles. Lastly, piles are most frequent in women, and are rare under puberty. General Treatment.—The grand objects are to remove the predisposing and exciting causes. The patient, if stout, plethoric, and of sedentary habits, ought to live abstemiously, and take plenty of exercise. The bowels should be regulated by some mild aperient, capable of producing daily copious soft evacuations without straining or griping. Senna, sulphur, cream of tartar, and magnesia, in the form of electuaries, F. 46-55, or com- pound colocynth pill, are frequently used for this purpose; or pills of rhubarb and soap, with ipecacuanha, taken twice a day, F. 52 ; or a small dose of castor-oil or Pullna water, F. 42, in the morning. It is a good plan to inject the rectum with cold water both before and after the motions. In some cases it is advisable that the patient have his regular daily evacua- tion at night, just before bedtime, so that the prolapsed and irritated parts may have time to become quiescent during the night. In cases of long standing, in which the mucous lining of the rectum is relaxed, cubebs, or Ward's paste, or the confect. piperis comp. may be given with great benefit in doses of 3J ter die. In similar cases, especially if the patient is advanced in years, and the piles are attended with a flow of mucus, copaiba may be given in the dose of thirty or forty drops every morning in milk; and a HEMORRHOIDS. 497 scruple of common pitch may be taken in pills every night at bedtime. Old people rarely dislike the taste of copaiba. If the piles are inflamed, leeches to the anus, or cupping on the sacrum, a dose of calomel and opium at bedtime, followed by castor oil in the morn- ing ; low diet, rest in bed, warm hip-baths, fomentations, and poultices. Cold lotions of lead, with a little laudanum, may be substituted for the warm applications, if more comfortable. If there is a tense, bluish, solid tumor, evidently containing coagulated blood, it may be punctured ; but perhaps it is better not to do so. Local Treatment—Having by the general treatment provided as far as possible against the original causes of the malady, it is the surgeon's duty to use such local measures as shall tend to restore the part to a healthy con- dition ; amongst which we shall mention, 1. perfect cleanliness. The anus should be well washed with soap and water after each motion ; and if the piles are internal, and protrude during evacuations, they should be washed before they are returned. 2. Astringents.—The zinc lotion, F. 117 ; or iron lotion, which is parti cularly recommended by Mr. Vincent, F. 128 ; or lotions of alum or tannin, of either of which a drachm or two may be injected into the anus after each motion, and be allowed to remain; the gall ointment, with or without lead, F. 162, and creasote ointment—are often of benefit. Dr. Burne recom- mends an ointment composed of pulv. hellebori nigri 3J, adipis Jj, which he says never fails of affording great relief, although exceedingly painful for a time. An ointment of a drachm of black oxide of mercury to an ounce of lard has also received high recommendations. 3. Pressure by means of a bougie introduced occasionally, or a firm pad of flannel, covered with oiled silk; or a pad of smooth wood or of ivory, made to bear up well against the anus by means of a stout perineal or T bandage (see Bandages), or by means of a spring like that of a truss, are often of service. There is an instrument consisting of a short egg-shaped ivory bougie, which is introduced into the anus, and which is attached by a slender neck to an ivory pad ; so that pressure is thus made both internally and externally, that may be useful in cases of internal piles with relaxed mucous membrane, and tendency to prolapse, when no measure for removing the piles is thought advisable. 4. But the most safe, speedy, and effective means of affording relief in cases of internal piles is the nitric acid; which was originally recommended by Dr. Houston, in order to destroy the tender, tumid, and bleeding surface of mucous membrane which covers them, and which is the source of their excessive irritability and hemorrhage. The bowel having been protruded, the diseased surface is to be wiped with lint; and a portion of it, the size of sixpence, to be deliberately dabbed with a smooth wooden stick dipped into the concentrated acid. When this has taken effect, any superfluous acid is to be mopped up, lard is to be applied copiously, in order to prevent the caustic being too widely diffused, and the parts are then to be returned within the sphincter.* The patient should go to bed, and the bowels be kept quiet—if necessary by opium—for forty-eight hours; and when the slough caused by the acid separates, the surface generally cicatrizes speedily, and leaves the part braced up and contracted. It is difficult to exaggerate the benefits of this plan of treatment. It seldom causes pain or any ill conse- quences. The author has by two applications of it relieved a patient perma- nently of pain and hemorrhage which had lasted for years, and which on the average caused him to lose two hours' time every morning, by rendering him incapable of attending to anything save his own miserable sensations. When the parts cannot be protruded, the acid may be applied through the speculum. 32 498 DISEASES OF THE RECTUM AND ANUS. 5. The Ligature.—But the acid will not be a sufficiently potent remedy if there are one or more actual tumors, or if a large track of mucous mem- brane is swelled and protrudes. For such cases, any tumors, together with a portion of relaxed mucous membrane, should be extirpated, and the ligature is the usual means of effecting it. But the surgeon must bear in mind that it is highly dangerous to operate upon internal piles if the health is broken, or if there is any organic disease of the liver or kidneys; and the operation must both be preceded and followed by a course of the most regular diet, and medicines to maintain the secretions, and to remedy any disorder in the health. The operation is performed as follows:—The bowels having been just previously cleared, the patient must be told to protrude the piles ; and if he cannot do it easily, he should sit over a vessel of warm water, or have an enema of warm water. Then (the patient having chloroform to render him unconscious of pain, and to relax the sphincter) the piles should be seized one by one and drawn out, and a small fine piece of hempen twine be tied as tightly Fig. 281. [Forceps for holding piles.] as possible round the base of each. They may be seized with any forceps; but one like that here depicted is very convenient. If one of the tumors is large, a double liga- ture may be passed through its base with a needle, and either half be tied separately. [For this purpose the instrument Fig. 282 will be found very serviceable.] Before finally tightening the ligatures, the piles should be slightly punctured. Any fold of superfluous mem- brane should be similarly seized and dealt with ; and the surgeon should take care, whilst about it, to tie up enough; to tie it in small portions so that it may quickly slough off; and to tie it so tightly as to kill it at once. After the operation, the ends of the thread should be cut short, and be returned into the rectum. The patient should remain in bed, and the bowels should not be disturbed for forty-eight hours after the opera- tion. Pain is to be relieved by an opiate, F. 32 ; and if it persist, the piles should be examined to see whether the ligatures remain as tight as possible, and if not, they should be reapplied. 6. Excision is the proper remedy for external piles. All loose ridges of skin around the anus should at the same time be removed with the scissors, and the edges of the cut be brought together by a fine suture. To apply the ligature to the skin is barbarous. For in- ternal piles, excision, although a cleaner and more summary, cannot be considered so safe an operation as tying, because of the great risk of hemorrhage, and the difficulty of checking it unless certain precautions are taken. It may, however, be done quite safely thus:—The tumor having been protruded, the base of it should be transfixed by a long needle, which will pre- [Fig. 281 Instrument used for passing a double liga- ture through the base of a hemorrhoid.] HEMORRHAGE. 499 vent it from returning into the anus. Then it may be cut off; and the cut surface being exposed to the air, will not bleed, or if it does, it is easy to apply cold, astringents, or ligatures. After twelve hours the needle may be removed, and the part allowed to go up. Mr. Henry Lee has adopted a plan of seizing the part to be removed between the blades of a sort of curved forceps, and cutting it off; then touching the cut surface with nitric acid, or, still better, with the iron at a black heat. The pressure of the forceps prevents all bleeding at the time, and the caustic not only prevents it after- wards but also renders the patient more safe from pyaemia (which is one possible risk of the ligature), hastens the cure, and leaves the parts more braced up. The ecraseur may be used in some cases. VII. Warts and Condylomata. See p. 203. VIII. Hemorrhage from the rectum is a very frequent concomitant of piles, and may be of two kinds. In the first place, it may be caused by the bursting of a varicose vein : in which case the blood is venous ; and the hemorrhage in general occurs at once in considerable quantity; and may never occur again. This form is rare. But far more frequently it proceeds from the vascular surface of internal piles, which gives way under the strain- ing which accompanies defecation. In the latter case the blood is arterial; it is squirted from the anus in jets when the patient is straining at the water- closet, and the bleeding occurs very frequently, especially when the body is feverish, or the bowels disordered, or the piles inflamed. Hemorrhage from the rectum may be distinguished from that which has its source higher up by noticing that the blood is generally of a florid hue, and that it covers the feces, but is not intimately mixed with them. Treatment—1. If the hemorrhage is moderate in quantity, if it has been of habitual or periodic occurrence, if it induces no weakness, and if it brings relief to pain in the head or any other feeling of disorder, before suppressing it the patient must be made to adopt a course of exercise, temperance, and aperient medicine. 2. But if the patient is weak and emaciated; if the lips are pale, and the pulse feeble, the bleeding should be at once suppressed. (We may observe here, that whenever a patient applies for relief in conse- quence of violent palpitations and shortness of breathing, or giddiness and swimming in the head—if the lips are pale, and the extremities tend to swell—the surgeon should always inquire for piles, because, as we before observed, some patients, through false delicacy, will not mention them.) Or if the bleeding, as sometimes happens, instead of relieving symptoms of heat and fulness in the rectum, aggravates them, it should be stopped, whatever the patient's complexion may be ; and if he is of a full habit, he should live abstemiously, and keep the bowels open. The means of checking hemor- rhage from the rectum are, 1. That piles, if any exist, should be treated as we have just directed. 2. Astringent applications, such as injections of dec. quercus, or F. 128. 3. The internal remedies most likely to be of service are salts of iron or bark with sulphuric acid, or the balsams of copaiba and Peru. F. 9, 13, 14, 186, kc. 4. In order to stanch violent bleeding, the anus must be distended with a speculum, and any bleeding vessel be tied, or touched with a heated wire. Or the anus must be plugged.1 1 In severe bleeding, occurring after an operation on the rectum, after the failure of more ordinary means, a plug of the following description may be used. A good-sized conical cork, with a string passed through its centre, is to be placed in the rectum, then graduated circular pieces of lint penetrated by the string must follow: two or three pieces of lint can be passed at a time, and the entire number must be sufficient to form a good-sized conical plug, which is prevented from floating about in the rectum by traction on the string. Firm pressure over a large space can be obtained by the adop- tion of this method. For this note the author is indebted to Mr. Sharman, some time of St. Mark's Hospital, now of the London Hospital. 500 DISEASES OF THE RECTUM AND ANUS. IX. Discharge of Mucus—clear and viscid—without fecal odor, may be caused by piles, ascarides, the use of aloes, or any other causes of irritation to the rectum. To be treated by mild aperients, astringent injections, and copaiba or cubebs. F. 37, 39, 13, &c. X. Abscesses near the rectum may be caused by the irritation of foreign bodies, or by caries of an adjacent bone, but they are much more frequently the result of the various causes of disordered circulation in the haemorrhoidal vessels that were mentioned as producing piles, and especially of that morbid state of mucous membrane which accompanies pulmonary tubercle or the tendency thereto. They may either be large and deep-seated, or small and superficial. 1. Deep-seated abscesses are attended with great aching and throbbing, difficulty and pain in evacuating the feces, and fever, and on in- ternal examination a fulness or fluctuation may be felt. If these abscesses are left to themselves, a vast quantity of matter may accumulate in the loose cellular tissue of the pelvis, and severe irritative fever result from its confine- ment. 2. Superficial abscesses are attended with more or less pain, tender- ness, and throbbing, and swelling around the anus. Or either may be quite chronic and indolent. Treatment—In acute cases leeches and fomentations may be tried at first; but if they do not very soon remove the pain and tenderness, or if there is the least suspicion that matter is forming, a bistoury should be pushed home into the inflamed part, and if it be at all extensive, two or three punctures should be made. XL Fistula in Ano signifies a fistulous track by the side of the sphincter ani. It is extremely difficult to heal, both because the constant contractions of the sphincter and levator ani interfere with the union of its sides, and because of the passage of fecal matter into it from the bowel. There are three kinds spoken of in books. 1. The complete fistula, which has one external opening near the anus, and another into the bowel above the sphincter, where it may be felt like a small papilla. The blind external fistula, which has no opening into the bowel, although it mostly reaches its outer coat. 3. The blind internal fistula, which opens into the bowel, but not externally, although its situation is indicated by a redness and hardness near the anus ; or perhaps the aperture is so small as to be scarcely percep- tible. This affection is a common result of abscess by the side of the rectum. Brodie's opinion is, that it always commences with an ulceration of the mucous membrane of the rectum, and an escape of fecal matter into the cellular tissue, which gives rise to abscess, and the abscess to fistula. But most other surgeons believe that it may be the result of abscesses around the anus, which have no connection with the rectum. Besides, there may be openings near the anus, leading from the tuber ischii, which may be carious. Treatment — The grand remedy for this affection is division of the sphincter ani, so as to prevent contraction of that muscle for a time, and division likewise of the internal orifice if any. The digestive organs and secretions must first be put into good order, and the bowels be well cleared by castor oil and an injection, so that they may not want to be disturbed for two or three days. Operation.—The patient being placed on his knees and elbows on a bed, or being made to kneel on a chair and lean over the back of it, or lying on his side close to the edge of the bed, and the nates being kept asunder by an assistant, the surgeon introduces his left forefinger into the anus, and at the same time explores with a probe the whole extent and rami- fications of the fistula. If it is of the blind internal kind, its situation must be ascertained, and a puncture be made into it by the side of the anus. Perhaps a probe bent at an acute angle may be passed into it from the PROLAPSUS ANI. 501 bowel, and serve as a guide for the puncture. Then, one forefinger being still in the anus, the surgeon passes a strong curved probe-pointed bistoury up to the further end of the fistula. Next (if the internal opening cannot [Fig. 283. Bistoury for fistula in ano.] be found) he pushes it through the coats of the bowel, so that its point may come in contact with his forefinger. Then he puts the end of his forefinger on the point of the bistoury, and draws it down out of the anus; and as soon as it is fairly emerged, he pushes the handle towards the orifice of the fistula, so as to divide skin, sphincter, and bowel at one sweep. Sir B. Brodie recommends that the bistoury should always be passed through the internal opening of the fistula, and says that the affection will very likely return if this is not divided ; he also condemns the practice of cutting through the bowel higher up than this opening; but all ramifications and burrowings of the fistula under the skin should be slit up. A little flake of cotton is then to be placed in the wound, and the patient to be kept in bed for three days. The subsequent treatment consists in the use of perfect cleanliness, and the daily introduction of a little flake of cotton (which may be dipped in some stimulating lotion if necessary) between the edges of the wound for the first few days, so as to prevent its edges from uniting, and to cause it to granulate from the bottom. If hemorrhage prove violent after this operation, and does not yield to the application of cold, or a bit of matico leaf, the anus must be well dilated with a speculum, so as to expose the bleeding surface to the air, and any artery discernible may be tied ; or else it may be firmly plugged with lint, which is to be secured by a T bandage. If the patient will not submit to this operation, or if he is laboring under disease of the lungs or liver or kidneys, in an advanced stage, so that it would be unsafe, the treatment must be palliative merely. The confect. piperis, or copaiba and tonics, may be administered internally, and stimulat- ing injections and ointments be applied to the fistula. Luke's operation of cutting the fistula by ligature may be adopted by any one who is fond of variety, or whose patient fears the cold knife. XII. Prolapsus Ani consists in an eversion of the lower portion of the rectum, and its protrusion through the anus. It is not merely that a fold of the mucous membrane protrudes; but that the muscular coat, and whole thickness of the bowel come down. This affection is most common in infancy and old age. It may depend on a natural laxity and delicacy of structure, or be caused by violent straining, in consequence of costiveness, or of the existence of piles, or stone, or stricture. Treatment.—Whenever the protrusion occurs, the parts should be care- fully washed, and then be replaced by pressure with the hand. If there is any difficulty in doing so, the forefinger oiled should be pushed up into the anus, and it will carry the protruded part with it. If, however, as some- times happens, a larger portion than usual has come down, and it is so swelled and tender from the constriction of the sphincter, and from being 502 DISEASES OF THE RECTUM AND ANUS. irritated by the clothes, that it cannot be returned, the patient should be put under chloroform, and so reduction be effected; but should the prolapsed Fig. 285. This cut, from a preparation in the King's College Mu- seum, shows a section of a prolapsed rectum—the whole circumference of the lower part of the bowel being everted and extruded. The mucous membrane is ex- cessively thickened from the irritation of exposure. portion come down again, the patient must keep in the recumbent posture, and assiduously apply iced water. In other cases, leeches, fomentations, and a dose of calomel and opium may be requisite. To cure this affection radically, the bowels should be so regulated as to pre- vent costiveness and straining; injections of dec. quercus, or of F. 128; sponging with cold water—tonics, especially steel, and support by pads and T bandages, may be used to give tone to the parts—and piles, or any other source of irritation, must be removed by appropriate remedies. Dr. Mac- Cormac, of Dublin, recommends that when the stools are passed, the skin near the anus should be drawn to one side with the hand, so as to tighten the orifice : this the author believes to be a very valuable suggestion. But if the diligent employment of these measures is of no avail, certain opera- tions may be resorted to. 1. The mildest consists in pinching up two or three folds of the flabby mucous membrane on the protruded bowel with the forceps shown at p. 498, and tying them tightly with ligatures. 2. Or liga- tures may be passed by needles through several folds of skin just at the margin of the anus, which are then to be tied up tightly. Or 3, a small patch of relaxed mucous membrane may be destroyed by acid. Either of these operations may be repeated as often as necessary. Their effect in producing adhesion and consolidation of the relaxed tissue must be obvious. There is a French operation, which consists in excising a portion of the sphincter ani; but when this operation used to be performed (as it com- monly was sixty years ago) for fistula, it was often followed by inability to retain the feces. XIII. Internal Prolapsus, or Invagination of the Rectum.—When the lower bowel in females has become distended, and has lost its tone from protracted constipation, and the abuse of warm enemata, the upper part of the bowel is apt to come down within the lower, and to be griped by it [Fig. 284. Prolapsus ani.] PERMANENT stricture. 503 after the manner of an invagination. This state of things causes great dis- tress, constant feeling of weight and of desire to pass motions, and difficulty Fig. 286. Stricture of the rectum from fibrous deposits.] [Stricture of the rectum.] in so doing. On examina- tion with the finger, the ca- nal of the rectum is found obstructed by a tumor with a capacious cul de sac around it, and with the natural pas- sage of the bowel in its centre. The Writer has rea- son for believing that some degree of this affection is not very uncommon amongst women. Treatment—Aperients, such as rhubarb, with cubebs or cinnamon ; or with small doses of nux vomica : mild astringent injections, and the bougie ; the point of which should be carefully guided into the orifice in the centre of the prolapsed portion.1 XIV. Spasmodic Stricture of the rectum—known by great difficulty in evacuating the bowels, with spasmodic pain on doing so—is a rare affection. " It generally depends," says Mr. Mayo, " on a vitiated state of the secre- tions0; and is more frequently relieved by a regulated diet and alterative medicines, and the use of injections, than by the employment of the bougie." (See Proctalgia.) , XV. Permanent Stricture.—In this affection there is a chronic thick- enin"- and contraction of the mucous coat of the rectum, so as to form a rino^encroaching on its canal. It is generally situated at from two inches and a half to four inches from the anus. More rarely it is met with higher up or even in various parts of the colon. It may follow the contraction of cicatrized ulcers. The symptoms are great pain, straining and difficulty in voiding the feces, which are passed in small, narrow, flattened fragments; i This malady is particularly described by Earle, Med. Gaz. vol. v. ; Chevallier, Med.. Chir. Trans, vol. xf; Mayo on the Rectum, p. 182 ; and Bushe on the Rectum, JNew York. ls>37. 504 DISEASES OF THE RECTUM AND ANUS. and on examination the stricture may in ordinary cases be readily felt. Irritation of the bladder and uterus, and pains or cramps in the leg, with headache and dyspepsia, are occasional additional symptoms. If this affec- tion be unrelieved, it leads to ulceration of the rectum above the stricture, with a consequent aggravation of all the symptoms, and death from irritation. Treatment—The remedies are aperi- ents and injections so as to produce daily soft unirritating stools, and the bougie. A bougie, capable of being passed with moderate facility through the stricture, should be introduced once in three or four days, and be allowed to remain fifteen or twenty minutes; and its size should be gradually increased when a larger one ad- mits of being passed. The best bougie is one invented by Mr. Partridge, made of a short cylinder of smooth metal, mounted upon a slender handle, so that the sphincter is not painfully distended. Instruments of every sort introduced into the rectum should be handled with the utmost gentleness. No- thing is gained by forcing a large bougie through a stricture. The cure is to be ef- fected by the repeated and gentle stimulus of pressure, so as to excite absorption, not by mere mechanical dilatation. There are numerous fatal instances on record in which the bowel has been torn by bougies, and by that most dangerous and loathsome instru- ment, the common clyster syringe, in the hands of careless or ignorant people. For the administration of enemata, the pipe should be only an inch and a half in length, with a large bulbous extremity. Or if in cases of stricture, or of obstinate costive- ness with great accumulation of feces, or of incarcerated hernia, it is desirable to in- troduce a tube further, it should be quite flexible like that of a stomach-pump. But the natural sharp fold at the junction of the rectum with the sigmoid flexture, and the fact shown by Mr. Earle that the bowel not unfrequently makes a horizontal curve to the right before descending into the pelvis, render the introduction of bougies into the sigmoid flexure a very blind, hazardous proceeding, and one that is not often to be justified. Moreover the surgeon must be on his guard lest he fall by inadvertence into another error. That is to say, he must not pronounce his patient to have a stricture merely because the point of the bougie catches in the folds of the mucous membrane, or is obstructed by the promontory of the sacrum. XVI. Polypus of the rectum, a rare disease ; must be removed by liga- ture, or by knife, or the ecraseur. XVII. Cancer of the rectum is usually of the scirrhous variety, and situated at first about two or three inches above the anus. It may either commence as a distinct tumor, or as an infiltration of some part of the walls of the bowel. The earliest symptoms are uneasiness in the rectum, with a Pathological changes induced by cancer of the rectum.] PRURITUS ANI. 505 sense as if some fecal matter had lodged there ; aching and pain in the back, hips, and thighs, and irritation of the bladder. As the disease ad- vances, the bowel becomes more or less obstructed ; there is frequent dis- charge of a fetid muco-purulent matter streaked with blood; and there is a most obstinate constipation, attended with enormous swelling of the abdo- men, and sometimes with all the symptoms of strangulated hernia; but this may alternate with the most profuse and exhausted diarrhoea. Abscesses about the rectum, opening perhaps into the bladder or vagina, aggravate the patient's misery, and death ensues from exhaustion, or from peritonitis, or perhaps from rupture of the distended bowels. This disease is to be dis- tinguished by examination with the finger, or with the speculum; which will detect hardening and ulceration, or perhaps fungating tumors blocking up the gut.1 Treatment.—The first object is, to keep up the action of the bowels by enemata of warm water, and by the mildest laxatives : and to allay irrita- tion by occasionally leeching the sacrum; by belladonna and opiate plasters; or occasional enemata or suppositories of opium, or large doses of henbane or conium ; and by the tepid hip-bath. Sir B. Brodie recommends injec- tions of linseed oil, either pure or mixed with lime-water, and balsam of copaiba with alkalies internally. When the obstruction threatens to become considerable, it will be expedient to use bougies, very gently, of the softest material, and not more frequently than is absolutely necessary. When these fail, it may be expedient, as a temporary resource, to cut through, or to excise some portion of the obstructing growth, or even to force the finger, or a flexible tube, through it, if possible with safety : some surgeons have even extirpated the lower extremity of the rectum ; but all these operations can only be regarded in the light of palliatives. As a last resource, an arti- ficial anus may be formed by Amussat's operation.3 For cancerous and epithelial diseases of the verge of the anus, and their treatment, by operation or otherwise, we may refer to the works of Lebert and Lisfranc. XVIII. Pruritus Ani, a very violent itching of the anus, is a very troublesome affection. It may be complicated with an excoriated or fissured state of the surroundimg skin (rhagades). The best plan is to keep the bowels open with sulphur, seidlitz powders, or castor-oil, with occasional doses of blue pill; to put the stomach into proper order; to bathe the part very frequently with water as hot as can be borne ; and to apply some stim- ulating or astringent substance, such as nitrate of silver, weak solution of corrosive sublimate, the citrine or creasote ointment, or lemon-juice. The liq. arsenici chloridi, F. 97, may be tried in an obstinate case.3 [The sur- geon should recollect also that the itching may be caused by the presence of ascarides in the rectum.] 1 In a case related to the author by Mr. Mayo, of Winchester, ulceration of the anus, of the worst syphilitic character, laid open the peritoneum between the rectum and va- gina : a portion of omentum protruded ; it was imperfectly replaced, as it was sup- posed, naturally enough, to be a prolapse of the rectum, and the patient died with symptoms of strangulation. 2 Walshe, op. cit. p. 297. Csesar Hawkins, Med.-Chir. Trans, vol. xxxv. s [For further and complete information on the subjects treated of in this chapter, the student is referred to the work of Mr. Ashton "On the Diseases, Injuries and Mal- formations of the Rectum and Anus." Phil. 18o'0. From 3d Eng. ed.] 506 DISEASES OF THE URINARY ORGANS. CHAPTER XX. DISEASES OF THE URINARY ORGANS. SECTION I.--RETENTION OF URINE FROM SPASMODIC STRICTURE. I. Retention of Urine.—This term signifies want of power to pass the urine from the bladder. It therefore includes the idea that there is urine to pass ; and must be carefully distinguished both in theory and in practice from the suppression of urine, in which no urine is passed because none is secreted. II. The urethra is a canal surrounded by various structures, whose actions are capable of hindering the flow of urine through it. There is a layer of Fig. 289. [Catheter, showing the proper curve] erectile tissue, which when turgid closes the canal; there is a layer of un- striped or organic muscular fibre ; and, besides, at certain points there are voluntary muscles—the muscles of Wilson and Guthrie, the levator ani, and accelerator urinae. The layer of organic muscle, the existence of which was inferred by Hun- ter, and demonstrated by Kolliker, has been more minutely investigated by Mr. Jabez Hogg and Mr. Hancock. According to the last-named gentle- man, it appears that the urethra is invested by a double-layer of organic or unstriped muscular fibre ; one layer immediately surrounding the canal, the other external to the prostate and the corpus spongiosum urethra?; which muscular coats are continuous with those of the bladder. Hence not only can the canal be closed by spasm of the voluntary fibres which are in rela- tion with its membranous portion, but any part of the canal may be closed by the layer of involuntary fibres. Moreover, it is well to bear in mind that violent voluntary efforts, as in straining to empty the bladder, tend to close the urethra by the action of the levator ani.1 The length of the urethra, according to Mr. H. Thompson,9 is about 8^ inches ; its circumference un- stretched .5 inch at the meatus, .7 inch in the bulbous portion ; both dimen- sions capable of being stretched. Its lowest point in the erect posture, is 1 Anatomy and Physiology of the Male Urethra, by Henry Hancock, F.R.C.S., Lond. 1852 ; Investigations of the Anatomy of the Urethra, &c, by Jabez Hogg, Pathological Trans. 1855. 2 Henry Thompson, F.R.C.S., &c, Pathology and Treatment of Stricture, being the Jacksonian Prize Essay, &c, Lond. 2d ed,, 1858. The cut shows a catheter, recom- mended by Mr. Thompson, and modelled according to the length and direction of tho urethra. It is divided to suit the size of the page, and is exactly one-half of the real size. The axis of the point forms a little more than a right angle to that of the shaft. SPASMODIC STRICTURE. 507 Fig. 290. A very useful syphon, which can be fixed on to the end of the catheter, for the more convenient flow of the urine. just anterior to the anterior layer of deep perineal fascia; its curved por- tion .3 of a circle 3.25 inches in diameter; but that this curve is sharper in thin persons than in the stout. In children the greater elevation of the bladder in the pelvis produces a greater curve in the urethra. Varieties.—Retention of urine may arise from causes functional or or- ganic. The functional causes may be, 1, want of power in the muscular coat of bladder and urethra ; 2, spasm of the urethra, mixed in some cases with some amount of inflammatory swelling. The organic causes include permanent stricture, that is to say, obstruction of the canal by organic disease and contraction; —cicatrices, the blocking up of the tube by stones or other foreign bodies coming down from the bladder, or introduced from without;—or by the presence of ab- scesses, or cancerous or other tumors ;— or of fractured and displaced bones ex- ternal to the urethra ; or by disease of the prostate gland. In the present section we shall speak of that form of retention of urine which arises from spasm of the urethra. III. Spasmodic Stricture generally affects persons who are already labor- ing under some slight degree of permanent stricture, or whose urethra has been rendered irritable by repeated attacks of gonorrhoea, or by a dis- eased condition of the urine ; these, therefore, are the predisposing causes. The usual exciting causes are, exposure to cold and wet, and indulgence in liquor, which disorders the stomach, and renders the urine unusually irri- tating. Hence, an attack of spasmodic stricture generally comes on at night. It may also be caused by cantharides, whether taken by the mouth, or absorbed from blisters applied to the skin. Like irritation of the blad- der, it may be a symptom of gout. It may likewise be caused by sexual excitement and by piles and other sources of irritation of the rectum or bowels. Symptoms.—The patient finds himself unable to pass his water, although he has a great desire, and makes repeated straining efforts to do so. The bladder soon becomes distended, and can be felt as a tense, round tumor above the pubes; and unless relief is given, the countenance becomes anxious, the pulse quick, and the skin hot. The straining efforts at micturition also become more frequent and violent, and the distress and restlessness are ex- treme. In this way the patient may, perhaps, go on for many days ; a little urine passing occasionally when the spasm is less urgent, but the bladder still remaining loaded, till relieved by treatment. If not relieved, and if the urethra were previously diseased, either the bladder may burst into the peri- toneum ; or, as more frequently happens, the urethra behind the stricture (which, of course, becomes dilated and weakened under the pressure of the urine impelled by the whole force of the abdominal muscles) burst into the perineum, and give rise to extravasation of urine, as will be described in the third section. The inflammatory stricture, in which great pain and tenderness of the perineum, and fever, are combined with spasm, is generally caused by abuse of injections, or by exposure and intemperance during acute gonorrhoea. The treatment of this and of the spasmodic variety must be the same. Treatment.—The surgeon's proceedings must be regulated by the duration 50 8 DISEASES of the urinary organs. of the retention, and the amount of distension of the bladder, and by the previous history of the patient, as to the time during which the urinary organs have been diseased, and as to the exciting cause of the retention. If the symptoms are not extreme, if they have been brought on by cold or conviviality, and there is no history of old stricture, a hot bath and dose of calomel, combined with a full dose of opium, and followed by castor oil, or F. 38, will often relieve the patient. In cases in which there is no need of an aperient, a full dose of opium or Dover's powder, or an opiate enema or suppository, or a whiff of chloroform will suffice ; for it is the great object to stop all violent voluntary efforts, and when they are discontinued the bladder will often empty itself easily. In inflammatory cases it may be requisite to leech or cup from the perineum, or even to bleed, or give anti- mony ; and large draughts of soda water, with a teaspoonful of the bicar- bonate added, and other alkaline liquids, are also often of great service in cases of no great urgency, arising from errors in diet. The muriated tinc- ture of iron, in doses of Tr^x every ten minutes, is an empirical remedy, which the writer has often seen used. Xo one pretends to explain its modus operandi; and as it is seldom or ever given without the warm bath or other means, it is difficult to say what amount of benefit is really due to it. But if these means do not succeed, a catheter must be introduced ; or if the distension of the bladder be very great, it should be done at once, the patient being narcotized by chloroform. A silver catheter, of good size (8 or 9), may first be introduced. (This cut shows the sizes of catheters Fig. 291. , 2 3 i. 5 S 7 S 9 ooooo o O OO and bougies adopted by Savigny and by most other makers, No. 1 being ,125 and No. 9, .25 inch in diameter.) The surgeon should well warm and oil it, and pass it through the palm of his hand, so that he may make sure that it is smooth and fit for use. The patient may either lie down flat, or stand with his back against a wall. The surgeon, holding the catheter in his right hand,.raises the penis with his left, and introduces the instrument, with its concavity towards the left groin. Then he gradually raises it till it is perpendicular with the abdomen ; and then the instrument ought to pass under the pubes into the bladder, whilst the handle comes down to a hori- zontal position. The instrument should be held lightly, and let make its own way, so to say, along the passage. The surgeon, if necessary, should draw the penis well forwards on it, so as to stretch the urethra, and prevent the instrument from becoming entangled. He should make the point slide along the upper rather than the lower surface of the urethra. On meeting with an obstruction, he should press against it steadily, but very gently; and by delicate manipulation for five or ten minutes, the stricture will in most cases be made to yield. The oiled forefinger of the left hand intro- duced into the rectum is a most useful help. If the silver catheter does not pass, the surgeon may try a gum catheter that has been kept for some time on a wire, so that it keeps its curve when the wire is drawn out. Instead/of oiling the catheter, Mr. H. Thompson carefully fills the urethra with pure olive oil by means of a glass syringe, forcing it down to and through the stricture, and retaining it by the finger and thumb at the orifice SPASMODIC STRICTURE. 509 till the catheter is introduced. Mr. Thompson says that the instrument passes with less pain by this means.1 Whenever spasmodic stricture occurs frequently or periodically, the sur- geon should examine most carefully into those conditions of the health generally, and of the urine particularly, which give rise to it; and should resort to the catheter as sparingly as possible, unless there is some organic stricture requiring it. When there is great depression or debility, tonics ; when periodicity of attack, quinia; when an overloaded state of the bowels, aperients; and, when the urine is irritating, the measures detailed in the eighth section of this chapter should be resorted to. Puncture of the bladder.—If none of these means succeed, and the bladder has become exceedingly distended, an operation will be necessary to relieve it, and save the patient's life. Although, we must observe, that this is never necessary from mere spasm, unless there is also extensive and old- standing disease of the urethra or prostate. The time at which it must be done must be decided by the surgeon's judgment; sometimes, as Sir B. Brodie observes, it is necessary within thirty-six hours, sometimes not for three or four days. The operations may be— 1. Forcing a passage; that is to say, pushing the catheter onwards through the obstruction into the bladder, as nearly as possible in the course of the natural passage. This is not applicable to stricture ; but to cases in which the obstruction is in the prostate, and should only be attempted by one who is an expert manipulator, and thoroughly acquainted with anatomy. 2. Incision of the urethra in the perineum, with or without division of the stricture. This, with the cases to which it is applicable, is described in the next section. 3. Puncture of the bladder by the rectum is performed by placing the patient on his hands and knees, or placing him on his back with his knees drawn up, and bringing him close to the edge of the bed, introducing the Fig. 292. [Puncture of the bladder through the rectum.] right forefinger into the anus, and a long curved trocar and canula by its side then feeling for, and making sure of, the distended bladder just behind the prostate, and exactly in the middle line, and plunging the trocar into it _leavino- the canula for four-and-twenty hours. The rectum should be first of all cleared by enema. The point of the trocar should be withdrawn slightly within the canula as it is being introduced into the anus, so that it may do no mischief, ,„„ OJ ' On Stricture, p. 179, 2d ed. 510 DISEASES OF THE URINARY ORGANS. This operation has been strongly recommended by Mr. Cock,1 who has had great experience of its utility. 4. Puncture of the bladder above the pubes.—This is performed by mak- ing a small incision through the linea alba just above the pubes, and then thrusting a long trocar and canula downwards and backwards into the blad- der, where it is not covered by the peritoneum. The canula must be retained, and the patient be kept on his back to prevent extravasation ; and no time should be lost in restoring the natural passage. SECTION II.--PERMANENT STRICTURE. Permanent Stricture, signifies a contraction of the urethra, caused usually by inflammation, infiltration of plastic Fig. 293. material, and subsequent shrinking of this material and of the canal, and gristly degeneration of the tissues around the canal. But Mr. Hancock has found, contrary to the general opinion, that lymph may be effused on the free surface of the mucous membrane, and then be developed into imperfect fibrous tissue, partially blocking up the canal. In some cases a small portion of the mucous mem- brane, perhaps only a line or two in extent, is found thickened and deprived of its natural elasticity; or perhaps contracted so as to form a sharp fold, as if it had been tied with a thread. But in old neglected cases, the canal with the corpus spongio- sum around may be converted into a thick, gristly, cartilaginous mass several inches in extent. The most frequent situation of stricture is "in the sub- stance of the bulbous portion of the canal, or a little anterior to it."3 The causes are repeated gonorrhoea, intemper- ance, and unhealthy conditions of the urine. Symptoms.—In what may be called the first stage, the patient finds that he wants to make water oftener than usual, and that he has more or less uneasy sensation in the perineum after doing so; he also notices that a few drops hang in the urethra, and dribble from him after he has buttoned up. Then he observes that the stream of water is smaller than usual, and forked, or scattered, or twisted, and that he requires a longer time and greater effort than usual to pass it. Itching of the end of the penis and gleety dis- charge are frequent concomitants. 1 Cock, Med.-Chir. Trans, vol. xxxv. 2 Henry Smith, F.R.C.S., quoted in Ranking, vol. x. 1849, with an account of exami- nation of ninety-eight specimens. See the same author's work on Stricture, Lond. 1857, p. 29 ; Mr. Henry Thompson (op. cit. 2d ed. p. 83) divides the urethra into three regions ; and finds that out of two hundred and seventy specimens, two hundred and fifteen, or sixty-seven per cent., are situated in the first region ; which comprises an inch of the canal before, and three-quarters of an inch behind, the junction between the spongy and membranous portions of the urethra. "That part of the urethra," says Mr. Thompson, " which is most frequently affected with stricture, is the portion com- prised in the inch anterior to the junction ; that is, the posterior or bulbous part of the spongy portion." The second region, comprising two and a half or three inches in front of the first, was the seat of fifty-one strictures, or sixteen percent.; and the third region, consisting of the anterior two and a half inches, fifty-four, or seventeen per cent. This drawing, from a prepa- ration in the King's College Museum, shows the urethra laid open, and a stricture in the membranous portion just in front of the verumontanum. permanent stricture. 511 If the disease proceeds to its second stage, the bladder becomes irritable, obliging the patient to rise in the night to void urine. He is liable to attacks of spasms with complete retention, as was described in the pre- ceding section. In one of these, the urethra may ulcerate or burst, giving rise to urinary abscess, or to extravasation of urine, as will be described in the next section. Rigors occurring in paroxysms like ague fits are not un- common. (See Section vn.) Finally, if the complaint is permitted to continue, the health suffers from the constant irritation and want of sleep; the bladder and kidneys become diseased ; the complexion becomes wan ; the appetite fails ; the patient com- plains of chills and flushes, of aching and weakness in the back, and of great languor and depression of spirits; and the urine is constantly loaded with fetid mucus. After death, the urethra behind the stricture is found greatly dilated ; the prostate, with its ducts dilated, and in a state of suppuration, or perhaps containing small circumscribed abscesses; the bladder sometimes dilated, but more frequently contracted, and enormously thickened ; some- times sacculated from a protrusion of its mucous coat between the fibres of the muscular ; the ureters dilated, and converted into subsidiary receptacles for the urine, and the kidneys either greatly dilated or disorganized. An engraving illustrative of this- will be found in the seventh section of the present chapter. Treatment.—The remedies for strictures are twofold. The first, which should always receive the earliest and greatest attention, are such as tend to remove any disorder of the stomach, or of the general health, and any irritating quality of the urine, or inflammatory tendency about the parts concerned. It must be recollected, especially with people of education, that the mind has an important share in producing the subjective symptoms of stricture ; and that gout will often produce pain and spasm in the perineum, which can be charmed away by an alkaline purgative and colchicum; further, that every irritated and infiltrated tissue has a natural tendency to recovery, when the exciting causes are removed. If sexual indulgence, drink, dissipa- tion, and gonorrhoea will produce chronic inflammation and tendency to stricture, it is equally true that chastity, temperance, rest, early hours, warm baths, purgatives, and alkaline remedies may undo the mischief. Hence it is a coarse and violent proceeding to introduce instruments into the urethra of a young man without pressing necessity, until a course of proper treat- ment has failed ; and it may be a mortiferous proceeding in the case of an old man. Shiverings, fever, suppression of urine, and death may follow. In every case, then, admitting of delay, the surgeon should begin by cal- culating how much of the malady is removable by regimen and medicine, and should remove that first. Warm baths ; opiate suppositories ; belladonna smeared in the" perineum ; and alkalies after meals may be of service. F. 38, 72, 77, 78, 79, 149, 181. (See Gleet, Chronic Inflammation, of the Blad- der, and Urinary Deposits.) Then will be the time for the second class of remedies, consisting of mechanical means, such as, 1. Dilatation by a bougie or sound : 2. Dilata- tion by means of expanding instruments : 3. By a catheter retained : 4. By the caustic bougie : 5. By incision from within : 6. By division from the perineum. These we proceed to discuss in succession. 1. The Bougie.—The common bougie is, as its name implies, a wax candle, or cylindrical body composed of linen imbued with wax or plaster. It is flexible, becomes softened by heat, and is supposed to be capable of doing less harm than a metallic instrument, if mismanaged. Similar instru- ments (less safe) are made of gutta-percha and caoutchouc. But, as has been well said by Mr. H. Thompson, the surgeon who knows what he is about will prefer to have an instrument that will obey his hand, and which 512 DISEASES OF THE URINARY ORGANS. is adapted to the normal direction of the passage. He will, therefore, prefer a metallic sound. But if the instrument is to be introduced by the patient himself, it may be flexible ; and if the canal is tortuous from disease, and the natural direction lost, and the unnatural direction difficult to find, it may be convenient for the surgeon to use a flexible instrument, in the hope that it may find its own way into the bladder. In the first place the surgeon desires to ascertain whether there is a stric- ture, and if so, where. For this purpose he takes a full-sized sound, i. e., one that will enter the orifice easily, and fill it; and having warmed, oiled, and passed it through his hand to make sure of its polish, he introduces it in the manner directed for the introduction of a catheter. If it seems to meet with an obstruction, it should be drawn a little backwards; then most gently pressed onwards, to see if it will enter, and be grasped by it. If not, it may be exchanged for a smaller one, and gentle persevering trials be made—not too much at one time—to get the instrument fairly, into the stricture. The surgeon should allow it to remain for five or six minutes, by which time probably the patient will complain of sickness or faintness ; and when he withdraws it, should make a note of the size. After three or more days—more or less according to the pain and irritation caused—the process may be repeated ; and it must be gone on with at the same interval, with a gradual increase of the size of the instrument, till the canal is restored to its natural calibre. For some months afterwards it is expedient to pass a sound about once a fortnight. Chloroform may be given if there is great pain or difficulty. Metallic bougies, or sounds made of silver, or steel plated, are always to be preferred to those of soft materials, 1st, if the stricture is old and very hard and gristly; 2dly, in cases of very irritable urethrae, because their smooth polished surface is not so apt to cause spasm; 3dly, in cases where a false passage has been formed, which these instruments, as they can be directed with greater precision, can be better made to avoid. They should be eight or nine inches long, not smaller than No. 4, their curved part need not be so long as that of a catheter, and they should be mounted on a firm wooden handle, and their point should be made to slide along the upper surface of the urethra, as it is at the bottom that false passages generally exist, and are most easily made. These instruments may also be used for the cure of old impassable stric- tures in the following way:—A sound of moderate size, about one-fifth or one-sixth of an inch in diameter, may be introduced once in three or four days, and be firmly pressed against the stricture for from five to fifteen minutes, taking care to keep its point against the upper part of the urethra. This will cause the anterior part of the stricture to relax a little ; and if the process is repeated often enough, it will at last clear the way to the bladder. Or a sound with a conical point may be introduced into the anterior part of the stricture, and kept there for an hour or two at a time. This is often called the cure by vital dilatation.1 The plaster bougie, if used, must be slightly bent, and oiled. If its pas- Fig. 294. Sound with bulbous point. Natural size. 1 Vide Sir B. Brodie on the Urinary Organs, 3d edit. 1842. Guthrie on the Urinary Organs, Lond. 1843. PERMANENT STRICTURE. 513 sage is resisted, gentle pressure may be tried, to see if it will enter the stricture. If it seems to pass, the operator should let go for a moment to see if it recoils ; for it must be remarked that it may bend against the stric- ture without entering it, and may thus lacerate the canal. If there is more than one stricture, an instrument with a bulbous point may be of use, because it will not be grasped by the first stricture after the bulb has passed. 2. Urethra Dilators.—The good effects of the bougie are owing to the stimulus of gentle pressure. But, in order to accelerate the cure, various plans have been proposed for effecting actual Fig- 295. dilatation of the stricture. First may be wund circular catheter, ■ Buchanan, of Glasgow, ed in the Med. Gaz. for . 296. [Buchanan's and Sheppard's instruments for dilating the urethra.] March, 1841. It consists of three or more graduated silver tubes sliding one over the other, and the smallest sliding over a round-pointed probe. The external tubes acting as guides enable the inner one readily to pass the stric- tured part, and when once a smaller tube has passed, it is safe and easy to slide in the others. In guiding this instrument along the membranous and prostatic portion, Dr. Buchanan retains his finger in the rectum. (See Fig. 295.) Dr. Sheppard, of Stonehouse, uses a very small catheter (Fig. 296), grooved on one side : along this a metallic button, or traveller, can be pushed by means of a fine wire which lies in the groove. The travellers are of various sizes. The instrument is made by Weiss. Mr. T Wakley's instruments (Fig. 297).—They consist of, firstly, a very small catheter, a, which is to be passed through the stricture into the blad- der. Secondly, a slender steel rod, b, which is next to be passed within the catheter and screwed into it. This rod and the catheter thus united form a directing-rod, over which other instruments are to be passed. Thirdly, there is a series of straight silver tubes, c, of graduated sizes; the smallest just one size larger than the directing-rod ; the largest equal to a No. 10 bougie. Each of these tubes is constructed so as to glide accurately over the direct- ing-rod ; and thus, the latter being in the urethra, any stricture can be dilated to as great an extent as the surgeon thinks prudent at one sitting. 33 mentioned the comi used by Dr. Andrew in 1831, and describ 514 DISEASES OF THE URINARY ORGANS. Of course the size of our page prevents the artist from showing more than two ends of these instruments; the middle will readily be imagined by the reader. Fig. 297. B________________ B [Wakley's instruments for dilating the urethra.] In the next place, Mr. Holt's improvement of M Perreve's instrument, may be mentioned. It consists of a staff, formed of two blades, a and b (Fig. 298), joined at the smaller extremity, c, and capable of diverging by Fig. 298. [Perreve's instrument, as improved by Mr. Holt.] means of a screw, d, at the handle. Between them is a directing-rod, e, and on this directing-rod, under cover of and between the two separate blades, a dilating-tube, f, can be passed down to and within the stricture after the staff in its undilated state has been passed Fig 299. [Coxeter's instrument for dilating the urethra.] Mr. Coxeter has an instrument consisting, like the foregoing, of two blades, joined at the smaller extremity. The upper blade, a (Fig. 299), is connected with a rod, e, which works within the lower blade, b, by several small bars riveted at each end, whose action is like those in the well-known instrument called the parallel ruler. By turning the nut d, the rod, e, which ends in the screw, f, is pushed forwards; thus the connecting bars cause the upper blade, a, to separate from the lower. Numerous other modes of dilating strictures are in existence, or may be invented by any man of ingenuity. But in these, as in other cases, whether the surgeon may venture to effect speedy dilatation, or whether he must be content to do but little at a time, is a question which he must decide from PERMANENT STRICTURE. 515 his knowledge of the patient's constitution. Rigors, abscess, and pyaemia may result from indiscretion. 3. If a small catheter is retained in the bladder for two or three days, the passage suppurates and dilates remarkably ; just as the lachrymal duct does from the presence of a style. This method of cure may be attempted when the stricture is very gristly and cartilaginous; when the urethra is irregular, or has had a false passage made in it; or when the urethra is so irritable that severe rigors and fever are occasioned by the passage of the urine after the use of the common bougie—a circumstance common enough with patients whose kidneys are unsound. The catheter should be of silver, and should be retained by means of two strings, which may be passed back- wards between the thighs, and be fastened to a band round the waist. It should be removed in two or three days, and a larger catheter should be passed four-and-twenty hours afterwards, and should be introduced often enough subsequently to keep up the dilatation. But the continued presence of the catheter is liable to cause so great an amount of irritation that it cannot always be borne, even with the aid of opium. 4. The caustic bougie is a most powerful agent in deadening the sensi- bility of very irritable stricture, but is liable, if mismanaged, to produce inflammation, retention of urine, hemorrhage, abscess, and any other con- ceivable mischief. Two kinds of caustic are used ; the nitrate of silver and the caustic potass. The caustic potass is much used by Mr. Wade, who speaks highly of its effects : 1st, in hard cartilaginous strictures through which no instrument can be passed without injurious force ; 2d, in hard strictures of long standing, which, though admitting the passage of a small bougie, bleed freely on its introduction ; 3dly, in irritable strictures; 4thly, in spasmodic strictures when not arising from acute inflammation ; 5thly, in strictures which have a marked tendency to contraction, after having been dilated by the common bougie. The manner of using it is the following :— "A small piece of potassa fusa," says Mr. Wade, "should be inserted into a hole made in the point of a soft bougie. The eighth part of a grain is the smallest, and a grain the largest quantity of the potass I am in the habit of using, but it will rarely be necessary to exceed the sixth of a grain. The bougie should be well moulded round the potassa fusa, so as to prevent the alkali from projecting, and it should be so placed that it may be more ap- plied to the upper than the lower part of the stricture. From three to four are the sizes of the bougies I generally employ, but to such as are pervious they should be used of a size or two larger than the obstruction, which the point of the instrument should penetrate. The armed bougie should be passed rapidly down to the stricture, and be held against it, with gentle but steadily-continued pressure, for one, two, or three minutes, according to the nature of the obstruction, for if it is very irritable and bleed readily, the caustic should be used for the shortest time on the first trial." Slight heat, and slight muco-purulent discharge, perhaps tinged with blood, are the effects which the patient is to expect; but they soon pass off, and it is alleged that it is an alterative and absorbefacient effect, not a mechanical destruction, which is to be wrought on the stricture. The caustic bougie may be used once in from three to five days, but never till the irritation caused by a pre- vious employment of it has quite subsided.1 The nitrate of silver may also be used by means of a small fragment inserted into the end of a bougie. There are, besides, instruments, used more especially for cauterizing the 1 Robert Wade on Stricture of the Urethra, 2d edit. Lond, 1849. See also H. Smith on Stricture, p. 121. The observations in H. Thompson on Stricture, 2d ed. p. 229, on the measured and observed effect of minute fractional parts of a grain of the potass, are well worth reading. 51G DISEASES OF THE URINARY ORGANS. prostatic portion, such as the porte caustique of Lallemand ; in which a stilette coated with the solid nitrate can be protruded : there is an instru- ment used by Henry Smith and others, in which the stilette is covered with sponge, dipped in a solution of the lunar caustic ;—and, still better, a catheter, devised by Mr. Erichsen, for injecting a few drops of caustic solu- tion into any part of the urethra that it may be desired to operate on. 5. Puncturation, or division of the stricture by means of the lancet ed stilette,1 invented by Mr. Stafford, or of Mr. Fergusson's urethrotome, may be resorted to in some cases of old stricture of small extent, at the anterior part of the urethra, which resist dilatation. The lanceted stilette consists Fig. 300. [Stafford's urethrotome.] of a tube, a, straight or curved, which is pushed down to the stricture, and from which a lancet, B, can be made to protrude by pressure on the head, c, so as to divide the contracted texture. The screw d regulates the extent to which the lancet protrudes; and a spring within the larger extremity of the instrument provides for the return of the lancet within its sheath. Mr. Fergusson's urethrotome consists of a very long director, under cover of which a very narrow blade can be introduced. Fig. 301. i. [Fergusson's instrument for incising the urethra.] Another instrument consists of a sound of ordinary dimensions, ending in a narrow director. The latter is passed through the stricture, and then a lancet-blade can be thrust forwards, along a slit running through the length Fig. 302. [Urethrotome tor cutting from behind forward.] of the director. Thus the lancet cannot get out of the proper channel. Many other forms there are, some intended to divide the stricture from be- hind forwards, as the instrument is being withdrawn, and these last are the safest. 1 Stafford on Stricture, Lond. 1829. Fergusson, Piact. Surg., 3d edit. p. 190. [4th Amer. ed. p. 584.] PERMANENT STRICTURE. 517 6. The operation of Opening the Urethra from the Perineum is ab- solutely requisite in all cases of rupture of the urethra with extravasation of urine, and in cases of stricture complicated with abscesses or false passage when no instrument can be passed; and it is expedient in cases of very old stricture with extensive urinary fistulas, when the health is giving way, and other means fail of affording relief. It is performed thus:—the patient is placed in the lithotomy position ; a grooved staff is passed through the stricture if possible. If this be not possible, it must be passed down to it. The left forefinger, introduced into the rectum, is to feel for the staff in the urethra, and serve as a guide to .the incisions. Then a straight bistoury is to be plunged in just above the anus to the depth of an inch, with its edge upwards, and made to cut its way out upwards in the middle line of the perineum. The end of the sound should next be felt for and cut upon, and the knife is then to be carried backwards through the stricture into the urethra beyond it, which is always more or less dilated and prominent, espe- cially if the patient is told to strain and try to pass urine. The stricture should be thoroughly divided, and all sinuses laid open. A catheter should then be passed into the bladder, and be retained there for twenty-four or forty-eight hours. If the operator desires merely to relieve the bladder, and does not think it prudent, from the patient's condition, to make the more extensive incisions through the stricture which we have just described, he may, after the first incision, keeping the back of the knife to the rectum, cut into the membra- nous part of the urethra behind the stricture, and so get a female catheter into the bladder, reserving the stricture for future treatment. 7. Perineal Section.—Professor Syme has recommended this operation, not merely for cases in which incision is commonly considered necessary, that is, for cases of impervious and complicated stricture ; but for others, in which, although an instrument can be passed, the stricture is excessively irritable, and resists the common treatment by dilatation, or contracts again perpetually, and is wearing out the patient's health by pain, rigors, and other signs of irritation, and in which the patient's state of health is such as to render an operation on these parts safe, and the residue of his life worth en- joying. The patient having been put under the influence of chloroform, and held in the lithotomy position at the edge of a bed, " a grooved director slightly curved, and small enough to pass readily through the stricture, is introduced and confided to one of the assistants. The surgeon, sitting or kneeling on one knee, now makes an incision in the middle line of the pe- rineum or penis, wherever the stricture is seated."1 It should be about an inch and a half long, and extend through [Curved grooved director, for Syme's operation] the skin and textures external to the urethra. The operator then taking the handle of the director in his left, and the knife, which should be a small straight bistoury, in his right hand, feels, with his forefinger guarding the blade, for the director, pushes the point into the groove behind the stricture, and runs the knife forward so as to divide the whole of the thickened texture at the contracted part of the canal. A full-sized catheter should be retained for twenty-four hours afterwards. The cases in which this operation is allowable are specified above. The amount of fatality attending it must be difficult to be estimated precisely : it will be less in private than in hospital practice, and in proportion as the patients are free from renal disease. Out of 219 cases collected by Mr. Thompson, i On Stricture of the Urethra, by James Syme, F.R.S.E., Edin. 1849. 518 URINARY abscess. only 15 deaths occurred within two or three months of the operation, and of these, 9 were hospital cases, which proved fatal by pyaemia. This is the greatest danger: hemorrhage seems not to be so great a source of risk.1 8. Lastly, supposing a case of old complicated gristly stricture, with complete retention from inflammation or spasm, the surgeon must estimate whether it might not be safer on the whole to puncture the bladder by the rectum, and so to give a period of tranquillity to the diseased parts, than to run the risk of a large wound in imperfectly-vitalized tissues, in a constitu- tion, perhaps, already almost worn out. In whatever manner a stricture has been cured, the bougie should still be used at intervals, to prevent a fresh contraction. Fig. 304. SECTION III.—URINARY ABSCESS, EXTRAVASATION OF URINE, AND FISTULA IN PERIN^EO. I. Urinary Abscess is a frequent consequence of stricture. Either an abscess forms in the cellular tissue close to the urethra, and after a time opens into that canal; or, perhaps, one or two drops of urine escape into the cellular tissue, in consequence of ulceration of the urethra behind the stricture; and this small quantity of urine produces inflammation, so that an abscess forms, filled with dark-colored putrid pus. In the same manner, a little urine may escape from a minute aperture in the bladder, and give rise to abscess behind the pubes, or between the bladder and rec- tum ; which may point above the pubes ; or in the groins, or may burrow amongst the muscles of the thigh. Symptoms.—A patient with old stricture com- plains of rather more difficulty of micturition than usual, and of some amount of obscure swelling of the scrotum or perineum, of an cedematous kind. There may be little or no pain, and little inflam- mation for the first twenty-four hours ; .after this the swelling increases ; if in the scrotum rapidly; if in the perineum it will be deep, hard, and pain- ful, but not prominent. Shivering, hot skin, and dry tongue follow. Treatment—The abscess should be opened im- mediately, and the patient may soon be brought from the gates of death to comparative health. It will also be expedient to cut through the stric- ture as directed in the last section, and pass a ca- theter into the bladder. II. Rupture of the Urethra and Extrava- sation of Urine.—This is another consequence of old stricture, and it generally happens in the fol- lowing way:—A patient, who has long been laboring under difficulty of micturition, has a fit of spasmodic retention more obstinate than usual. He is repeatedly getting out of bed, and straining with all his might to pass his water. At last, during one violeut effort, he plainly feels that something has given way ; his painful sense of distension becomes immediately less, and he is very well pleased, and thinks himself better. And perhaps he is now 1 See the very fair and impartial summary of the value of this operation in Mr. H. Smith's work on Stricture, p. 252; also in Mr. Thompson's work, p. 302. This cut exhibits the urethra laid open; a stricture at the commencement of the bulbous portion ; and false passages, one of which leads into an abscess that surrounds the membranous portion. FISTULA IN PERIN^EO. 519 able to make a little water by the natural passage, because the stricture generally relaxes, when, by any means whatever, it is relieved from the former pressure. But at the time when something seemed to yield, the urethra burst; the urine was forced by the whole power of the abdominal muscles into the cellular tissue of the scrotum, perineum, and groins; the patient soon complains of a smarting or tingling about the anus and peri- neum ; the urine, which has become putrid and concentrated by long con- finement in the bladder, speedily causes inflammation and sloughing; the skin over the infiltrated parts displays a reddish blush, which is soon suc- ceeded by black spots of gangrene; low typhoid symptoms appear; the tongue is black, the pulse begins to falter, the skin is clammy; low muttering delirium and hiccup come on ; and the patient soon departs this life, unless proper measures are taken for his relief. A black spot on the glans penis, indicating that the urine has penetrated the corpus spongiosum, is a very fatal sign. Treatment—A staff or catheter must be passed as far as possible, and it may sometimes be passed quite into the bladder, because, as was observed above, the stricture generally relaxes after the bladder is unloaded, be it how it may : the perineum must be incised in the middle line, and at the same time free incisions must be made into any parts that are swelled or emphy- sematous, showing that they have been pervaded by the urine. The first points necessary for the patient's safety, viz., the relief of the bladder, and the escape of putrid pus and urine, being thus provided for, the surgeon must use his own discretion as to meddling with the strictured part then, or reserving it till the patient has rallied a little. The urethra may also be ruptured by blows or kicks on the perineum, or by accidents that fracture the bones of the pelvis. The symptoms will be pretty evident. The patient will be unable to make water; or if he attempts it, the urine will be extravasated into the perineum and scrotum. There will also be bleeding. The treatment consists in introducing a full-sized catheter into the bladder, and retaining it for twenty-four hours; and in incising the perineum if urine has been extravasated. III. Fistula in Perin^eo, or Urinary Fistula, signifies an opening from the perineum into the urethra, through which the urine dribbles when the patient makes water. It is a frequent consequence of urinary abscess and extravasation. Treatment.—The first and most essential measure is, to restore the urethra to a healthy state, and to dilate any strictures that may happen to exist, by the bougie. When this has been done, the fistula should be stimulated to granulate by injections of arg. nit., or by passing a heated wire into it; and the external orifice should be occasionally touched with potass, so as not to allow it to heal before the whole track is closed—otherwise fresh abscesses will form. In extreme cases the urethra must be laid open, as before directed. For loss of substance, an incision may be made on either side, and the vivified edges be brought together by suture. Sometimes there is a blind fistula in perinaeo; that is, a small narrow fistula, opening into the urethra, but not externally. It is occasionally inflamed and tender; and may be felt as a small tumor in the perineum; perhaps the size of a horse-bean. It is attended with more or less discharge from the urethra. The treatment consists in laying the tumor open, and dilating any strictures that exist. Sometimes a fistulous communication forms between the urethra and rectum. This may be known by air passing through the urethra. It is to be treated by dilating the urethra, so that the urine may pass freely; and then a heated wire may be introduced into the fistula from the rectum, in order to close it by the adhesive inflammation. 520 AFFECTIONS OF THE URETHRA. SECTION IV.—OF SOME OTHER AFFECTIONS OF THE MALE URETHRA. I. Contraction of the Urethra following injuries, such as blows on the perineum, must be treated in the same way as permanent stricture. II. Contraction of the Orifice of the urethra may be a congenital affection, or may be caused by the cicatrization of ulcers. It must be counteracted by the daily passage of a short bougie, otherwise it may produce all the evil consequences of stricture further back. If the con- traction is very great, and causes retention of urine, one of Anel's probes, a common probe, and a director may be introduced in succession, and then, when the bladder is emptied, the orifice must be dilated by a slight incision downwards. III. False Passage.—This may be produced by using too small a sound, and pushing it out of the urethra, or by the misuse of caustic bougies. There is nothing to be done for the false passage ; but the stricture, which was the origin of it, must be treated either with the metallic sound, or by keeping in a small catheter. When the surgeon suspects that he has pushed an instru- ment out of the right passage, he ought to leave the urethra untouched for at least a week. IV. Hemorrhage from the Urethra may be caused by the rude intro- duction of bougies, or by injuries from without, or by the separation of a slough formed by the caustic bougie ; or, lastly, by a rupture of blood- vessels during acute chordee. If the application of cold does not check it, pressure may be tried. A flat piece of cork should be pressed by the patient against the perineum far back, and be gradually moved forward, till it lights on the right spot, and the dripping of blood ceases. Gallic acid may be of service. Y. Solid Tumors in the course of the urethra, composed of indurated follicles, torment the patient by keeping up a perpetual gleet and chordee. The mercurial ointment with camphor externally ; and the passing of a bougie ; or keeping a small catheter in the bladder for a few days at a time —are the chief remedies. TI. Tumors within the Urethra, formerly called Caruncles, consist either of vascular excrescences near the orifice, which may be snipped off or cauterized ; or of small polypi growing from the prostatic or membra- nous portion. Both are rare. TIL Acute and Chronic Inflammation of the mucous lining of the urethra, from whatever cause arising, present the symptoms, and consequences, Fig. 305. Fig. 306. Fig. 305. Discharge from gonorrhoea, all but cured. 1+a. The same, with acetic acid. Fig. 306. Discharge in a case of obstinate non-venereal gleet. and require the treatment of the gonorrhoea and gleet which arise from con- tagion. The author has found mere epithelium in discharges from the male urethra, which yet caused great irritation to the female after connection. VIII. Foreign Bodies in the urethra may consist of calculi, pieces of bougies, straws, slate pencil, or of other bodies introduced from without; of clots of blood, of mucus, or, in rare cases, of portions of fecal matter, or foreign bodies in the urethra. 521 worms that have passed into the bladder from the intestines by means of an ulcerated opening. They may perhaps be pushed forwards by the fingers, Fig. 307. This instrument consists of two blades, capable of being expanded by being pushed through the canula a, and being closed if the canula is pushed forwards above them ; d, a screw, regulates the dis- tance to which they can be expanded. aided by the patient's strainings,—and then may be brought out through the orifice (which must be slightly dilated if necessary) by forceps, or a bent probe. Many instruments have been invented for this purpose, and espe- cially by lithotritists. The urethral forceps of Weiss ; the instrument con- sisting of two blades b, passing through a canula a, and having a central file c, for pulverizing any substance that admits of it;—and the scoop with a tongue are the most useful. A loop of fine wire, and a pair of very fine dissecting forceps may also be found useful. During the necessary manipu- lations a finger or thumb should be pressed on the urethra behind the foreign [Weiss's and other instruments for foreign bodies in the urethra.] body—through the rectum if needful—in order to prevent it from slipping backwards into the bladder. With this precaution it may answer to inject a good stream of water from a large syringe, so as to dilate the passage. But if these means fail, the substance must be pushed back into the mem- branous portion (if not there already), and be extracted by an incision in the perineum. Incisions into the front of the urethra should be avoided, for they are apt to leave irremediable fistulas; or, if near the scrotum, may occasion infiltration of urine into its loose areolar tissue. 522 diseases of the prostate. section v.—diseases of the prostate.1 I. Acute Inflammation of the prostate is generally a consequence of acute gonorrhoea, but may be caused by stricture, calculus, or any other source of irritation. The symptoms are, great weight, pain, and throbbing at the neck of the bladder, and'tenderness of the perineum ; the gland feels swelled and tender on examination by the rectum, and there are frequent, violent, and exceedingly painful efforts to make water: as the disease subsides, a grayish viscid muco-purulent matter is voided with the urine. Treatment—Rest in bed, cupping or leeches to the perineum, or general bleeding if the patient is strong, hot baths, poultices, and fomentations : and enemata of starch ^ii, laudanum 3ss every night. If the urine cannot be passed without it, a very small gum catheter may be introduced; but it should be avoided if possible. II. Chronic Inflammation, with enlargement from interstitial deposit, may be a sequel of the acute ; and should be treated by baths, small doses of mercury, alkalies, and iodide of potassium. III. Abscess of the prostate is an occasional, though rare, consequence of tubercular deposit in scrofulous subjects. It is more commonly an acute affection, and may be suspected if rigors, and obscure swelling in the peri- neum, follow the symptoms of acute inflammation. In any such case, the swelling should at once be freely punctured with a bistoury. If left to itself, the abscess may burst into the rectum or the urethra, which latter circum- stance will be indicated by a sudden discharge of pus with the urine, and a stinging pain accompanying the discharge of the last few drops. Perhaps there may be hemorrhage. If the case is chronic and the habit scrofulous, quinine and tonics, and small doses of cubebs, to act as a gentle stimulus on the parts, will be of service. IV. Chronic Enlargement, or Hypertrophy.—" The prostate," says Mr. Ellis, " is essentially a muscular body, consisting of circular or orbicular involuntary fibres, with one large central hole from the passage of the urethra, and another smaller oblique opening, directed upwards below the former for the transmission of the common ejaculatory seminal ducts to the central urinary canal. ... Its circular fibres are directly continuous behind, without any separation, with the circular fibres of the bladder." The pros- tate is thus essentially a circular involuntary sphincter to the neck of the bladder, and expeller of the seminal fluid ; but although it contains many mucous glands and follicles, intermixed with the muscular fibres, it is by no means entitled to the name gland. It contains, further, a small vesicle or utricle, at the mouth of which the ejaculatory ducts open, and which is be- lieved to be the male homologue of the female uterus. The affection we now treat of is peculiar to advanced life, and consists in an hypertrophy or enlargement of the natural muscular structure, and inci- dentally of the glandular. " In youth," says Mr. Thompson, " the organ becomes enlarged by interstitial plastic effusion, the result of inflammatory action. In age there is an unnatural development of the prostatic tissue itself." The increase may be but slightly above the ordinary chestnut size of the gland, or it may render it as large as a man's fist, or larger. It may affect the whole organ, especially the lateral lobes, pretty uniformly; in which case the prostatic portion of the urethra is greatly lengthened ; or it may affect 1 For the latest and best account of the structure and diseases of the prostate, see Henry Thompson on the Enlarged Prostate and Stone in the Bladder, Lond. 1858; also Med.-Chir. Trans, vol. xl.; Ellis, ib. vol. xxxix.; also Coulson on Diseases of the Blad- der and Prostate Gland, 4th edit., Lond. 1852, p. 421. Adams on the Prostate Glaud. ENLARGED PROSTATE. 523 one side more than the other, in which case the canal will be twisted; or it may affect the posterior median portion, which lies between the ejaculatory Fig. 311. Fig. 312. Enlarged prostate. Cyst of the prostate, from the King's College Museum. ducts, enlarging it into what is commonly called the middle or third lobe; a lobe which, according to Mr. Thompson, is purely the result of unnatural enlargement and does not exist in health. The consequence of this is, that there is a projection at the very orifice of the urethra, causing a most serious impediment to the issue of the urine. The prostatic portion of the urethra, besides being lengthened, twisted, and obstructed, may be very much nar- rowed ; or, on the contrary, may be expanded into a sort of pouch, which may communicate with cavities formed by the dilated ducts of the gland, and contain calculous matter. Hypertrophy and derangement of the mus- cular fibres at and near the trigone, may produce a transverse bar at the neck of the bladder. The enlargement, further, may be due to an increase of the organ gene- rally ; or to the development of one or many masses of fibrous tumor ; exactly similar in structure to those concentric masses of muscular- fibre, which are developed in the womb, and are commonly known as fibrous tu- mors. One or more of these masses, involving more or less glandular tissue, may be developed alone, and may project as a pedunculated tumor ; or may be contained within the mass, capable of enucleation, and may constitute the whole disease ; or may be combined with general hypertrophy. The symptoms of this disease may be divided into those which the surgeon ascertains by physical examination, and those of which the patient himself makes complaint. On examination, by means of a well-oiled forefinger introduced into the empty rectum, the surgeon ascertains the existence of the tumor; and on using the catheter, finds an obstruction at the neck of the bladder. Most probably, too, after the patient has voided all the urine that he can, the catheter will relieve him of a further quantity. The symptoms which the patient describes are slowness and difficulty in making water, sense of weight in the perineum, and tenesmus; so that, as Coulson observes, he often believes he has internal piles. In the next place, the bladder becomes irritable, and the calls to make water are oftener than before. Then, as the patient cannot empty the organ completely, in conse- 524 ENLARGED PROSTATE. quence of the projection formed by the tumor, a portion of urine always remains behind, and decomposes, and becomes ammoniacal. Sometimes a fit of complete retention ensues, and it may be brought on by exposure to cold or excess in venery. Next the mucous coat of the bladder, irritated by the frequent strainings, and by the alkaline urine, inflames and secretes a viscid mucus. Finally the obstacle continuing to increase, the bladder is constantly distended, the urine perpetually dribbles away, the ureters become dilated, the kidney disorganized, the patient's little remaining strength is exhausted, and he dies. Abscess in the gland, or ulceration of that surface which projects into the bladder, sometimes adds to the patient's misery, and hastens his death. The causes of this hypertrophy are as unknown as those of any other tumor. It generally commences, as Sir B. Brodie observes, about the time that the hair turns gray, and when earthy specks begin to be deposited in the coats of the arteries. Not, however, that all old men have enlarged prostates ; on the contrary, as Mr. Thompson observes, the change is ab- normal and exceptional. Out of forty-three specimens from men of 50 and upwards, he found two atrophied ; nine enlarged slightly ; and only five considerably, or to such a degree as to have given rise to symptoms during life. He believes that the change rarely begins before fifty-five, or after seventy. Treatment.—This must be palliative. The patient should avoid irregular diet, fatigue, and exposure to cold. The bowels must be kept easy, so that there may be no straining at s'tool;—irritation of the bladder must be alle- viated by the measures we shall speak of in the next section ; and occasional fits of pain or congestion by leeching and hot baths. The surgeon must take care that the bladder is regularly emptied, and if not he must introduce the catheter at intervals to get rid of the residual urine. The catheter should be long; its curved portion about a quarter of a circle whose diameter is 4.5 or 5 inches. The handle should be well depressed between the legs as the point is entering the bladder, in order that the point may ride over the projection. The finger also may be introduced into the rectum to guide it. A small gum catheter which has been kept a long while on an iron wire of the proper curve, may be useful. A silver catheter, with a very short abrupt curve, is recommended by Coulson. In order to empty the bladder completely, it may be necessary to turn the patient on his hands and knees. In any long-neglected case the urine may be drawn off in small quantities at a time, and the strength be well supported with tonics, wine, and plenty of nutriment. Radical remedies for producing absorption of the tumor, such as mercury, the iodide and bromide of potassium, and certain mechanical arrangements, have been proposed. But in the present state of knowledge, it is not desirable to use any such remedy in any way that shall interfere with the patient's health and comfort. V. Complete Retention of Urine from enlargement of the prostate. In this case, if there are inflammatory symptoms, cupping from the perineum, the hot bath, and opium are indicated. The catheter should be passed if possible. If, however, the catheter cannot be passed by the natural route, the surgeon, guiding it with his left forefinger in the rectum, may thrust it through the projecting part of the gland into the bladder, or he may use a lanceted stilette. But if this cannot be done, the last resource is puncture of the bladder ; by the rectum, if possible ; if not, above the pubes. VI. Calculi of the prostate are composed, according to Dr. G. Bird, like other calculous concretions on mucous membranes, of phosphate of lime mixed with triple phosphate, and may be deposited either in the dilated urethral canal of an enlarged prostate, or in the ducts and cells of the DISEASES OF THE BLADDER. 5 25 gland, or in both. The most remarkable instance of prostatic calculus on record is related by Dr. Herbert Barker, of Bedford, to whose kindness the writer is indebted for the an- nexed engraving of it. The en- Fig. 313. tire calculus is nearly 4| inches in length, and, at its broadest extremity, 4f inches in circum- ference, and weighs 1681 grains. It is composed of twenty-nine separate portions, slightly ad- hering by COnchoidal Surfaces, [Prostatic calculus.] no doubt originally deposited in separate cells of the prostate, and the whole agglomerated into one mass by the absorption of the intervening tissue.1 The symptoms of these concretions are, at first, irritation of the neck of the bladder, and difficulty of micturition, as in other cases of enlarged pros- tate ; the calculi may also be probably felt with the sound, or by the finger in the rectum. In some cases it may suffice to keep the urethra well dilated, so as to favor spontaneous escape ; or it may be possible to remove one or more with the urethral forceps ; but, should they cause great irritation, ab- scess, or retention of urine, it will be necessary to cut down on them from the perineum, and remove them, as was successfully done by Dr. Barker. VII. Cancer of the prostate is very rare. In one or two cases of hard cancer which occurred in Sir B. Brodie's practice, the gland was enlarged, of a stony hardness; there was great pain in the groins and perineum, irri- tability of the bladder, and cancerous cachexia. Soft cancer is equally rare. The symptoms are nearly the same as those of cancer of the bladder.2 SECTION VI.—DISEASES OF THE BLADDER. I. Irritable Bladder.—Many cases described under this title are cases of gout or of inflammation. Simple irritability, that is, a frequent inclina- tion to pass the urine with or without spasm ; but without inflammation or organic disease, may be caused, 1. By an irritating state of the urine ; the qualities of which, and the presence or otherwise of oxalate of lime, triple phosphate, and albumen, should be ascertained ; 2. It may be the effect of mere nervousness, which is not uncommon in elderly people, or of mental agitation ; 3. It may be caused by irritation of the rectum, womb, or other adjacent organs ; 4. By general debility; 5. By exposure to cold. The surgeon should examine into causes. Soothing medicines, such as bella- donna, F. 149, may be of use. II. Nocturnal Incontinence.—Involuntary flow of urine during the night is common enough in delicate children; but the surgeon may be consulted on account of its continuing to an age at which such an infirmity becomes very troublesome and degrading. Any such case should be care- fully studied under these heads. 1st. It should be ascertained whether the urine is irritating in quality or excessive in quantity ; which it very fre- quently is. Thus, it will often be found, that the malady is aggravated when the bowels are confined, or the diet unwholesome, or saccharine drinks used too freely, or when there has been too much fatigue; all which circum- stances must be avoided. (See Section 8.) 2d. If there is nothing wrong in the urine, the condition of the bladder must be attended to ; blisters to the sacrum ; tonics, or very small doses of nux vomica, may be of service. 1 Trans, of Provincial Medical Association, N. S. vol, iii. 2 For cases, see Coulson, op. cit.; Stafford M. C. T. xvii. 526 DISEASES OF THE BLADDER. 3d. The habit must be attacked ; the patient may be awakened at a certain hour, so that he may void his urine of his own accord : sometimes touching the orifice of the urethra with nitrate of silver, so that the flow of urine may cause severe smarting, is worth trying. Small doses of tincture of cantha- rides are also recommended ; but the writer has more than once seen the malady increased tenfold by the empirical use of this drug in cases in which irritating and too copious urine was the source of the mischief. [By far the most effectual medicine in nocturnal incontinence is belladonna, first recommended for this purpose, we believe, by Trousseau. On this subject the paper of Dr. Addinell Hewson, in the Amer. Journ. Med. Sci., October 1858, will be found an interesting one.] In cases of irritation of the bladder from any cause, immense quantities of epithelium may be passed with the urine, forming a thick white pus- looking sediment. It is easily distinguished by microscopical examination, and by the fact that the urine is not albuminous. III. Paralysis of the bladder may occur under many circumstances. It may be caused by injury or disease of the head or spine; it is often present in typhus fever—it may be caused for a time by any severe injury, especially of the legs—it generally remains for a few days after the bladder has been long distended, whether from prostatic disease or stricture—and it some- times occurs suddenly to nervous sedentary people, who, if they let their bladder get filled beyond a certain point, find that they cannot empty it. The symptoms of it are, either retention of urine, i. e., that the patient can- not make water; or else incontinence of urine, i. e., that the water dribbles away without his being able to hold it. The diagnosis of retention through palsy, from retention through stricture, is easy. The retention from palsy comes on suddenly, and there is no obstacle to the introduction of a catheter. Yet palsy of the bladder may be combined with spasmodic stricture. Treatment—The catheter, if required ; in pure palsy, the muriated tinc- ture of iron : cubebs, buchu, strychnine. F. 21, 180, &c. IV. Incontinence and Dribbling of Urine.—This is a symptom that requires particular notice ; because in nine cases out of ten it happens, not because the patient cannot hold his water, but because he cannot pass it— either from stricture or enlarged prostate, or palsy of the bladder. For it must be noticed, that in either of these cases, so soon as the bladder becomes full, a little urine begins to dribble away through the urethra—and besides the patient may perhaps be able to squeeze out a little by straining with his abdominal muscles, and may believe his bladder to be empty, although all the while it is enormously distended. No surgeon will fail to put his hand on the pubes when he sees the urine dribbling away. The obvious remedy is the catheter. V. Hysterical Retention of Urine.—There is one form of palsy of the bladder which is not unfrequent in hysterical women, and which consists in a deficiency of will rather than of power. They are not unable to empty the bladder if they try—but they are unable to try. These cases must be treated with purgatives, and fetid medicines, both internally and as enemata, F. 102. If the catheter is not employed, the patient will generally begin to make water so soon as she suffers much from distension. VI. Acute Inflammation of the bladder (cystitis) in young persons is most frequently a consequence of neglected or ill-treated gonorrhoea; in older persons, it may arise from gout; or it may be an aggravation of per- sistent chronic inflammation from stone, or stricture. The symptoms are pain, referred to the perineum and sacrum, tenderness of the lower part of the abdomen, micturition exceedingly frequent, attended with great strain- ing, and followed by an aggravation of the pain, a mucous or muco-puru- lent sediment in the urine, and fever. (See page 530.) DISEASES OF THE BLADDER. 52, Treatment—Leeches to the lower part of the abdomen or perineum, hot baths, and warm fomentations; a good dose of calomel, followed by castor- oil, to divert irritating matters from the kidneys ; opium by mouth, or by enema, or suppository, in sufficient doses thoroughly to allay pain, and the bicarbonate of potass, neutralized with lemon-juice, or F. 58, 78. VII. Chronic Inflammation of the bladder (catarrhus vesicas) is a very frequent consequence of irritation from stricture, diseased prostate, or stone. Symptoms.—Micturition frequent, and attended with scalding pain ; the urine loaded with muco-purulent matter, which is sometimes tinged with blood, sometimes yellowish and puriform, but more generally grayish, streaked with white, alkaline, and excessively viscid, so as to stick to the bottom of the chamber-pot when turned upside down. In the early stages there is but little mucus, and the urine may remain acid ; but as the disease advances, the quantity of mucus becomes enormous, and the urine is voided of a brownish hue, and of a most offensive ammoniacal odor. Moreover, it may clog the urethra, and cause retention of urine ; a kind of retention diffi- cult to manage, because the mucus clogs up the eyes of the catheter. In this stage there is very frequent desire to make water, and constant pain above the pubes. In general, the mucus contains phosphate of lime, which may be seen in it in white streaks, and which is apt to collect and form a stone in the bladder. Ulceration.—Perhaps the mucous membrane of the bladder may ulcerate, and after death it may be found as cleanly dissected from the muscular coat as if it had been done with a knife. This will be attended with an intense aggravation of the pain in micturition, and with a dark color of the urine ; owing to the admixture of a little blood which exudes from the ulcerating surface, and which, after the urine is passed, sinks to the bottom like coffee- grounds. The bladder frequently throws out flakes of lymph, which become incrusted with patches of phosphate of lime. Moreover, it becomes ex- ceedingly thick (the common opinion is that it is hypertrophical; Mr. Han- cock finds that the thickening is inflammatory); and portions of it are apt to form pouches which are soon filled with mucus, or with phosphatic calculi. Finally, disease of the kidneys ensues, and the patient dies. Treatment—In the first place, if there is a stricture, or enlarged prostate, or stone in the bladder, proper measures should be taken for their removal or relief. In the next place, if the symptoms are at all severe, the patient should keep himself in the recumbent position as much as possible, with the pelvis elevated. Thirdly, if there is at any time a great aggravation of pain, and the strength is pretty good, a few ounces of blood may be taken hj cupping on the sacrum or perineum ; but, as a general rule, all' lowering measures are injurious. Pain and irritation are to be allayed by the hip- bath, and by enemata or suppositories of opium. Opiate plasters to the sacrum are sometimes of use. The bowels should be kept properly open by mild aperients. The diet should be nourishing, but plain ; with weak brandy or gin and water, or sound sherry, for drink. Of medicines, the most useful, according to Brodie, is the root of the pareira brava. Uva ursi, buchu, Chian turpentine, cubebs, copaiba, and tinct. ferri mur. in small doses three times a day, are remedies of similar virtues. Hyoscyamus or opium, and small doses of mineral acids, if the urine is highly alkaline, may be added to any of them. The sulphate of zinc may also be highly useful, F. 9, 181, 182, &c. Injections into the bladder are not to be thought of when there is acute inflammation of the bladder, and blood mixed with the mucus, but they are highly serviceable in chronic cases, by relieving the irritability of the blad- der, and washing out the organ, getting rid of the decomposed stinking 528 ORGANIC DEPOSITS IN THE URINE. , urine and mucus. Injections of simple warm water are very useful: the best way of effecting them is that employed by Mr. Fergusson: it is to have a catheter with a double passage, and to throw in the water in a continuous stream by means of a small syringe like that of a stomach-pump. Three or four pints of water may thus be passed through the bladder daily. Injec- tions of very dilute nitric acid (r^i—ii—ad Jiss. aq. destil.) are of great service when the urine is highly ammoniacal. Injections of the nitrate of silver have also been used : these require a catheter of very pure silver strongly gilt; those of the acid may be passed through the nickel silver in- struments used in lithotrity ; or with an elastic bottle and elastic catheter.1 In the excessively painful case of ulceration of the bladder, opium given regularly and largely, and introduced into the rectum, is the chief remedy. Injections into the bladder of strong solution of extract of poppies, or of salts of morphia, may be tried. VIII. Cancer and Epithelioma sometimes affect the bladder either in the form of solid deposits, or of vegetations. The ordinary symptoms are frequent desire to make water; and uneasiness in the region of the bladder, aggravated after micturition, and often extending to the glans penis, peri- neum, rectum, and groins. The urine is generally turbid, and deposits an adhesive purulent mucus, and it is very frequently mixed with blood, in irregular clots; and with these, portions of cancerous substance, or of epi- thelial granulations, are sometimes intermingled. These symptoms, com- bined with the absence of a calculus, and the probability perhaps of detecting a tumor within the bladder by means of the sound, or by examination of the rectum ; or the tumor formed by the thickened bladder in the hypogastrium, and microscopic examination of fragments which pass, are the chief means of diagnosis. The epithelial granulation depicted at p. 120 was taken from the urine of a gentleman who died of epithelioma. The treatment consists in allaying pain by opiates, and in checking hemorrhage and catarrh of the bladder by gallic acid or tincture of steel, and in giving an abundant diet. IX. Villous Vascular Growth.—A growth of excessively fine arbo- rescent tufts, consisting, like the villi of the chorion, of loops of large capil- laries, and clothed with a cell-growth—generally proving early fatal from profuse hemorrhage Whether the growth be in its essential nature really vascular or warty, or epithelial, or cancerous, or sometimes one or the other, is yet uncertain. Mr. Partridge has collected some cases of this malady, and thinks that the frequent presence of blood in the urine, with no other morbid condition to account for it, is the best diagnostic sign. X. Polypus of the bladder will display many of the symptoms of stone, but may be distinguished by not being movable. It has been extirpated. XL Tuberculous disease ; abscesses bursting into the bladder; and can- cerous or corroding ulceration spreading from the bowels, rectum, or vagina, must be treated on general principles. SECTION VII.—DIAGNOSIS OF BLOOD, ALBUMEN, PUS, AND EPITHELIUM IN THE URINE, DISEASE OF THE KIDNEYS, HEMATURIA, AND SUPPRESSION OF URINE. I. Organic Deposits in the Urine.—This is the most convenient place for giving a brief description of those organic substances which are occa- sionally mixed with the urine, through disease of the organs which secrete it, or through which it passes. For a complete account of the subject, we must refer to Dr. George Johnson's work on the kidneys, and to Dr. Lionel 1 See Coulson on the Bladder, &c, 4th edit. p. 170, ALBUMINOUS URINE. 529 Beale on the "Microscope in Clinical Medicine." Here we can find room for a few practical remarks only. 1. Blood is very frequently found in the urine, rendering it dark and smoky if the quantity is but small, but betraying itself by red clots if the quantity is large. The blood-cells may be detected by the microscope, and the serum by the test to be presently mentioned. If it proceed from the secreting portion of the kidney, it will most likely be in small quantity, and uniformly diffused through the urine ; and fibrinous moulds of the kidney tubules will be found in the sediment, and may be detected by the micro- scope. If the blood comes from the pelvis of the kidney, it may be in larger quantity, and there may be worm-like clots moulded in the ureters. (See Haematuria, p. 532.) 2. Serum, without red particles (albuminuria), is very frequently mixed with the urine ; when the kidneys are affected with any of those forms of degeneration of chronic inflammation known by the collective term Bright's disease ; or when, without original disease in themselves, they are exceed- ingly congested from pregnancy, disease of the heart, or any other cause. It is not at all unfrequent in the urine of children at the commencement of the exanthemata, or, properly speaking, in most acute diseases. Serum may be detected by the discovery of its albumen, the presence of which causes serous urine to be commonly known as albuminous urine. Fig. 314. [Urinary deposits.] 1. Small globules ; blood, nuclei, small epithelial cells, and spherules of oxalate of lime. 2. Pus. 3. Epithelium from the bladder ; the typical form, a long oval, pointed at each ex- tremity, with central nucleus ; the younger cells spherical and pellucid ; the older ones flattened, often full of granules or oil. 4. Small casts from the kidney, consisting of fibrinous matter entangling few epithelial cells ; two of these cells distinct. 5. Triple phosphate. To detect albumen, heat a small quantity of filtered urine to the boiling point, in a test-tube over a spirit lamp ; when the albumen will coagulate, and, according to its quantity, may either produce a mere opacity, or may even solidify the entire specimen heated. If the urine be alkaline, this test will fail, because then heat alone will not coagulate the albumen ; and, more- over, heat alone may cause a deposit of white phosphates; therefore a few drops of nitric acid should be added after the boiling, which will dissolve the precipitate if phosphatic, but not if albuminous, and will throw down the albumen if the urine is alkaline. 3. Fibrine in the urine, when present in large flocculi from any ulcerated surface in the bladder, is readily distinguished. This substance, however, is most interesting when moulded in the tubules of the kidney, and accompany- in <>• albuminous urine ; thus giving evidence of the seat of the effusion. These fibrinous casts of the tubuli uriniferi may vary much in size and ap- pearance. They may be small and transparent, or large and transparent; 34 530 ORGANIC DEPOSITS. or they may contain kidney epithelium in large or small quantity. When small, they show that they have been moulded in tubules not deprived of epithelium. 4. Epithelium, from any part of the urinary organs, may be present in urine. Here we may recall to the recollection of our readers, that under slighter degrees of irritation the uniting medium which gives consistence to any epithelial or cuticular layer becomes loosened, the epithelium is formed in greater abundance, and is shed or desquamated more rapidly than natural. Under higher degrees of irritation or inflammation, the entire epithelial covering is stripped off or excoriated—a state of things usually followed by the evolution of pus globules on the inflamed surface. 1. The small round gland epithelium from the kidney, and the nuclei of disintegrated epithelium cells, are often found in small quantity in the urine when containing oxalate of lime, or when irritating from any other cause. 2. The kidney epithelium may be agglutinated by fibrinous effusion, and may be found in the sediment of albuminous urine in the form of epithelial casts, in those acute and chronic inflammations which Dr. G. Johnson calls desquamative nephritis. 3. The same epithelial cells and casts also may be found loaded with oil globules in certain stages of some varieties of Bright's disease. 4. The epithelium from the pelvis, ureters, and especially from the bladder, is often found in great abundance when these parts are irritated by the urine, or by any other cause. The writer has found immense quantities in the urine after difficult labors ; it presents itself as a purulent-looking deposit, seen under the microscope to consist of columnar or oval cells, of very various shapes and sizes, with single nuclei, the larger and older cells often full of granular matter, and almost disintegrated. The urine is not albu- minous of necessity. (See Fig. 314, 3.) 5. Mucus, a viscid, stringy, structureless substance, coagulated by acetic acid ; alkaline in its reaction, when proceeding from the bladder and fauces; acid, when coming from the vagina ; not albuminous ; often containing large quantities of phosphate of lime, and having the property of rendering the urine alkaline, and of precipitating triple phosphate. It usually contains some amount of desquamated epithelium, and a few globules, perhaps epi- thelial nuclei in a granular state. 6. Pus may be present at the urine, through suppuration of any part of the mucous lining of the urinary passages, or from an abscess in some con- tiguous part which has burst into them. It generally falls to the bottom of the vessel containing the urine, "forming a dense homogeneous layer of a pale-greenish cream color, seldom hanging in ropes in the fluid, like mucus, and becoming, by agitation, completely diffused through it. The addition of acetic acid neither prevents this diffusion, nor dissolves the deposit. If a portion of the deposited pus be agitated with an equal quantity of liquor potassae, it forms a dense, translucent, gelatinous mass. On decanting some urine from the deposited pus, the presence of albumen may be detected by heat and nitric acid."1 The pus globules may be recognized under the mi- croscope, and the addition of acetic acid reveals the characteristic nuclei. 1. When pus comes from the uriniferous tubes, the kidneys being in a con- * firmed state of suppurative disorganization, it may sometimes be found moulded in the form of the tubules; but at all events it may be presumed to come from this source, if constantly present in the urine, and equably dif- fused through it, and if there are the other signs of kidney disease to be presently described. 2. Pus from the bladder will probably be mixed with large quantities of mucus, constituting muco-purulent matter. 3. Pus from an abscess will be variable in quantity, and not equally diffused. We must 1 Golding Bird on Urinary Deposits, 2d edit. p. 273. DISEASES OF THE KIDNEY. 531 Fig. 315. here remark that a few pus globules are often mixed with epithelial debris without the urine being albuminous. 7. The Echinococcus occasionally infests the kidney, producing severe disturbance. Small cysts, containing the animals, with their characteristic hooklets, p. 168, may be found in the urine, as in a case lately published by Dr. Herbert Barker. Turpentine in diuretic doses is the best means of dis- lodging them. II. Acute Inflammation of the Kidney (Acute Nephritis) is some- times caused by blows on the loins, or by the irritation of renal calculi, but is very rarely an idiopathic primary affection. The symptoms are, burning pain and tenderness in the loins ; colicky pains in the belly ; the urine scanty and high colored, and the bladder irritable, so that there are constant at- tempts at micturition ; fever and great thirst, and vomiting. The remedies are__cupping, leeches, and castor oil—repeated doses of calomel, opium, and antimony, with colchicum if the habit is gouty ; warm baths, or warm fomentations to the loins, and barley-water and other demulcent drinks. III. Chronic Disease of the Kidneys, when it comes under the sur- geon's care, is generally a con- sequence of long-standing dis- ease of the urethra or bladder. When the bladder has been subject to frequent distension through stricture or enlarged prostate, and its mucous mem- brane inflamed, the ureters are liable to become distended and converted as it were into sub- sidiary receptacles for the urine, so that all the violent strainings to evacuate it tell upon the kid- neys ; and these become dis- eased, through the mechanical irritation, and the extension of inflammation from the bladder. The pelvis and infundibula un- dergo suppurative inflammation —a state described as pyelitis, and then the disorganization of the uriniferous tubes easily fol- lows. Symptoms.—A person, who has long been laboring under some chronic affection of the bladder, begins to complain of general weakness and languor, both bodily and mental. The sleep is unrefreshing, the tongue nauseous, and the appetite lost. There is frequent pain of a weak aching character in one or both loins; occasionally shooting down to the testicles or groins. The urine is albuminous; it is generally pale-colored and opaquish when passed ; some- times it is tinged with blood, and sometimes containing shreds or flakes ot This engraving from a preparation in the Middlesex Hospital Museum, represents the beginning, middle, and end of a fatal case of disease of the urinary organs. It shows a tight stricture about three inches from the ex- tremity of the penis; the urethra dilated behind it; another stricture in the membranous portion ; false pas- sages and abscess around ; the bladder contracted in siz« but enormously thickened ; the ureter dilated and tortu- ous, looking like an intestine; and the kidney expanded and atrophied, with scarce any of its secreting substance remaining. 532 diseases of the kidney. lymph. As the disease proceeds, it deposits pus after standing. Fits of sleepiness, headaches, and sickness come on. These cases are almost sure to end fatally. Sometimes the patient dies of exhaustion and obsiinate vomiting; sometimes of suppression of urine and coma; sometimes in a sudden fit of severe shivering; and sometimes of a rapid attack of acute inflammation. The kidneys are found after death to be soft and disorgan- ized ; readily separating from their capsule, which however adheres firmly to the fat and cellular tissue of the loins; and most likely they are dilated into cysts; the secreting tissue being spread out over the dilated pelvis and infundibula. IV. Abscess in the Kidney.—This may be suspected if dull pain in the loins and repeated shivering follow the symptoms of nephritis. Sometimes the abscess bursts into the ureter, and an immense quantity of pus is dis- charged with the urine. Abscess of the kidney also sometimes bursts on the loins, and the patient has been known to recover. V. Treatment of Chronic Kidney Disease.—On this subject we can but give a few general hints. When there is much tenderness in the loins, a moderate quantity of blood may be taken by cupping. Blisters or plasters of the emp. ammoniaci, or of opium or belladonna, may also be of service. The skin should be kept warm by flannel. It will be necessary to provide for the free action of the liver and bowels, and to keep up the secretion of the kidneys, if deficient, by the milder sorts of diuretics, such as small doses of neutral salts; the infusions of buchu, and uva ursi, of carrot-seed, or of the root of parsley. The tartrate of iron will be of great service. The diet generally should be plain, but nutritious. If the loss of albumen is great, it should be combated by gallic or tannic acid, or tincture of galls or rhatany, or decoction of oak-bark internally, and by the use of strong essence of meat. F. 198. VI. Hematuria, or Bloody Urine.—The seat of the hemorrhage may be either the kidneys, or the prostate or bladder. 1. Hemorrhage from the kidney may be caused by the irritation of renal calculi, or by blows on the loins ; by the congestion consequent on scarlet fever; and by other diseased states of the whole system, as in typhus and scurvy. 2. Hemorrhage from the prostate or bladder may be caused by the rude introduction of instruments, or by the irritation of stone ; or by the existence of an ulcer or fungoid tumor, of which, in fact, it is often the earliest mani- festation. When the blood is derived from the bladder, some portion of it often flows pure after the urine is discharged, and it is in much greater quantity, and often in larger and more irregular clots than when derived from the kidneys; moreover, the pain in the back, and other signs of renal irritation that accompany bleeding from the kidney, will not be present. Treatment.—When hemorrhage from the kidneys is attended with inflam- matory symptoms, cupping, purging, and the acetate of lead are indicated; when with symptoms of debility, the dilute sulphuric acid, alum, tinct. ferri muriatis, or gallic acid. Cold may be applied to the loins and hips by means of bladders of ice. In hemorrhage from the bladder a catheter should be passed and be retained, in order to prevent both accumulation of blood in the bladder and straining efforts at micturition. If the hemor- rhage is obstinate, the bladder may be injected with cold water containing a scruple of alum to each pint; and if much blood have coagulated in the bladder, it may be necessary to break it down by repeated injections of water. Small doses of turpentine will sometimes check a hemorrhage from the bladder, which resists all other means. VII. Suppression of Urine (Ischuria Renalis).—When the kidneys have been long abused by inordinate indulgence in strong drink, and are falling into disease—or when they have become diseased, they are liable URINARY DEPOSITS. 533 suddenly to lose their function of secreting the urine. The consequence of this is, that the urea and other elements of the urine accumulate in the blood ; the patient complains of great uneasiness in the head and loins ; he becomes first drowsy, and then comatose, and dies in four or five days. The affection is alluded to here in order to hint at the diagnosis between it and retention of urine. In suppression, if the catheter is introduced, the bladder will be found empty ; whereas in retention, whether from stricture, or from diseased prostate, or from palsy of the bladder, it may be felt full and dis- tended above the pubes. SECTION VIII.—URINARY DEPOSITS OR GRAVEL.1 In the urine are washed away the refuse matters derived from digestion, assimilation, and the wear and tear of the body. Any deviation, therefore, from a healthy state of digestion and nutrition is sure to be followed by a deviation .from the healthy properties of the urine. So extensive and com- plicated is the chemical and physiological history of these changes, that we can but refer to the works of Prout, Liebig, Golding Bird, Bence Jones, Owen Rees, Garrod, Hassall, and Lionel Beale, and must confine ourselves to the immediate bearings of the subject on surgical practice. We may observe that when the surgeon examines the urine, since it varies extremely in its properties at various hours of the day, the whole quantity that is passed during twenty-four hours should be collected into one vessel; so that its acidity and specific gravity and-quantity may be fairly estimated. We may observe as a further preliminary, that when a precipitate is let fall from the urine after it has been voided, it is called a sediment; that when precipitated in the bladder or kidneys it is called gravel; and that gravel lodging in any part of the urinary passages may concrete into stone. Further, that when the urine of any person habitually presents any one kind of deposit, he is generally said to have a corresponding diathesis; as the lithic diathesis, &c. The principal diseased conditions we are at present concerned with are those in which the urine deposits—1st, uric or lithic acid ; 2dly, oxalate of lime; 3dly, phosphates. I. Lithic, or Uric Acid, or Red Gravel.—This is deposited in the Fig. 316. 1. Lithic acid. 2. Lithates in powder, and spherules of lithic acid or lithate. 3. Basic phosphate. 4. Torula. 1 For information on the subject of this and the following sections, consult Prout on Stomach and Urinary Disease ; Garrod, Lancet, 1849 ; Bence Jones, Lancet for 1850, vol. i.: Brodie on Diseases of the Urinary Organs, 3d ed. ; Golding Bird on Urinary Deposits, 3d ed. ; Hassall, Lancet, 1850-53; Lionel Beale on Microscope, 1854. [Gross, a Prac- tical Treatise on the Diseases, Injuries, and Malformations of the Urinary Bladder, the Prostate Gland, and the Urethra, 2d ed.] 534 GRAVEL. y ^ form of minute crystals, tinged with the coloring matter of the urine. It generally indicates a highly acid state of the urine, through which it is pre- cipitated from the ammonia and other substances which ought to hold it in solution. The amorphous lithates of ammonia, soda, and lime form a very common sediment, varying in color from nearly white to dark red or yellow. The urine from which it is deposited is generally acid ; clear when passed, but clouded as it cools ; and this sediment may readily be distinguished by its dissolving when heated slightly. Lithates, deeply tinged by pink or brick-dust coloring matter, form the sediments observed in fever, gout, and chronic diseases of the liver. The lithate of soda is sometimes found. II. Oxalate of Lime is generally deposited from urine which is highly acid, and contains much lithate. It is in the form of minute octahedral Fig. 317. Fig. 318. Fig. 319. vie0: © ®vx; Lebert sur le Cancer, p. 674 ; Hannover on Epithelioma, p. 141. Paget's Lectures, vol. ii. SYPHILOPHOBIA. 561 on the head, or spine, are apt to be followed by impotence ; which sometimes is relieved, but more frequently is permanent. A cautious course of mer- cury, followed by the stimulating aphrodisiacs just mentioned, are the reme- dies most likely to be of use. A similar result sometimes follows a fit of apoplexy. 4. Certain diseases are always attended with a diminution, and sometimes with a complete loss of sexual power; especially diabetes, dis- eases of the kidneys, some forms of dyspepsia, and the latter stages of most chronic organic diseases. 5. It sometimes happens that a young man, the first time he yields to carnal temptation—or that a newly-married man on the night of his nuptials, finds himself incapable of accomplishing his wishes—through awkwardness, or timidity, or over-anxiety, or perhaps, be- cause on nearer inspection he finds his chere amie less tempting than she seemed, or because the consciousness of guilt prevails over the sense of desire. He straightway fancies himself impotent. The surgeon should cheer his spirits, and should inform him that his case is by no means uncommon—he should advise him, if married, to banish his fears ; if single, to wait till he can gratify his passions legitimately in marriage. There is a very frequent and distressing class of cases, in which the patients, generally young men of good education and refined feelings, and with vigorous development of the genital organs, believe themselves to be impotent, or to have spermatorrhoea; or perhaps to be laboring under secondary syphilis ; a state designated Syphilophobia. These cases require very skilful and kind treatment. The malady is in reality mental; caused often by the struggle between natural passion and religious sentiment, and aggravated usually by some disorder of bodily health, such as oxaluria, or other form of poisoned blood. If the surgeon foolishly makes light of the case, or if he still more foolishly tries to argue the patient out of his malady,- the patient immediately flies to the advertising quacks, to the great detriment of mind, body, and estate. The proper course to pursue is, to improve the general health. The writer has cured many an in- veterate case of imagined impotence or syphilis by a few grain doses of calomel, followed by combinations of quinine with Epsom salts, and afterwards steel or zinc. Lastly, impotence may be produced by premature and excessive venery, or by the practice of self-pollution. Such cases not unfrequently come under the observation of the London practitioner. The sexual organs have been rendered so weak and irritable, that the least excitement from a lascivious idea or from the mere friction of the clothes, brings on an im- perfect erection, followed immediately by the discharge of a thin fluid. The erection is so imperfect, and followed so soon by the discharge, that the patient is incompetent for sexual connection ; and the frequent and abun- dant losses of seminal fluid (whence the term spermatorrhoea is given to this malady), together with the patient's consciousness of his own imper- fection, bring on a most miserable state of bodily weakness and mental despondency. General tonics, and cold-shower-bathing, will do something to relieve this state ; but the most essential thing is, the observance of per- fect chastity of idea, so that all excitement may be avoided. The prostatic portion of the urethra, in these cases, is often preternaturally irritable and sensitive ; and this condition of the parts at the orifice of the seminal ducts tends greatly to keep up the excessive secretion, and to promote the action by which it is expelled. It is a very important indication, therefore, to attack this irritable surface, destroy its sensitiveness, and so interrupt the chain of morbid phenomena. The author has found great benefit from the use of enemata of cold water at bedtime; cold or tepid salt hip-baths; F. 72, 38, 21, 181, and opiate suppositories. He has seen cases in which a preternatural irritability of 36 562 DISEASES OF THE FEMALE GENITALS. the ejaculatory apparatus, with involuntary nocturnal emissions, even of a bloody fluid, together with very great pain in the back, languor, and despondency of mind, have been caused by the presence of irritating urine, containing oxalate of lime, and cured by the means described in the section on Urinary Deposits. Lastly, there is the application of nitrate of silver to the prostatic portion of the urethra, as directed at p. 515 ; of which it may be said, that if sometimes useful, it is often useless, if not mischievous. Any tampering with, and every means of directing the patient's thoughts to, the genital organs, should be avoided if possible. CHAPTER XXII. SURGICAL DISEASES OF THE FEMALE GENITALS. I. Catarrhal Vulvitis.—Women—even young girls—are subject to mucous or purulent discharges from the parts at the entrance of the vagina ; which may also perhaps be excoriated. Purgatives, tonics, soap and water, and astringent lotions are the remedies. (See p. 185.) II. Noma signifies a phagedsenic affection of the labia pudendi of young female children, precisely resembling the cancrum oris, p. 410, in its causes, and nature, and symptoms. After two or three days of low fever, the little patient is observed to suffer considerably whilst making water, and on examination, the labia present a livid erysipelatous redness and vesications, that are rapidly followed by phagedsenic ulcers. This disease is very fre- quently fatal. The treatment is the same as directed for cancrum oris. The surgeon must be very careful not to mistake this or the preceding affection for venereal disease ; an error common enough among parents. In the year 1853 there were several criminal trials at Dublin of persons falsely accused of tampering with children.1 III. Yesico-Vaginal Fistula signifies a communication between the bladder and the vagina. It generally results from sloughing of the parts after a tedious labor.2 As soon as it is discovered, the patient should be made to lie on her face ; the utmost cleanliness should be enforced by means of astringent injections and fomentations ; by which means the cicatrization and contraction of the aperture will be promoted. When the spontaneous processes of cure are carried so far as can be, art must step in. The application of a cautery at a black heat to the edges of the fissure, at intervals of from ten to thirty days, so as to get them not to slough but to contract, is much used, and with very excellent results, by Dr. Arthur Farre, both in the vesico- and recto-vaginal fistulae and in lacerations of the perineum; and the writer has seen it used with excellent effect in a case of recto-vesical fistula by Dr. Tanner. But in such cases an operation should be performed as follows:—The patient, gently chloroformed, must be comfortably supported, leaning for- ward, on her knees, with the chest at a lower level than the abdomen; but 1 Kinder Wood on a fatal affection of the Pudenda of Female Children, Med.-Chir. Trans, vol. vii. p. 84. Wilde, Med. Times, Oct. 1853. 2 With the improvement of midwifery, and with less cowardice and delay in resorting to the forceps, this accident ought to disappear. Midwifery lecturers are to blame for the absurd overcaution which they inculcate with regard to the forceps. It is, by-the- by, curious to remark, that out of nineteen cases related in Remarks on the Urethro- vaginal, and Vesico-Vaginal Fistules, by N. Bozeman, M.D., of Montgomery, Ala., 1857, fourteen occurred in colored girls, or negresses. VESICO-VAGINAL FISTULA. 563 if preferred she may be in the lithotomy position; then, whilst an assistant on either side separates the labia and keeps the rectum out of the way by finger or bent spoon-handle, the ope- rator, by means of forceps or hook Fig- 336- and long narrow knife, entirely and thoroughly denudes or vivifies, as the French say, the edges of the aper- ture, especially at each extremity. Too much care cannot be taken in this respect. Then sutures are to be passed ; and the best suture is of fine silver wire. These may be passed by means of a needle with a fish-hook curve, which the writer devised for the purpose, first through the farther, then through the nearer edge ; the needle being so curved that it can be introduced and withdrawn without wounding the vagina, and so that the operator's hand does not get in the way of his eyes. When a sufficient number have been passed, their ends may be passed through a bar of white metal, drilled with holes ; one bar on the farther the other on the nearer side of the fissure, so as to act as quill sutures; the ends of the wires to be secured by split shot, pushed on the wire close up to the bar, then pinched by forceps to make them bite the wires. This is Dr. Marion Sims's plan. Fig. 337. Vesico-vaginal fistula. Sketch of a patient in the position described in the text, with a catheter in the bladder ; a, edge of fistula. [Druitt's suture needle with fish-hook curve.] A better needle, however, is the hollow one represented here, described bv Dr. Simpson, and said to have been devised by Mr. Startin. Other modes of securing the wire sutures, are—the metallic button of Dr. Boze- man, a plate of lead adapted in size and curvature to fit the spot; and perforated with holes through which each pair of ligatures is drawn, and then fixed with split shot. This apparatus insures great fixity of the parts, and its use has been attended with great success. Instead of using a shot the wires may be twisted. [For this purpose Dr. Coghill's twister will be 564 DISEASES OF THE FEMALE GENITALS. found to answer admirably. The wires are passed through the fine tubes at the end of the steel rod, which is then twisted round.] Dr. Simpson has devised a wire splint, to hold the margins, or rather the whole site of Fig. 338. [Fig. 339. Fig. 340. Fig. 341. Fig. 342. I [Fig. 338. Tubular needle for passing wire threads through the lips of vesico- vaginal fistulas. A wire is represented as passing through the tube. The figure is of full size—the extremity of the needle looking thicker and larger than it really is. Only the commencement of the handle is represented in the woodcut. Fig. 339. Bozeman's "button suture" finally applied and fixed with perforated shot. (From Bozeman.) .Fig. 340. Bozeman's "button" as it is being passed along the threads down to the wound. (From Bozeman.) Fig. 341. The instrument for adjusting and twisting the ends of the wires after the splint has been applied (half size). Fig. 342. The end of the same instrument represented of full size, and as in the act of twisting the wire passed through its two terminal eyes.] the wound steadily, and to hold the sutures. It is made by twisting fifteen or twenty strands of fine iron thread into# a cord; the ends of which are plaited together in a circle, which may be moulded so as to surround the VESICO-VAGINAL FISTULA. 565 wound. A sufficient number of apertures is made with a common borer, to allow the sutures to pass. Fig. 343 shows it applied.1 Fijr. 343. [This cut shows the iron-wire splint finally adjusted and the ends of the stitches twisted and secured across the lower bar of the splint. (From Simpson.) The annexed engravings represent needles adapted for wire sutures in these or any other operations. Mr. Price's has two holes, about half an Fig. 344. [Price's needle for wire suture.] inch apart, and the upper and under surfaces grooved ; wire passed from hole below to that above ; end of wire doubled to hold it. Mr. Murray's has a groove and open box end. Mr. Lister's, one hole ; the side grooved. Fig. 345. Fig. 346. [Murray's needle for wire suture.] [Lister's needle for wire suture.] After the operation, a short metallic catheter, curved like S, communi- cating with an ox-gut or elastic urinal, should be retained in the bladder, so that no urine may accumulate there. The patient should lie on one side, turning rather over towards the face ; cold water be occasionally injected into the vagina; opium be given in the dose of a grain at bed-time, and another once or twice more in the day; and the wound should not be exa- mined, nor the sutures be disturbed, nor the bowels be opened, till the fifth or sixth day. Opium is most necessary : in one case, spite of it, the author was foiled by spasm of the bladder, which drove out the catheter, and sent urine gushing through the wound. [' Copied from Dr, Simpson's Lecture in Medical News, Feb. I860.] Dr. Simpson pre- fers the common blue annealed iron wire, No. 32. 566 DISEASES OF THE FEMALE GENITALS. To provide for cases in which there is extensive loss of substance, M. Jobert de Lamballe detaches the vagina from its attachment to the anterior part of the neck of the womb, and so draws it down that there may be no strain on the stitches.1 IV. Recto-Vaginal Fistula must be treated at first by cleanliness and mild laxatives. If after a time the aperture does not close, it must be treated as in the last case. V. Laceration of Perineum during labor, if up to, but not through the anus, and if the patient when passing her water turn upon her hands and knees and uses extreme cleanliness, will generally heal, so as to give little or no subsequent inconvenience. Yet it would be better, immediately after labor, to close it by quill suture. Complete laceration of the perineum into the anus is attended with distressing incontinence of feces, and is pre- vented from healing by the action of the sphincter. Hence it is necessary to divide the sphincter on each side of the laceration, then to sew together the edges of the laceration, and to prevent the new wounds from uniting, by placing a few threads of lint in them, until the laceration has united. If possible it should be done at once ; if not, the operation must be delayed till the lochia have entirely ceased. Then the patient being chloroformed, and placed in the lithotomy position, the opposite surfaces of the lacerated parts and of the lower part of the vagina between must be freely denuded of mucous membrane. Hemorrhage must be checked by iced water, or if necessary by ligatures ; then the parts are to be brought together by the quill suture. Three good-sized ligatures should be passed quite deeply through the tissues, and be attached to a piece of bougie on either side, and the edges of the skin be brought together by two or three interrupted sutures. Then the finger being introduced into the anus, and a straight probe-pointed bistoury by its side, the sphincter should be divided. The catheter must be retained after the operation, to prevent the contact of urine with the wound, opium be freely given, and the bowels kept confined for four or five days.2 VI. The Catheter may be easily introduced into the female urethra with one hand, thus:—The surgeon holding it like a pen, but with its point on the tip of the forefinger, Fig. 347. passes the forefinger between the labia, and feels for the y*5^^^^ meatus. The catheter is then ^yy^Z^--. ""^\^ ^~v, easily slipped into the orifice. /-■ '^ :=sSSs«s4H^ ''■■^'Vt/''} Either hand may be used, ac- y JJlP^Bfe^^^^^^!^ Y ' A cording to the patient's posi- jjr ^tZ^B™^^ VII. A Vascular Excre- ^fgp 7 scence, varying in size from a ^Wf large pin's head to that of a *' horse-bean, is liable to grow [Method of holding the catheter, for female urethra.] from the female urethra, caus- ing great distress through its exquisite sensibility. It should be cut off, and the potassa fusa be applied to the surface to prevent its reproduction. But, immediately after the 1 See some observations by R. Druitt, Lancet, 1852, vol. ii. p. 576. Marion Sims, quoted in Ranking, vol. xv. Jobert de Lamballe, Gaz. des Hop., Oct. 16, lb4L». Traite des Fistules Vesico-uterines, &c, Paris, 1852. [For the mode of operating in these cases, much may be learned from the case reported by Dr. Washington L. Atlee, in the Amer. Journ. Med. Sci. for January, I860.] 2 The plan of dividing the sphincter was proposed by Horner : the necessity of opium by Davidson: all'the essentials of the operation are summed up by I. B. Brown, in his work on Diseases of Women, Lond. Ib54. CORRODING ULCER. 56, caustic, a sponge dipped in diluted vinegar should be applied, in order to prevent injury to the surrounding sound parts; and if it is necessary to in- troduce the caustic within the urethra, it must be by means of a tube which has an aperture in it corresponding to the diseased surface. VIII. Imperforate Hymen.—Sometimes this membrane completely ob- structs the vagina, and causes the menstrual fluid to accumulate and distend the uterus. The impediment is easily got rid of by a crucial incision. Then all the black treacly fluid that has accumulated should be immediately syringed out with warm water, otherwise it might putrefy, and cause typhoid fever and death. The abdomen should be bandaged, and the patient be confined to her bed till the uterus has resumed its healthy size. IX. The Labia may be the seat of acute inflammation, and of encysted tumors, which perhaps may be connected with the round ligament; of hernia, and of fibrous or fatty tumors. The treatment of these cases requires no distinct comments. The clitoris and nymphse, if they grow to an inconve- nient size, should be curtailed by incision. X. Varicocele.—Enlargement of the veins of the labia, forming a soft tumor, which enlarges when the patient rises, and increases so as to form a most painful impediment to exercise, but disappears when she lies down. Treatment—Cold bathing, and support by a firm truss, or T bandage with a pad. XI. Prolapse of the Vagina is a consequence of structural debility, and is liable to follow parturition, and to accompany and aggravate conges- tive diseases of the womb. When the posterior wall prolapses, bringing with it the rectum, there is great distress and difficulty in getting rid of the motions ; when the anterior wall with the bladder prolapses, there is a great irritability of the bladder; difficulty of emptying it; decomposition of re- sidual urine, and other ill consequences. Cold astringent injections ; tonics; baths of alum water, and firm perineal bandage (see Bandages) are the first set of remedies. Should these fail, it may be necessary to resort to a pessary —a thing which no one, however, should use if he can help it. Lastly, there is the ingenious operation of I. B. Brown, which consists of two parts; first, in contracting the circumference of the vagina; secondly, in uniting the posterior portions of the labia, so as to bring forward the perineum, as it were, to act as a natural cushion and support to the prolapsed parts. The first object is accomplished by denuding a longitudinal slip each side of the vagina, bringing the cut surfaces together longitudinally, and uniting them by suture ; the second, by denuding and uniting the inner surfaces of the posterior halves of the labia, as in the operation for ruptured perineum. XII. Cancer of the Vulva ; fungoid bleeding projection, or scirrhous thickening leading to deep and rapid ulceration, with adherent and hard base ; must be treated as directed at p. 129. XIII. Corroding Ulcer, Epithelioma, Elephantiasis, Esthiomene of Huguier. The external female genitals are liable to various kinds of enlargements and of ulceration, whose nature and alliances require even yet to be further studied. 1. There is the superficial lupus (p. 95), affecting the young and scrofulous; puffy congestive swelling, and infiltration of the skin in soft tubercles; ulcerating in one direction, healing in another. 2. The corroding ulcer, or (esthiomene perforant, p. 95) a deep glassy ulcer; base slightly infiltrated, burrowing up by side of vagina ; distinguished from pure syphilitic ulcers by its rebellion to anti-syphilitic treatment, and by its not being followed by secondary symptoms. 3. Elephantiasis; enlarge- ment of the labia and other external parts (well described by Egan) ; ren- dering them a huge, warty, fissured, and most cumbrous mass; consisting in great hypertrophy of the fibrous dermis, in infiltration of fibro-plastic matter, and, as the author believes, sometimes superadded epithelioma. 4. A com- 568 DISEASES OF THE BREAST. bination of corroding ulceration, with hypertrophy in various forms; thick- ened cutis, warty excrescences, and soft tubercles. Of these various in- stances of disease, many owe their origin to the combined forces of filth, gonorrhoea, syphilis, and scrofula or some other kind of cachexia. The treatment mnst consist of, 1, cleanliness and astringents ; 2, anti-scrofulous, or anti-syphilitic remedies, according to circumstances; 3, these failing, ex- cision of the diseased parts; either at one coup, or at several, according to their extent; and the destruction of corroding ulcers by the actual or some other efficient cautery.1 CHAPTER XXIII. DISEASES OF THE BREAST. I. Hypertrophy of the breasts to an enormous size is very common during the earlier months of pregnancy in plethoric women. Aperients will assist time in effecting a perfect cure. In unmarried women the same thing sometimes happens ; the breasts becoming so large as to be a perfect burden. If there are any remedies they are the preparations of iodine, and the vari- ous means for insuring the healthy action of the womb. II. Boys and Girls about the age of puberty are subject to slight swelling and tenderness of the breast, which soon disappears of itself if not interfered with. III. Lacteal Tumor.—Sometimes a lacteal duct becomes obliterated, and the milk accumulates in it, forming an oblong fluctuating tumor near the nipple. If this is punctured, milk will continue to be discharged dur- Fig. 348. This cut shows a very convenient mode of bandaging the breast. The bandage consists of a piece of linen split into two tails, of which one is fastened round the waist, whilst the other supports the breast, passes over the opposite shoulder, and is fixed to the first, behind. 1 See Egan on Syphilis, p. 146 ; Huguier sur l'Esthiomene ; Mijm. de l'Acad. de Med. 1849 ; Lebert, Hannover, Paget, op. cit. ACUTE INFLAMMATION. 569 ing lactation, and, after the child is weaned, it will dry up and heal. In a few very rare instances there has been formed a IV. Lacteal Calculus.—The fluid part of the milk in an obstructed lacteal duct having been absorbed, whilst its more solid and earthy ingredi- ents remained, and concreted into a calculous mass. V. Abscess in the Lacteal Tubes.—An elderly woman applied to the author some time since with a painful, elongated swelling, stretching from the nipple to the circumference of the breast. It evidently consisted of a lacteal tube which had suppurated; and, after being punctured and yielding half an ounce of pus, it soon got well. VI. Sore Nipples.—Excoriations and cracks of the nipples not only cause great pain and inconvenience in suckling, but are a frequent cause of acute inflammation of the breast. The tannin lotion, originally recommended by the author many years ago, F. 131, and a touch with lunar caustic, to a very deep irritable fissure, were the best remedies, till the discovery of collo- dion ; which is certainly a better means of gluing up and protecting the fissure. The nipple should be defended, if need be, from the clothes and from the child's mouth, by a metallic shield. Women who are subject to this affection should frequently wash the parts with salt and water, or solu- tion of alum, during pregnancy ; or should apply every night a liniment composed of equal parts of rectified spirit and olive oil. VII. Acute Inflammation of the breast (Acute Mastitis) is known by great swelling, tenderness and pain, and fever. These symptoms are gene- rally soon succeeded by formation of matter. The abscess, if confined by the fascial envelope of the organ, is very slow to point. This affection may occur at any period during lactation. It may be caused by cold—by too stimu- lating a diet—by neglect in suckling—by irritation propagated from the nipples, and by a loaded state of the bowels and defective biliary and urinary secretion. The suddenness with which it may come on is sometimes sur- Fig. 349. Mode of supporting the breast by strapping. prising, i A woman may get up apparently well; may be seized with shiv- ering, pain, swelling of the breast, violent fever, and delirium; and these 570 diseases of the breast. symptoms as suddenly subside when calomel and black draughts have cleared away some most offensive motions. Treatment—At first purgatives, leeches, and fomentations, or poultices after them ; the milk should be drawn off, if it can be done without very much pain, and Dover's powder should be given to allay restlessness. The arm should be kept quiet in a sling. So soon as fluctuation is well estab- lished, a puncture should be made. And then efficient support should be given by bandages, or by cross strips of adhesive plaster, so as to take off the weight of the organ, compress the distended vessels, and prevent all bagging of matter. Likewise if, after leeches and purgatives, the tender- ness and pain diminish, so that there seems a chance of resolution without suppuration, similar support is most useful. The preceding cut shows the manner in which the breast may be supported by strips of plaster (but those represented are too short): a sufficient number should be applied to cover the entire breast, except the nipple, and they should be long enough to go over the shoulder, so as to suspend the breast, and not allow it to drop. VIII. Chronic Inflammation may be a sequel of the acute ; or may be of a scrofulous nature. Swelling and considerable hardness of part, or of the whole of the breast, ending usually in burrowing suppuration, are the characters; tonics, pressure, and puncture of abscesses, the remedies. IX. Neuralgia of the Breast may exist pure et simple; or may (as more frequently happens) be superadded to a small glandular tumor. Ex- treme pain, aggravated at each monthly period, and out of proportion to all local structural disease (if any) is the characteristic. The treatment was detailed in the section on Neuralgia. X. The True Hydatid Disease consists in the development of a parent cyst, containing other secondary cysts, consisting of parasitic ani- malcules (echinococcus hominis) floating in a clear limpid water. It pre- sents a globular oval hard tumor, attended with more or less pain, but no derangement of the general health. As it increases, fluctuation becomes perceptible, and the skin becomes distended and ulcerates. The cyst may be punctured (p, 168), and allowed to suppurate, or may be excised, which is preferable. XL Partial Hypertrophy (Chronic Mammary Tumor, of Cooper; Sero-cystic Disease, of Brodie; Imperfect Hypertrophy, of Birkett; Glandular Tumor, of Paget).—Morbid growths of many kinds may be developed upon or near the breast, or within it; including enchondromatous, fatty, and vascular tumors. But the morbid growth which requires to be most carefully studied, and compared with cancer, is Partial Hypertrophy, or Glandular Tumor. In this three things will probably be met with. 1. A development of more or less perfect gland tissue, the characters of which are delineated at p. 118. 2. Concurrently with this, a hypertrophy of the fibrous tissue (p. 114), which envelopes and intersects the gland; through exudation of fibro-plastic matter, more or less developed into tissue, firm or gelatinous. 3. In the meshes of this interstitial fibrous tissue, cysts, or cavities filled with a serous fluid, are exceedingly liable to form (p. 114). The growth of glandular or fibro-plastic matter, projecting into the cavities of the cysts, was formerly designated by the name sero-cystic sarcoma. The abundant formation of epithelium has induced some persons, most improperly, to describe this disease as epithelial cancer. We may add that portions are often found softened, and in a state of fatty decay. The growth is usually slow. The size attained may be enormous. Mr. Fergusson, in 1853, removed one weighing twenty-seven pounds. Xo age is exempt; yet the majority of cases occur in women under thirty-five. The tumor generally commences at the circumference of the breast, and is partial hypertrophy. 571 produced by the hypertrophy of one lobule. It is movable under the skin ; feels granulated just as the natural organ does when its tissue is developed Fig. 350. From a preparation of the late Dr. Hooper's, now in the "King's College Museum. It shows cysts in the breast, some empty, others partially filled, others entirely filled with new growth of glandular tissue. by lactation or during menstruation ; may increase so as to cover over and hide, or cause atrophy of the remainder of the organ ; yet is not attended with retraction of the nipple, or adhesions, or enlargement of the lymphatic glands. There may be pain, especially at the menstrual period, at which time the entire gland becomes more enlarged and tender ; yet not the wearing rheu- matic pain of cancer. When cysts are formed, fluctuation becomes percepti- ble at one or more points ; the disease increases slowly or quickly ; at last it distends the skin, and a round aperture is formed, from which a cauliflower excrescence sprouts out; and the pain and discharge may be very ruinous to the health. The disease may last almost any number of years, and may increase to a great size without greatly affecting the health. In some cases it disappears of itself; in others it remains stationary. The writer had (at the date of the 6th edition, 1853) three ladies under his care with this tumor. In one, the mother of eleven children, it came after the health had been broken down by puerperal fever, which completely hindered suckling. This patient (1855) had got well spontaneously. In the second, a very feeble and anaemic person, it came shortly after weaning one child, and disappeared during the next pregnancy. In the third, it was first noticed at nineteen ; • she was married at twenty-one ; at twenty-three the tumor was slowly on the increase, and was excised by Mr. Henry Lee ; it furnished a capital specimen of the disease. In a year after the operation, the tumor returned ; continued stationary for two years ; and in the past year, 1859, has dis- appeared, concurrently with great improvement in the health. Treatment.—In the early stages, tonics, and measures adopted to regu- late the bowels and the menstrual functions—such as the iodide of potassium with bark, the iodide of iron, saline and chalybeate mineral waters, &c.— should be administered at discretion. If it should be hot, swelled, and painful, a few leeches may be of use. Lebert speaks highly of the tepid douche, and of ointment of iodide of lead in the intervals. The breast should be enveloped in cotton wool. Severe pain or distension may be allayed by opiate or belladonna liniment. Lastly, should the growth increase rapidly, with cyst formation or suppuration, the part of the breast containing it should be extirpated. XII. Gland Cysts (p. 118), not like the last, developed between the 572 DISEASES OF THE BREAST. lobules, but consisting of an expansion of obstructed gland ducts, may be situated on the surface, in the centre of, or behind the organ; and may be of various sizes, though rarely larger than a filbert They are lined with epithelium, and enclose a yellow, reddish, or green mucous fluid, containing milky and fatty globules and epithelium, which last accumulates after a time, and renders the contents of the cyst more solid. Serous fluid sometimes exudes from the nipple.1 For these cysts, unaccompanied by glandular tumor, puncture so as to empty them, and moderate pressure may be tried, when perhaps they may shrink with or without suppuration. But if great irritation and discharge are created, a part or the whole of the organ should be removed. XIII. Cancer of the breast is, according to Lebert, of the hard or scirrhous variety, in three-fifths of the number of cases; of the soft or medullary in one-fifth; and of intermediate forms, including a few rare and exceptional cases of melanotic and colloid cancer, in the other fifth. Paget believes that of every hundred primary hard cancers, ninety-five would be found in the breast; and rates the number of soft cancers in this part much lower than Lebert does. Symptoms.—It is usually felt first as a tumor about the size of a nut; not tender nor painful; situated in, and incorporated with, some part of the breast. It gradually increases, feels excessively hard, becomes irregular or tuberculated, and not circumscribed from the surrounding parts. Its ten- dency is to increase in breadth, rather than in prominence, and to involve more and more of the gland. In fact the gland may appear shrunken; especially when the disease produces adhesion of the skin and nipple and atrophy of the subcutaneous fatty tissue. From this cause the nipple and the skin often become drawn in and puckered. During this first period, the general health may be good, and the patient only be troubled with slight pains, especially about the menstrual times. The second stage is one of active local progress. Stabbing or lancinating pains of great severity come on ; the cancer more and more involves the skin, which reddens, then excoriates, then melts away, forming a chasm with hard jagged edges, greenish ashy surface, most foully-smelling discharge, and pain like coals of fire. This ulcer may be almost stationary for years; or may increase rapidly by sloughing; or may throw up fungous granu- lations ; or even at some part may undergo an imperfect cicatrization. But slowly or quickly, on the disease goes. Adhesion of the gland to the pectoral muscle; cancerous infiltration of the axillary glands, and in- creasing decay of health and strength, complete the usual phenomena of this stage. In the third stage, other organs become affected. Severe rheumatic pains, deposit of cancer in the bones, with perhaps fracture ; cancerous deposits in the liver, with consequent sickness, and failure of appetite ; or in the uterus, or the breast; infiltration of the ribs and intercostal muscles, and effusion into the pleura, with pleuritic pain and dyspnoea: these added to the con- stantly-increasing original disease, at last wear out the miserable remnant of the patient's life. The average age at which this disease begins, is from thirty-five to fifty- five. Of 62 cases adduced by Lebert, 158 by Paget, 147 by Birkett, 22 only appeared before thirty. There is no evidence whatever of any essential connection of this disease with marriage, celibacy, sterility, previous disease, mental causes, or external violence. The average duration of life is less than four years ; but in this matter there is great diversity. In some cases the disease begins with a furious onslaught, and kills in a few months. The 1 See Birkett on Diseases of the Breast, Lond. 1850. CANCER OF THE BREAST. 573 younger and more robust the patient, and rapid the early symptoms, the worse will the prognosis be. On the contrary, cancer affecting the aged and atrophied, may linger on for many years, and kill the patient by inches. Treatment.—The first question that will arise, is the propriety of extirpa- tion ; regarding which we must refer to p. 129. Suffice it to say, that although it were proved that the operation does not prolong life in the end ; although the disease is sure to return in the cicatrix, in the other breast, or elsewhere ; yet, that the surgeon should advise it as a means of procuring about a twelvemonth's relief from the weariness and anxiety of disease ; provided, 1, that the internal organs are sound, and the health such that the operation itself is not likely to be mortal; and 2, that the breast is yet not so adherent, nor the glands so diseased as to render it unlikely that the wound will cicatrize. Again, an exceedingly rapid progress, especially of soft cancer, in young persons, may render the operation hopeless ; whilst an exceedingly slow progress in the old would render it unnecessary. Palliatives.—But, in proportion to the hopelessness of cure, so ought our efforts to be strenuous in devising means for assuaging the bodily torments, the loathsomeness, the mental despondency, which render the sufferer insup- portable to herself and to others. In addition to the directions which we have already given (p. 131), we may subjoin the following brief hints to the younger practitioner. In the first place, study the effects of opium and other narcotics on each individual patient. Learn the form and combination which serve in smallest doses to procure sleep by night, and to allay pain by day, with least head- ache and loss of appetite. When the ordinary forms of opium or morphia do not agree, try the black drop ; the preparations of Squire, Battly, or Jeremie ; make great use of opiates locally. Try chloroform inhalation in its mildest degree. We have observed great relief to the miserable rheu- matic pains from daily administration or sulphuric or chloric asther; or of negus or good beer. Lebert speaks highly of the value of sulphate of qui- nine for the same purpose. Thus death will be postponed so far as it is induced by the exhaustion of pain. In the next place, for a disorder, whose starting-point is some error of nutrition, it is more than probable, that, if any remedy is to be found, it will be in some article of diet, which shall supply to the cancer matter, the complemental material required for its con- version into healthy plastic matter. Besides the articles mentioned at p. 131, turtle soup, eels, American oysters, Edinburgh ale, Tent or Constantia, oatmeal porridge, with wine or beer, may give a stimulus to nutrition. As to particular symptoms, the oedema of the arm, which is often such a dis- tressing complication of the later stages of this disease, may be somewhat retarded by bandages, and by keeping the limb in an elevated posture. Blisters near the shoulder, and punctures of the skin, may be tried when it becomes excessive. Itchings may be allayed by glycerine, infusion of to- bacco, tincture of aconite or of belladonna painted on the part; or by baths of bran or gelatine ; or by the local application of chloroform, and espe- cially by astringents, as the tincture of galls, or solution of tannin. It is important to save the skin from excoriation as long as possible, by tannin, black wash, bismuth, kc. XIV. Extirpation of the Breast is thus performed :—The patient being narcotized and on a convenient couch, an assistant takes the arm of the affected side and holds it out, so as to put the pectoralis on the stretch. The surgeon then makes a semi-elliptical incision below the nipple along the lower border of the pectoralis major, and another on the upper and inner side of the nipple, so as to include that part between them. He next dis- sects out the lower and outer part of the gland, quite down to the pectoralis (taking care not to get behind that muscle), and then, cutting from below 574 DISEASES OF THE HANDS AND FEET. upwards, he separates the remainder. If an adjacent gland is enlarged, the incisions should be managed so as to include it also. When the mass is removed, its surface should be wiped and examined, and the wound should also be well examined, to ascertain that no part of the gland, and that no hardened or discolored portions of cellular tissue or of muscular fibre, are left behind. Arteries are then to be tied, and the patient to be put to bed, and when all oozing has ceased, sutures and a few strips of adhesive plaster may be applied. If desirable to effect gentle pressure on the wound, to stop oozing, a small flat sand-bag, says Mr. Birkett, may be placed upon the flaps. XV. Men occasionally suffer from cancer of the breast, and other morbid growths, which manifest themselves in the same manner, and require the same treatment as in the female.1 CHAPTER XXIV. Fie. 351. DISEASES OF THE HANDS AND FEET — CLUB-FOOT, AND OTHER DEFORMITIES OF THE LIMBS. I. Club-Foot (Talipes) signifies a deformity of the foot, produced by rigidity and contraction of various muscles of the leg. 1. In the most simple and most common variety, talipes equi- nus, the heel merely is raised, so that the pa- tient walks on the ball of the foot. 2. In the talipes varus, which is the more common con- genital form of club-foot, the distortion is much more complex. In the first place the heel is raised ; secondly, the inner edge of the foot is drawn upwards ; and thirdly, the ante- rior two-thirds of the foot are twisted inwards; so that the patient walks on the outer edge, and in confirmed cases, on the dorsum of the foot, and outer ankle. 3. In the talipes valgus the outer edge of the foot is raised up, and the patient walks on the inner ankle. (See Fig. 353.) 4. In the talipes calcaneus the toes are raised and the heel is depressed, so that the patient walks upon it. There are also compound varieties; as the talipes equino-varus, equino-valgus, and cal- caneo-valgus; whose names sufficiently point out their nature. Each of these deformities may be congeni- tal, or may come on after birth, with the exception of the talipes equinus, respecting which, it is very doubtful if it is ever congenital. Causes.—Their origin may be traced to contraction and shortening of muscles. The exciting causes may be any circumstances that interfere with the supply of nervous influence, or with the proper nutrition of the muscles. Thus, to take the simplest case first, it may be caused by primary spasm Talipes equinus, from a cast in the King's College Museum. 1 For all necessary information, see Mr. Birkett's Treatise ou Diseases of the Breast; Lebert, op. cit.; Paget, Lectures, vol ii. CLUB-FOOT. 575 affecting one or many muscles ; and this again may be dependent (in non- congenital cases), 1st, on a rheumatic or sub-inflammatory state of those muscles ; 2dly, on irritation propagated directly from the spinal cord, from actual disorder of that part; 3dly, on irritation reflected from the spinal cord, but originating in disorder of some other organ, especially of the bowels. The cause of intra-uterine spasm is probably some shock to the nervous system of the mother. Secondly, instead of being caused by primary spasm of any given mus- cles, it (in non-congenital cases) may be caused by primary paralysis of their antagonists ; so that there being no proper balance of forces about the Fig. 352. Fig. 353. Talipes varus, from the King's College Museum. Talipes valgus, from Mr. W. Adams's collection. ankle joint, the foot becomes fixed in one of the above-mentioned deformed positions ; probably by a process of adapted atrophy; which is, in plain English, a process by which a muscle shortens itself permanently, if long placed in a shortened position. TJiirdly. It may be caused as a sequel of bruises, injuries, or disease of joints. (See Spurious Anchylosis, p. 273.) General Treatment.—The indications axe, first (in non-congenital cases), to remove all causes, and to soothe spasm, and give power to palsied mus- cles'. If any case comes under treatment, before the contracted muscles have becomes fixed in their rigidity, this may be done by purgatives, and other means of sweeping away eccentric causes of irritation; or by fomenta- tions and anti-rheumatic remedies, as the case may be. The writer has met, in his practice as an accoucheur, with cases of valgus in newly-born children from spasm of the peronei and other muscles which raise the outer edge of the foot; in which castor oil and friction, and manipulation, effected a cure; in other cases, if the spasm has seemed obstinate, he has divided whatever tendons were rigid. In one case this form of spasmodic valgus was associ- ated with wry-neck. Both did well. Tonics, especially steel, are of service with older children. The cases in which deformity arises from paralysis are less promising. But here a distinction must be drawn between local paralysis and general. Local paralysis, such as the blighting and atrophy of an entire limb, from exposure to cold, or even 'Vom fever, or irritation of teething, is curable by friction, galvanism, and other means of keeping the muscles from lapsing into quietude and defeneration, combined with tonics and proper nourish- ment. But when it depends on primary disease of the nervous centres, such as a hydrocephalic attack in a 'strumous child, and in adult paralysis gene- rallv, it is much less so. As to mechanical measures, in slight cases, splints of gutta percha, or of 576 TALIPES VARUS. wood, with bandages, and great care, may do everything. But delay is injurious ; and from the healthy condition of the muscles at birth, active treatment will be more likely to be satisfactory if adopted early. Therefore if these measures do no speedy good, it is better soon to resort to Stromeyer's operation of subcutaneous tenotomy; our knowledge of which, and in fact of the entire pathology of these deformities, and the establish- ment of what is now called orthopaedic surgery, is dated from the publication of Dr. Little's Thesis, in 1837.1 The rationale of this operation may readily be comprehended. The tendon being divided, its separated extremities heal by a new connective tissue, which renders it longer, and which, while recent, may be stretched to any desired length.3 Thus the mechanical shortening of the muscle is neutralized. At the same time, the antagonist muscles, which become wasted and inert, are relieved from a constant state of tension, and are enabled to resume their natural functions, so that the limb rapidly increases in strength and bulk. The operation is easily performed thus:—The tendon is put on the stretch; and a narrow sharp-pointed knife is thrust through the skin on one side of it; then its edge is turned against the tendon, and made to divide it as it is being withdrawn. The tendon to be divided is the tendo Achillis in the talipes equinus. The same in the varus, and those of the tibialis posticus, anticus, and flexor longus digitorum. In the valgus, the peronei and the extensor longus digitorum : any tendons, in fact, which oppose the restoration of the foot to its proper position. It is often ex- pedient to divide a portion of the plantar fascia, or of the muscles of the sole of the foot. Immediately after the operation, the foot should be put quietly up with splint and roller, with a dossil of lint and strip of plaster over the punctures, and be retained in the same position of deformity as before the operation. In the course of four or five days, apparatus must be adapted for bringing the part into proper shape. II. Talipes Varus.—In the foregoing paragraphs we have described club-foot generally. Now we proceed to detail the anatomy more particu- larly of the talipes varus, and in so doing avail ourselves of the description, by Mr. W. Adams,3 of a severe form in an adult female ; since essentially similar deviations, especially in the head of the astragalus, exist in the fcetus at birth.4 In reference to this deformity, the foot may be regarded as consisting of two portions, which move in different directions upon two distinct centres of motion. The division between these two portions corresponds to the articulation between the first and second rows of the tarsal bones, viz :— between the astragalus and scaphoid, and the os calcis and cuboid bones (indicated by the oblique line a a in Fig. 355). At this great transverse tarsal joint, a considerable amount of motion exists in the healthy condition of the foot; and in talipes varus the inversion of the foot takes place essen- tially from this centre of motion, and involves only the anterior two-thirds of the foot. The posterior third of the foot, consisting of the os calcis and astragalus, has its centre of motion in the ankle-joint, from the construction of which it can only move in the direction of flexion and extension ; at least this is essentially the direction of its motion. 1 Symbolse ad Talipedem Cognoscendum, Berol. 1837. See also Dr. Little's Treatise on Deformities, Lond. 1853. 2 [See Mr. Adams's paper in the Med.-Chir. Trans, vol. xiii., or the Amer. Journ. Med. Sci., Oct. 1859, p. 559.] 3 The writer has to thank Mr. Adams for the three cuts illustrative of the anatomy, which are taken from his original paper in Trans, of Patholog. Soc. vol. vi. 1855. 4 See vol. ii. of the Trans, of the Pathol. Soc, where representations of the foetal astragalus are given. TALIPES VARUS. 577 In a severe case as that represented, the posterior third of the foot is ele- vated by the action of the muscles of the calf upon the os calcis, and the astragalus is raised from its horizontal into a vertical position; its centre Fig. 354. Fig. 355. Talipes varus ; outer side of leg. Posterior aspect of leg, and sole of foot. of motion being at the ankle-joint. The anterior two-thirds of the foot are drawn inwards and upwards, producing the inversion characteristic of varus, by contraction of the tibialis anticus and posticus, the flexor longus digito- rum, and in severe cases the extensor and flexor pollicis ; its centre of mo- tion at the great tarsal joint is indicated by the line a a in Figs. 355 and 356. In this movement the navicular bone is drawn directly under the inner malleolus (see Fig. 356). These are the only movements essential to varus ; but, in some cases, shortening of the foot takes place from con- Fig. 356. traction of the plantar fascia and flexor brevis—and also in severe cases, after the period of walking, more or less transverse rotation of the foot takes place from the superincumbent weight telling upon the foot in the act of progression, so as to narrow the transverse arch, and approx- imate the fifth to the first meta- tarsal bones, as seen in Fig. 355. As a result of these changes in position affecting different portions of the foot, the bones become somewhat misshapen. The head of the astragalus pre- sents the most important devia- tion in form, which Mr. Adams, in opposition to Scarpa and Little, describes as existing at birth, and regards as an adaptation of the bone in its carti- laginous condition to the altered position of the navicular bone. In a severe case the head of the astragalus, instead of its regularly convex surface directed anteriorly, as in the healthy foot, presents two articular facets at right angles to each other, and divided by an abrupt line; one, the larger, 37 Anterior aspect of leg, and dorsum of foot. 578 TALIPES VARUS. looking directly inwards, and articulating with the displaced navicular bone ; the other, looking directly forwards, is left exposed by the altered portion of the navicular bone, and covered only by the elongated portion of the ligament which in a healthy state connects these bones. The most important alterations in the direction of the tendons relate to those of the anterior and posterior tibial muscles. The anterior tibial tendon deviates to the inner side, and crosses the inner malleolus in a curved direc- tion downwards and backwards in proportion to the severity of the case. The posterior tibial tendon does not pass from behind the inner ankle ob- liquely downwards and forwards, beneath and then in front of this process towards the navicular bone, as in a state of health; because the navicular bone itself is displaced inwards, backwards and upwards, by the contraction of the tibialis posticus muscle, so as to be held in contact, and articulate with the inner malleolus. The tendon, therefore, passes directly downwards to its insertion, or even with a slight inclination backwards.1 In Fig. 355, this tendon turns a little under the malleolus to reach the navicular. The ligaments are elongated in front of the ankle-joint, and on the con- vexity of the foot, and shortened in the sole of the foot and behind the ankle-joint, in proportion to the severity of the case, and its duration. Treatment.—In the cure of talipes varus, the great practical rule is to divide the treatment into two distinct stages, and to accomplish the objects of the first stage very thoroughly before commencing the second. In the first stage the inversion of the foot is to be overcome by division Fig. 357. The above four cuts, for which the author has to thank Mr. W. Adams, exhibit—1, talipes varus ; 2, the bandage applied after division of the tibialis tendons ; 3, the distortion reduced to simple equinus ; 4, restoration complete. of the anterior and posterior tibial tendons, and that of the flexor longus digitorum ; and then by bandaging the foot to a straight splint placed on the outside of the leg extending to the knee. For an infant the splint should be 1^ inch in width and made of wood, or sheet iron, softly padded. When by this means the foot is sufficiently everted so as to form a straight line with the leg, and does not exhibit any disposition to turn inwards upon the removal of the bandage; when in fact, instead of varus, a state of ex- treme equinus has been produced,—the second stage may be commenced. This consists in dividing the tendo Achillis, and subsequently bringing down the heel by means of a Scarpa's shoe; or in slight infantile cases the foot may be bandaged to a bent splint applied in front of the ankle-joint. In slight cases it is by some recommended to divide all the tendons at once, but the objects are best accomplished by dividing the treatment into two stages. 1 As in case exhibited to the Pathological Society by Mr. H. Thompson, vol. vi. p. 357. 37 CONTRACTION OF THE TOES—BUNION. 579 In severe adult cases, and where the deformity is extreme, and accom- panied with much rigidity, the same principle is to be followed, but a more complicated apparatus is desirable. That invented by Mr. Adams, and described in his lectures on " Orthopaedic Surgery," appears to be well adapted for these cases.1 III. Weak Ankles and Flat Foot.—In this affection the foot is flattened, its arch is sunk, and the astragalus forms a projection below the internal malleolus, rendering the in- ternal border of the foot convex, in- stead of concave. In bad cases the inner ankle almost touches the ground, and the patient walks with great pain and lameness. This affection depends on a weakness and relaxation of the ligaments, and is more common amongst girls than boys. Treatment—The patient should wear shoes or boots with high heels, and with the inner edge of the heel much thicker than the outer. He should also be directed to turn the foot out very little, if at all. Benefit Fiat-foot.] may also be derived from a well-ap- plied bandage, such as is represented at p. 88. It should always be applied so as to be carried round the ankle from the inner side of the foot. In severe cases the patient should wear a boot with a piece of steel or whale- bone fastened to the sole, and passing perpendicularly upwards to the middle of the inner side of the leg, and having an India-rubber pad to support the arch of the foot. IV. Knock Knees are treated by Mr. Lonsdale on the same principles as the crooked rickety leg; by adapting a long well-padded splint to the outer side of each limb, fastening it below by straps and buckles at the outer ankles, and above by a broad belt, to which both splints are attached, and which is buckled round the body at the level of the hollow part of the loins. The splints should be hindered from coming too far forwards, and should bear well against the trochanter and outer ankle. Meanwhile, the knee is to be drawn into its proper place by a band buckled over it, and wide enough to embrace both the head of the tibia and condyles of the femur.3 V. Contraction of the Toes.—It often happens that one of the toes is permanently elevated, and rides over its neighbors, from the habitual use of narrow boots ; and the upper surface of this toe, being peculiarly exposed to friction, is generally covered with corns so painful, that many persons have been compelled to have the part amputated. Or the toe may be bent into the position of the so-called hammer-toe. Division of the extensor tendon (or of the flexor, in the hammer-toe variety), may, however, enable the toe to be brought down into its place, and prevent the necessity of amputation. \l. Bunion—a swelling over the metatarsal joint of the great toe—is a disorder which is much more talked of than understood, but which the writer has taken pains to study the varieties of, which are these : 1. A recent bursal tumor, or ganglion; thin, easily burst under the skin by pressure, which is the proper treatment. 2. A thickened bursa in the same place, filled more or less with liquid, somewhat tender and inflamed. Best, 1 Med. Times and Gazette, 1856. 2 Lonsdale, Med. Gaz. June, 1S49. 580 WEBBED FINGERS. Fig. 359. Contraction of the palmar aponeu rosis. From a dissection by Mr, Partridge. a leech or two, fomentation, and anti-arthritic purges. 3. The same bursa in an indolent state ; thickened but not tender. Iodine paint, or empl. hydrag. 4. The same in a state of suppuration. To be treated like any other abscess or fistula, according to its condition. 5. Different from all these is a distortion of the foot, in which the great toe is thrown outwards, whilst the head of the metatarsal bone projects and forms a swelling on the inner side of the foot; but the foregoing bursal swellings may be superadded. This affection depends on natural formation, and the changes induced by age and labor, and, above all, by gouty enlargement. Beyond properly-fitting boots, roomy at the toes, tightly fitting the instep, there is little to be done for this ; unless any tendon which pulls the toe outwards can be divided, and the joint be restored by extension with a splint; all the preceding four varieties, however, are curable. VII. Contraction of the Fingers gene- rally depends, not on any spasm of the tendons, but, as Mr. Partridge has shown the writer, on shortening and rigidity of the palmar apo- neurosis and tendinous sheaths ; or on a liga- mentous degeneration of the areolar tissue on the palmar aspect. of the fingers. This is a part of the morbid changes accompanying chronic rheumatic arthritis. Treatment.—Friction and extension are of no use. But the contracted tissues may be divided by subcutaneous section. If any of the muscles of the forearm be rigid, its tendon may be divided. VIII. Congenital Contraction of Fingers is generally seen in the little finger, and is not very uncommon. The finger can be straightened, but the skin is then seen to be very tightly stretched in a line at the junc- tion of its radial with its palmar surfaces, and, as it were, continuous with the cutaneous web between the fingers. The last phalanx of the finger is always drawn inwards, as well as bent; and the contraction depends upon a congenital deficiency of the skin in the direction of the length of the finger. Thus a longitudinal web is produced by extension. The most diagnostic sign is the absence of the deep transverse folds in the skin corresponding to the bend.of the joints. In contractions produced by muscular action these transverse cutaneous folds are deepened instead of being obliterated. Treatment.—This form of contraction does not require any division of tendons, but yields to long-continued mechanical extension, constantly ap- plied for several months, or perhaps a year. A steel plate may be adapted to the palmar and dorsal aspects of the outer third of the hand, and held in position by elastic bands, so as to afford a fixed point, and from this plate a straight and narrow bar of steel may be carried along the upper and outer margin of the finger; a little ingenuity in padding and bandaging will then bring the finger into a straight position.1 IX. Webbed Fingers.—This is a deformity consisting of an union of the fingers to each other. It may be congenital, or may be caused by burns. It is a most intractable affection. Mere division of the connecting skin is 1 This instrument is constructed under Mr. W. Adams's direction by Bigg, of Leices- ter Square. ONYCHIA MALIGNA. 581 not often of any avail, for the fingers almost inevitably grow together again when the wound heals. In order to counteract their union, a flap of skin may either be brought from the dorsum of the hand and be engrafted be- tween the fingers, or, as Mr. Liston proposed, a perforation may first of all be made in the connecting skin near the roots of the fingers, and be pre- vented from closing by keeping a piece of cord in it till the edges have healed, and then the remainder of the connection may be divided. [In a case of this kind that came under our notice, in a young girl, after dividing the uniting medium between the fingers, cicatrization was prevented from extending from the commissure, by means of an elastic band of India-rub- ber, passed between the fingers and fastened before and behind the wrist to a bracelet. It is of importance, also, in making the incision between the fingers, not to make it in the line equally distant from each finger, but on the side of one of them.] X. Ulcers about the Nails.—1. A very common and troublesome affection is that which is popularly termed "the growth of the nail into the flesh," and which most usually occurs by the side of the great toe. It does not, however, arise from any alteration in the nail, as its name would imply, but the contiguous soft parts are first swelled and inflamed by constant pres- sure against the edge from the use of tight shoes. If this state be permitted to increase, suppuration occurs, and an ulcer is formed with fungous and ex- quisitely-sensible granulations, in which the edge of the nail is embedded, and which often produces so much pain as totally to prevent walking. Treatment.—The objects are to remove the irritation caused by the nail, and reduce the swelling of the soft parts. In most cases, if the nail, hav- ing been well softened by soaking in warm water, is shaved as thin as pos- sible with a bit of glass, the pain and irritation may easily be allayed by rest for a day or two, with fomentations and poultices; and then any ulcer that has formed will soon heal, with the aid of black wash on lint, or a touch of lunar caustic. But if the case is more obstinate, the edge of the nail may be removed, by passing the sharp blade of a pair of scissors resolutely under the nail, cutting it through, and then quickly tearing away the offending portion with forceps. The pain attending this operation renders chloroform expedient. XL Onychia Maligna is a peculiarly unhealthy ulcer occurring at the root of the nail, either of the fingers or toes, but more frequently of the latter. It commences with a deep-red swelling, and an oozing of a thin ichor from under the Fig. 360. fold of skin at the root of the nail; and, lastly, an ulcer is formed, with a smooth tawny or brown surface, a very fetid sanious discharge, and swelled jagged edges of a peculiar livid dusky hue. It is in general extremely painful, especially at night. Treatment—Mr. Wardrop recommends mer- cury to be employed, so as to affect the gums in rr. .. .. .. , _, , J , » , ■ i / j ,i , ,i ,i n [Onychia Maligna] From a cast about a fortnight: and says that then the swell- in tae King's college Museum. ing will generally subside, and the ulcer become clean. The mercurial effect should be continued gently till the sore is healed, and for a short time afterwards. The best local applications are solution of arsenic (liq. arsen. 3ij. ad aq. Jij.) as recommended by Mr. Abernethy, which will generally be found to succeed ; or solution of nitrate of silver, or black or yellow wash.1 1 Vide Lawrence, Lectures, in Med. Gaz.; James Wardrop, F.E.S.E., on Diseases of the Toes and Fingers, Med.-Chir. Trans, vol. v. 582 WHITLOW. XII. Whitlow, or Paronychia, signifies an abscess of the fingers. There are four kinds : the cutaneous, subcutaneous, tendinous, and car- buncular. The cutaneous whitlow consists of inflammation of the surface of the skin of the last phalanx, with burning pain, and effusion of a serous or bloody fluid which elevates the cuticle into a bladder. The subcutaneous is attended with greater pain and throbbing, and suppuration under the skin at the root of the nail, which may come off. Treatment.—Purgatives, followed by tonics; fomentations, and poultices; but if these measures do not easily cause resolution, a pretty free incision should be made into the inflamed part. If the tip of the finger is long pain- ful and tender without suppurating, it should be well pencilled with lunar caustic. The resin ointment is recommended by Mr. Vincent as an applica- tion, after the part has been opened. The tendinous whitlow, or thecal abscess, affects the tendinous sheath or periosteum, and was described at p. 210. We may observe here, however, that if purgatives and fomentations do not speedily relieve, the finger should be freely laid open with a scalpel. If matter Fig. 361. have extended into the palm, the incision should be continued along the metacarpal bone till it freely gushes out. It is better not to cut into the spaces between the metacarpal bones (unless mat- ter points there very decidedly indeed), for fear of wounding the digital artery. If it be neces- sary to slit up the palmar fascia, a cut should be made over the head of a metacarpal bone, in order that a director may be passed under it. The carbuncular whitlow is an unhealthy in- filtration of the subcutaneous tissue of the finger, brawny, slow to suppurate, and altogether resem- bling, and requiring the treatment of, carbuncle, p. 205. XIII. Exostosis.—A fibrous tumor, which subsequently ossifies, is not uncommon on the dorsal surface of the last phalanx of the great [Exostosis on last phalanx of toe- To cut away the anterior half of the nail, :eat toe.] and dissect it out, is the only useful treatment. PART V. OF THE OPERATIONS OF SURGERY. CHAPTER I. OF OPERATIONS IN GENERAL. I. The Apparatus necessary for operations in general comprises bis- touries, scalpels, or other cutting instruments adapted for specific purposes, dissecting forceps, tenaculum, and Assalini's forceps to take up arteries ; plenty of hempen ligatures, needles threaded, fine sponge, water both warm and cold, and brandy and hartshorn in case of faintness. There should also be a sufficient number of assistants—there should be one whose sole busi- ness it should be to administer the chloroform, and to watch its effects ; others to keep the patient in a proper position, to hand the different instru- ments to the surgeon, or to assist him in other respects ; besides a good light, and a bed or table, with pillows or cushions to make the patient's position as convenient as possible. Mr. Fergusson gives the useful hint that it is desirable to have delicate instruments made to shut in a handle like a pocket clasp-knife, so that they may be kept in the surgeon's waist- coat-pocket till they are wanted, and that their edge or point may not be injured through the carelessness of the assistants. Moreover, the operator should himself see that everything is at hand that may be wanted. It would be awkward in the middle of an amputation to send out for a saw, II. Incisions.—In making incisions there are several points that demand attention. First of all, the manner of handling the knife, which, as syste- matic writers say, may be held either like a common dinner knife, or like a pen, or like a fiddlestick. The first two positions are those which are em- ployed commonly ; the third is resorted to in cutting into the different layers over a hernial sac, and in sundry other delicate operations. Secondly, be- fore commencing an incision, the skin must be gently stretched and steadied with the points of the fingers, otherwise it will be dragged along by the knife, and the incision will be ragged, and shorter than was intended. Thirdly, in cutting through the skin, the knife should be passed in at right angles to the surface, and should be at once carried down to the subcutane- ous tissue ; then the blade should be inclined downwards, and be made to cut through the skin to the requisite extent; and, lastly, as the incision is finished, the instrument must be again brought to a right angle with the surface. By these means the whole thickness of the skin will be cleanly divided, both at the beginning and end of the incision. Timid operators are apt to make the incision through the skin too limited, which embarrasses their subsequent proceedings ; besides that cutting more of the skin sub- sequently (unless the patient is under the influence of chloroform) is very painful. When two incisions are to be made to meet near their extremities (as, for example, the two semi-elliptical incisions in amputation of the breast), the second should fall into the first nearly, but not quite at its extremity, so that (583) 584 ether and chloroform. there may be no little isthmus of skin left undivided between them. Again, in making a V incision, the second cut should not be begun where the first terminated, but at its other end ; that is to say, it should be made toivards the first, and not from it. In making a T incision likewise, the transverse cut should be made first, and the other be directed towards it. Lastly, the angle of a V incision should, if possible, be always dependent. III. Preparation.—The object is to have every organ and every function in as healthy and tranquil a state as possible. Recourse should be had to regular diet, aperients, and gentle alteratives, with or without small doses of sedatives, till the pulse has become quiet, the tongue clean, the bowels regular, the liver, kidneys, and skin in good order, and the mind cheerful. IV. The After-treatment should be conducted so as to ward off the most probable sources of danger—whether sinking from shock, or from loss of blood, or the occurrence of unhealthy changes in the surface of the wound and in the fluids exuded thereby, such as give rise to the various kinds of inflammation, phlebitis, erysipelas, diffused inflammations, and pyaemia. In the observations we have made on incised wounds, we have shown how im- portant it is that the patient should be supplied with beef-tea, and solid nourishment, and with wine in sufficient quantity to maintain a healthy state of blood; and that he should be kept quiet. The late Mr. Copeland is said always to have given his patients half a grain of opium every five or six hours for the first two or three days after an operation, for the purpose of tranquillizing the nervous system, and his success proved the benefit of the plan. V. Air in Veins.—The entrance of large quantities of air into a vein is a most dangerous accident, that has sometimes occurred during the extir- pation of tumors from the neck or axilla. A large vein being cut across, whose coats adhere to some firm textures around, so that they cannot col- lapse, a sort of bubbling sucking noise is suddenly heard, the patient instantly faints, and generally dies soon afterwards. On examination the right auricle is found distended with frothy blood. If any such sound should be perceived during an operation, the surgeon should instantly put his fingers on the spot that it proceeds from, and the patient, if faint, should be kept in the recumbent position with the head low, and should be well plied with brandy. The air has no noxious properties in itself, and if introduced slowly, in small quantity, does no harm; large quantities prove fatal by interfering mechanically with the action of the heart.1 CHAPTER II. MEANS OF PRODUCING INSENSIBILITY TO PAIN. History.—So terrible is the idea of the surgeon's knife, that it cannot be wondered at that many attempts have been made, at various times since surgery was first cultivated, to diminish the tortures which it inflicts, both in apprehension and in reality. Dr. Simpson2 brings forward quotations from Dioscorides, Pliny, and Apuleius, authors of the Roman empire, showing that in that age the root of the mandragore or mandrake (atropa man- 1 For the best account of these curious cases, refer to Sir C. Bell's Practical Essays, Lond. 1841. 2 Edinburgh Monthly Journal of Medical Science, December, 1847 ; Simpson's Obstetric Works, 1856, vol. ii. ETHER AND CHLOROFORM. 5S5 dragora) steeped in wine, was given to cause insensibility (rtoitlv avatoOyaiav) in persons who were to be cut or cauterized ; and that whilst the influence of this remedy lasted, a limb might be cut off without any pain or sensation. The seeds of the rocket (eruca) infused in wine were taken, according to Pliny, by criminals about to undergo the lash, in order to induce a certain recklessness or hardihood of feeling. The vinegar mingled with gall, men- tioned by St. Matthew (or the wine mingled with myrrh, as it is rendered by St. Mark), which was offered to our Saviour, before his Passion, furnishes an instance familiar to every one. The bang, or extract of Indian hemp, is used in India for the same purpose at the present day. Dr. Simpson has shown further that the inhalation of narcotic vapors was used as a pre- paratory to surgical operations in the thirteenth century. So far concerning the ancients. The modern history of anaesthetics may be said to begin at the end of the eighteenth century, when Mr. James Moore, son of Dr. Moore, of Clifford Street, and house-surgeon to St. George's Hospital, introduced a plan for diminishing the sensibility of limbs before amputation, by compressing the principal nerves. This he effected by means of an instrument resembling Signoroni's tourniquet, de- picted in the chapter on Aneurism, except that his instrument consisted of a horseshoe-shaped arch of steel, with a pad at each extremity, and a screw to act upon one of the pads. Moore was permitted by John Hunter in 1784, to try his plan upon a patient in St. George's Hospital, who had lost all his toes, and had a large irritable ulcer on his foot, and whose leg, after having been submitted to the process, was cut off below the knee by Mr. Hunter, with an extremely small amount of pain.1 This plan, however, was soon given up; it is not certain, and is not without some disadvantages ; for Malgaigne,8 who attempted by this means to benumb a patient's leg, before an operation, found that although some amount of insensibility was produced, yet that considerable pain was caused by the instruments used for compression. At the end of the last century the brilliant discoveries of oxygen and other gases by Priestley, Black, and Cavendish, and the fervent study of pneumatic chemistry, created a new, though very short-lived branch of therapeutics. The attention of the profession was hopefully directed to pneumatic medicine, as it was called ; that is, to the possibility of curing diseases, and especially consumption, by the inhalation of various kinds of gases. A Medical Pneumatic Institution was set up at Clifton by Dr. Bed- does,3 with huge reservoirs of gases for the use of patients. Humphry Davy, just out of his apprenticeship, was appointed superintendent in 1799;—his experiments on the inhalation of nitrous oxide added to the excitement;—S. T. Coleridge, Robert Southey, John Rickman, P. Roget, Boulton, Watt, Wedgwood, and others, since distinguished as poets and philosophers, eagerly made proof of the effects of the intoxicating gas ;— the gas oxygenium and gas acidum carbonicum, and other gases, were in- troduced into the catalogues of medicinal drugs ; it was now fondly hoped that we were in possession of remedies simple, and certain, for almost all maladies; and even Davy, though far from participating in the sanguine dreams of Beddoes, believed it possible that by various combinations of carburetted hydrogen and nitrous oxide, "we should be in possession of a regular series of exciting and depressing powers, applicable to every devia- tion of the constitution from health." But experience ruthlessly proved the 1 A Method of preventing or diminishing pain in several operations of Surgery, by James Moore, Member of the Surgeons' Company of London. 1784. 2 Malgaigne's Operative Surgery, by Brittan, p. 42. 3 A Letter to Erasmus Darwin, M.D., on a New Method of Treating Pulmonary Con- sumption. By Thomas Beddoes, M. D. Bristol, 1793. 586 MEANS OF PRODUCING INSENSIBILITY TO PAIN. fallacy of these, as of many other ingenious and plausible speculations. In the course of his experiments, however, Davy found that the nitrous oxide relieved him from headache after a profound fit of intoxication which he had brought on by drinking a bottle of wine in eight minutes, with the purpose of comparing the effects of wine with those of the intoxicating gas ; he also found that it mitigated the pain of cutting a wisdom tooth ; and he threw out the hint that as it appeared " capable of destroying physical pain, so it might probably be used with advantage during surgical operations."1 Nothing in good earnest, however, was done ; there was no established or systematic use of anaesthetic means until the year 1844, when Horace Wells, a dentist of Hartford, Conn., U. S., acting upon Davy's suggestion, both inhaled the nitrous oxide gas himself before one of his teeth was ex- tracted, with the effect of producing a complete unconsciousness of pain, and administered it to several patients who underwent the same operation, with the same beneficial results. In the December of that year he visited Boston, and made public trial of the administration of the gas, before the Medical College of that City. But this experiment failed from want of proper management; and the failure subjected Wells to so great an amount of ridicule, that he fell sick through vexation, retired from practice as a dentist, engaged himself in stuffing and exhibiting birds and in the sale of shower-baths ; afterwards came to Europe as a picture-dealer, then returned to America, became more and more unsettled in his mind, and died by his own hand in January, 1848. But the experiment of Wells, at Boston, fatal as its results were to him- self, was not altogether devoid of fruit. W. G. T. Morton had been a pupil and partner of Wells, and afterwards settled in Boston, where he studied medicine and chemistry for a short time under Dr. Charles T. Jackson, and then practised as a dentist. He was the person who intro- duced Wells to the Medical Society of Boston, and a share of the ridicule attached to the unsuccessful experiment fell upon his shoulders. It appears that the idea of finding some means of extracting teeth without pain occu- pied the attention of both Morton and Jackson, and was the subject of conversation between them. Morton learnt from Jackson the use of chloric ether as a local application to aching teeth. Both had read in Pereira's work on Materia Medica, that the vapor of sulphuric aether was inhaled in spasmodic asthma, chronic catarrh, and hooping-cough, and to relieve the effects caused by the inhalation of chlorine gas. In fact, for these purposes, the inhalation of ether, pure, or medicated with conium or other substances, was a well-known and not uncommon remedy, and had been spoken of by various authors from the time of Beddoes and Richard Pearson2 in the latter end of the eighteenth century. Jackson himself had inhaled ether to relieve the irritation caused by accidentally breathing chlorine gas. Morton's Discovery.—But the merit of first employing the inhalation of ether in such a way as to produce a decided and controllable state of insen- sibility to the pain of surgical operations, is undoubtedly due to Morton. He first made several experiments on himself, with imperfect success, arising from the great difficulty of procuring ether sufficiently pure ; but having at last, on the 30th of December,. 1846, by inhaling it from a flask through a glass tube, succeeded in making himself unconscious, he determined to try the experiment on the first fit subject that presented himself. So eager was he, that he sent out agents that afternoon to try and tempt some Yankee, 1 See Memoir of Sir H. Davy, by his brother, John Davy, M. D., Lond. 1839, and Researches, Chemical and Philosophical, by Humphry Davy, Superintendent of the Medical Pneumatic Institution, Loud. 1800, p. 465 et seq. 2 Short Account of Different Kinds of Airs, so far as relates to their Medicinal Use, by Richard Pearson, M. D. Birmingham, 1795. ETHER AND CHLOROFORM. 587 with the offer of five dollars to come and inhale the ether, and lose a tooth. Xo one, however, would be so tempted; but that same evening the very person wanted came of his own accord. A man, Eben H. Frost by name, applied to have a tooth extracted, and being wonderfully timid, and wishing to be mesmerised in order that he might feel no pain, he was easily per- suaded to inhale some ether from a handkerchief. He soon became uncon- scious, and Morton extracted a bicuspid tooth, the patient knowing nothing of the operation till he recovered his senses, and saw the tooth lying on the floor. A Dr. Hayden, who held the lamp for the operator, and one Tenny, a journalist, were witnesses of the fact, and, together with the patient, im- mediately drew up and signed a document attesting it. And so, a new era in surgery began with the painless extraction of Frost's tooth by Morton, at 19, Tremont's Row, Boston, at nine in the evening of the 30th of Sep- tember, 1846.1 Morton lost no time in prosecuting the discovery he had made, although he did not at first disclose the nature of the agent employed. He continued to make experiments at his own house ; and having made the subject known to Dr. Warren, was permitted to introduce his anaesthetic agent into the practice of genuine surgery, and on the 16th of October administered the ether in the Massachusetts General Hospital, at Boston, to a patient from whom Dr. J. C. Warren removed a tumor in the neck; and on the day fol- lowing to a patient from whose arm a tumor was extirpated by Dr. G. Hay- ward. From that time the use of the novel remedy spread rapidly in all directions ; but before pursuing its history we must drop a passing word of regret at its disastrous effects on the fortunes of its discoverer. Morton endeavored to make a mystery of the means he employed, and to secure to himself, by patent, the exclusive right of administering it. But Jackson, seeing that the thing promised to be both famous and lucrative, now laid claim to the discovery as his own, on the plea that certain information which he had given Morton, respecting the properties of ether, had directly led Morton to the use of it. To pacify Jackson, and bar any claims he might hereafter set up, he was allowed a share in the patent which was taken out. Nevertheless he sent a communication to the French Academy, in which he suppressed Morton's name, and claimed the whole discovery as his own. Meanwhile the patent turned out to be good for nothing, and Morton, who had neglected his business, and injured his health by the excitement of his discovery, was left with his pockets empty, and even the bare honor of the invention almost wrested from him.9 From America the news of the discovery was conveyed to England in a communication from Dr. Bigelow, of Boston, to Dr. Francis Boott, and it was received most cordially.3 On the 21st of December 1846, Mr. Liston tried the ether with the best possible results in a case of amputation of the thigh, and in one of evulsion of the toe-nail. On the 31st, the writer was present when Mr. Fergusson used it in the King's College Hospital, and in less than a fortnight it was tried by almost every surgeon in the kingdom ; whilst the medical periodicals for a long time were crowded with fresh in- stances of its powers in alleviating suffering, and with descriptions of various apparatus for administering the vapor. It was employed in every variety of surgical operation, from the Caesarian section, in which it was used by Mr. Skey, at St. Bartholomew's Hospital, on the 25th of January, 1847, down to tooth-drawing ; and in all kinds of painful examination or manipu- lation ; it was used in cases of strangulated hernia and of dislocation and 1 Ether and Chloroform, by Henry J. Bigelow, M. D. Boston, 1848. 2 See a report of the Trustees of the Massachusetts General Hospital, with a History of the Ether Discovery, in Littell's Living Age, Boston, 18th March, 1848. 3 Vide Lancet, January 2, 1847, and all the Medical periodicals of that year, passim. 588 MEANS OF PRODUCING INSENSIBILITY TO PAIN. in the obstetric operation of turning, in order to diminish the resistance of the muscles; in various cases of painful and spasmodic affections, such as tetanus, neuralgia, and spasmodic asthma ; it was employed to tranquillize the insane, to detect feigned disease, and to diminish the sufferings incidental to parturition. It was used too on infants, on the aged, and on animals. Its modus operandi closely resembles that of chloroform, and need not be described separately. Chloroform.—Brilliant as was the career of the ether discovery, it was destined soon to be eclipsed. Ether, whose chemical symbol is C4H50, is one of a numerous class of bodies, all composed of hydrogen and carbon, with variable proportions of oxygen or some other electro-negative. Dr. J. Y. Simpson, of Edinburgh, believing that amongst these bodies some might be found equal or superior to ether, made many experiments on himself and friends with chloride of hydrocarbon, acetone, nitrous ether, and other an- alogous substances, and at last, on the 4th of November, 1847, in company with Dr. Keith and Dr. Matthews Duncan, found in a heavyish liquid that had been put by and almost forgotten, an agent which was manifestly supe- rior to ether in its narcotizing virtues, and immeasurably more pleasant. This was chloroform. It had been investigated some time before by Dr. Glover, and it was recommended to Dr. Simpson by Mr. Waldie, of Liver- pool ; moreover, inhalation of the fumes of that solution of it in alcohol which is known by the name of chloric ether had been tried some time before by Mr. Jacob Bell; but undoubtedly the merit of establishing the anaesthetic power of chloroform, as a matter-of-fact, belongs to Dr. Simpson. The surgeons who first performed operations with the aid of it, were Dr. Miller and Dr. Duncan, at the Royal Infirmary of Edinburgh, early in November, 1847.1 Chemical History.—Chloroform is a terchloride of a hypothetical base, termed Formyle, which consists of two atoms of carbon and one of hydrogen. Hence the symbolic designation of chloroform is C2H,C13. It was discovered by Soubeiran in 1831, by Liebig in 1832, and by Mr. Samuel Guthrie, of Sackett's Harbor, New York, in the same year ;3 its real nature was ascer- tained by Dumas and Peligot in 1835. It is obtained by distilling rectified spirit with water and chloride of lime, in the proportions of four pounds of powdered chloride of lime, twelve pounds of water, and twelve fluidounces of rectified spirit. These are mixed and distilled, so long as a dense liquid which sinks in the water with which it comes over, is produced. It is rec- tified by agitating it with the strongest colorless sulphuric acid, which if it contain any impurities, such as the empyreumatic oils with which it is liable to be contaminated, at once destroys them by charring, and renders them manifest by the dark color of the line where the chloroform and acid come into contact. It is poured off and agitated with fresh acid, if necessary, then poured carefully off into a dry stoppered bottle, and shaken with some peroxide of manganese, from which it may be decanted, fit for use.3 Pure chloroform is a dense colorless liquid, having the specific gravity, when quite pure, of from 1.480 to 1.5. It is exceedingly volatile, and boils at about 140°. It has an agreeable sweet fruity smell and taste, and if poured on a piece of blotting-paper and evaporated, ought to leave no oily empyreumatic smell behind. By passing its vapor through a red-hot tube, it is decomposed, and hydrochloric acid is given off, which may be detected by means of paper moistened with solution of nitrate of silver. By such a process Dr. Snow has detected it in the bodies of kittens poisoned by a very 1 Consult Miller's Principles of Surgery, vol. ii. p. 756, for a facetious account of the circumstances attending the discovery. 2 Cogswell, Lancet, 1847, vol. ii. p. 631; Waldie, ib. p. 687. 3 Gregory, quoted in Ranking's Abstract, vol. xi. p, 231. CHLOROFORM. 589 minute quantity of it, and in the muscles of a child's leg which had been amputated at St. George's Hospital after inhalation of the vapor. Chloroform is almost incombustible, thus offering an advantageous contrast to ether, from the explosion of which at least one serious accident happened during its administration.1 Effects on the Animal Economy.—When the vapor of chloroform is received into the lungs, it is absorbed into the blood, and conveyed to the nervous centres and rest of the body, upon which it soon produces very marked effects. These it is convenient to divide into degrees, and the divi- sion which the writer proposes as the most practically useful, is the follow- ing :—The first, or slightest degree, corresponds with what may be called exhilaration or slight intoxication. The pulse is quickened, and the whole surface, especially the face and eyes, becomes suffused with red. The cur- rent of ideas is vivid and not quite under control; fear is banished ; vision, perhaps, unsteady, and the gait staggering; but there is perfect conscious- ness of all that is going on, and the severe pain of operations is still felt intensely ; although that part of suffering which depends on mental appre- hension is relieved. In the second degree there is no longer perfect consciousness ; the mental faculties are almost abolished ; the patient generally neither speaks nor moves, though it is possible for him to do both if spoken to or roused, and he is in a condition of deep drowsiness ; it may sometimes be called drunken- drowsiness. All the varieties, too, of intoxication may be displayed, accord- ing to the mental peculiarity of the patient. One man is noisy, and inclined to fight; another laughs at jokes of his own making; a woman may weep or talk of her husband or children. But these phenomena are not universal, and are of very short duration ; for this degree soon passes into the next, if the inhalation be prolonged, or into the first, if it be discontinued. In the third degree, there is profound sleep; all voluntary motion and sensation are at a standstill; the eye is suffused and turned upwards, the pupil contracted, and the breathing slow, as in natural sleep. But yet in this degree, the eyelids wink if touched ; sneezing is excited by tickling the nostrils ; in fact, reflex movements are vividly performed, as they are in sleep; and though the patient lie unconscious, he is not yet sufficiently motionless for severe or prolonged surgical operations. The fourth degree, which may be termed perfect insensibility (or anaes- thesia, if a Greek term is better), is distinguished by the circumstance that, in addition to the profound sleep of the third degree, reflex actions are no longer excited by the nerves of common sensation. The eyeball may be touched freely without winking ; the muscles are perfectly relaxed; and it is the very beginning of this degree, which it is desirable to produce, for the commencement of surgical operations. The fifth degree approaches the condition known as coma; it is marked by tendency of the pupil to dilate; and slower breathing: if the quantity of vapor be increased, death may occur from coma. If this account of the increasing effects of chloroform be carefully perused, it will be seen that it belongs to the class of substances of which opium and the various preparations of alcohol are examples. It begins by affecting the mind and consciousness. In its smallest dose it stimulates, then disturbs, then suspends the mental operations. It next diminishes the power of the nerves in receiving and communicating, and of the brain in perceiving sen- sations, whether arising from causes within the body, or without; hence it diminishes or abolishes the perception, and the existence of pain. It further benumbs that power called the reflex function of the spinal cord ; the power ' Med. Gaz., 20th Sept. 1850. 590 MEANS OF PRODUCING INSENSIBILITY TO PAIN. by which the spinal cord, upon the production of any change in the nerves of sensation, puts into play the corresponding nerves of motion, and this quite automatically and independently of the will or consciousness. This is the power by which irritation of any part causes its muscles to contract. Hence, the torpefaction of this power insures the absence of involuntary movement, and the complete relaxation of the voluntary muscles. But it must never be forgotten that it is this function of the spinal cord which pro- vides for the continuance of breathing; and that if it be altogether abol- ished, the necessary impulse is no longer given to the respiratory muscles; breathing ceases ; the heart stops in a minute or two afterwards,—and life' is extinguished. Thus chloroform, administered to excess, may cause death, as opium does, by a series of changes beginning in the animal, or cerebro-spinal part of the nervous system, whereby breathing is slowly stopped; whilst the actions controlled by the vegetative nervous system, including those of the bowels, womb, and above all of the heart, although somewhat enfeebled, are not greatly affected, till they are least compelled to cease, by the cessation of breathing. But if chloroform be administered too rapidly, or if certain imperfectly understood conditions be present, sudden death may be the result. We shall discuss this point presently. Dose.—In speaking of the dose of chloroform, it must be remembered that it is not the mere quantity inhaled, without reference to time, but the quantity present in the blood in a given time, which is to be regarded. Patients may be kept under its influence a long time, and thus may inhale a large quantity with safety; but even a small quantity too rapidly inhaled, and insufficiently diluted with air, may be dangerous. When we hear the dose of chloroform estimated by drachms, and are told of a patient who consumed thirty-two ounces in twenty-four hours, we must not forget that it is the actual quantity present in a given time in the blood, and its effects on the sensibility and respiration, that are to be the real guides as to the safety or danger of the quantity administered, and not the mere quantity by measure that is evaporated. Dr. Snow calculated that about twelve minims of chloroform circulating in the blood of an adult produce the second degree of narcotism, eighteen minims the degree in which operations are performed ; a little more than thirty suffice to arrest respiration, and thirty-six or thirty-seven to stop the action of the heart. These numbers refer to the quantity actually circulating in the blood at a given time. It is necessary also to bear in mind, that when a patient is inhaling air highly charged with chloroform, the narcotic effects continue to increase, as Dr. Snow pointed out, for twenty seconds, after the inhalation is discontinued, owing to the absorption of the vapor remaining in the lungs. But it seems very certain, that much less is requisite for producing full insensibility in some persons than in others.1 Mode of Administration.—Dr. Simpson, the father of chloroformization, uses no apparatus whatever, but a simple handkerchief; and the writer, from his own experience, thinks that this unpretending way is the best in all cases in which the slighter degrees only are required; as, for instance, in common midwifery cases, and in cases in which pain has to be allayed with- 1 Sibson, Med. Gaz. vol. vi. p. 276; T. Wakley, Lancet, 1848, vol. i. p. 19; Dr. Snow, Med. Times, 31st August, 1850; On Death from Chloroform, London Journal of Medicine, April, 1852; case of Death, Med. Times, Oct. 19, 1852; see also Lancet, Oct. 29, 1853.—Dr. Crisp, Lancet, 1853, vol. i. How shall we insure safety in the administration of chloroform? By Patrick Black, M. D., 1855; Further Remarks on the Cause and Prevention of Death from Chloroform. By John Snow, M. D., Lancet of Feb. 1S56. CHLOROFORM. 591 out deep or protracted narcotism. It is equally safe, too, for the profounder degrees of insensibility required for severe operations, provided the ad- ministrant uses that degree of care without which no sane person would touch this remedy ; but it is rather more wasteful of the vapor. The patient should lie down. This is particularly necessary if a hand- kerchief and not an inhaler be employed. If sitting, the attitude should be such as to allow of the completest repose ; but it is much more difficult to narcotize a person sitting. He should be encouraged to be as tranquil as possible, and compose himself to sleep. A napkin should be folded into a hollow cone, and twenty minims of chloroform, by measure, be poured into its apex; then it should be held about two inches from the face of the patient, who should be instructed to begin to breathe through open mouth, slowly and deeply, so as to inhale as much of the vapor as he can. If there is any choking, the napkin should be removed a little further. The nar- cotism should be insinuatingly begun ; so as to avoid any distressing gulp- ing, or choking, or struggling, especially in the case of children. When the first twenty minims are exhausted, the same quantity should be repeated ; and this should be done again and again at intervals, till the requisite degree of narcotism is produced. So soon as the eye, when opened, looks suffused and heavy and turned up, and the patient scarcely speaks if spoken to, then the second degree is at its acme, and the third beginning. If the inhalation be continued, the degree of profound sleep, and next that of complete insensibility, will be established, and then, so soon, as Dr. Snow observes, as the eyelid can be raised, and the conjunctiva touched without winking, the surgeon may begin. When the operation is fairly commenced, it is not necessary to keep up so great a degree of narcotism. The patient having been secured against the first plunge of the knife, may be kept in a ^ sufficient state of unconsciousness by an occasional whiff of the vapor, when- ever his countenance exhibits any signs of feeling. In fact, during a pro- tracted administration, when the patient is thoroughly narcotized, the vapor should be intermitted ; the patient should for certain intervals be allowed pure air, and the chloroform be resumed from time to time when there is some approach to wincing under the hands of the operator. If, however, the surgeon chooses an apparatus, a very simple and good one is Dr. Sibson's mask. This consists of a mask, covering nose and mouth, constructed of thin flexible metal, so that it can be adjusted to a face of almost any form or size. It has attached to it a small cavity, within which is a piece of blotting-paper, on which the twenty minims of chloro- form are dropped from time to time. Through this cavity the air is drawn in by the act of inspiration, bringing the chloroform vapor with it. A valve of vulcanized India-rubber permits the entrance of the air, but prevents its escape by the same route. Another valve opens to allow of the escape of the air that has been once breathed, but shuts during inspiration. This latter valve, if entirely turned aside, permits the atmospheric air to enter freely without any chloroform, or, if removed partially, permits it to be mixed with it in any proportion. Dr. Snow's Inhaler consists of Dr. Sibson's mask, which is connected by a long flexible tube to a double metallic bottle. The inner bottle con- tains the chloroform, and has proper apertures for the transmission of air. The outer bottle contains cold water, in order to provide that the vapor may be raised at an equable temperature. Another rude but very good apparatus is made by folding a piece of very stiff paper into the shape of a fool's cap ; leaving an aperture at the top. A piece of sponge is sewed to the inside of the paper near the top; and on this (first wetted with cold water) the chloroform is poured. Mr. Armstrong Todd has devised a very ingenious instrument, consisting 5 92 MEANS OF PRODUCING INSENSIBILITY TO PAIN. of a tube perforated on all sides, and having a movable piston, on which last the chloroform is put. By increasing the distance of the piston, the amount of pure air which comes through the perforated sides is increased. Messrs. Weiss, also, have devised a very good inhaler, more portable than Dr. Snow's, by which the quantity of chloroform and of air can be regu- lated. But the best of all is one which Messrs. Weiss have shown the author, which is fixed to the operating-table; and which provides against waste of the vapor, and excessive doses. The following hints may be of use to beginners :—The chloroform should not be allowed to touch the lips, or it may blister them. The patient should not be chloroformed within two hours of a full meal. This precaution may prevent the annoyance of vomiting. He should be narcotized before he is removed to the operating table, and before he can see any preparations or knives. The humanity of this precaution, if a timid patient is to be brought into the operating theatre of an hospital, is evident. He should be taken back to bed again in a state of unconsciousness. There should be no hurry in the first stage of the process, because complete insensibility to pain, and absence of involuntary movement and wincing, are more safely obtained after the vapor has had time to permeate all the capillaries and benumb all the peripheral nerves. Dr. Snow makes the most valuable observation, that insensibility to pain cannot be obtained in a very rapid manner without a dangerous degree of narcotism of the nervous centres. The inhalation should occupy at least from four to seven minutes before the third degree of narcotism is established; and then it will usually be another minute more before the surgeon should begin. The loud talking or violence of the in- toxication stage is no cause of alarm ; quite the reverse ; it shows that the vapor has not produced a dangerous effect, and that a slight increase is ne- cessary to produce the next degree. At every operation the management of the chloroform should be com- mitted to one competent person, whose duty it should be to attend to it, and nothing else, with his eye on the breathing, and his finger on the pulse. The class of patients on whom chloroform acts most pleasantly and safely are women in childbirth ; next, young children, in whom it scarcely ever causes either mental excitement or struggling. Moreover, immunity from pain is obtained with less narcotism of the nervous centres than in adults. The very aged are long in recovering their consciousness after inhalation. The more feeble a patient is, the more quickly and pleasantly does the vapor generally act; if very strong and robust, considerable mental excite- ment is apt to occur in the second degree of narcotism, and struggling or rigidity of the muscles in the third. Some patients hold their breath for some seconds. In this case, the first deep inhalation should be of pure air only. The cases in which the inhalation of chloroform is useful comprise, in the first place, every surgical manipulation attended with pain ; of which it seems not only to render the patient unconscious, but also, by preventing its effects on the mind, to neutralize its depressing power on the body. To lull the pain during operations as well as the smarting after them ; to lull the pain and shock of violent injuries, and of the surgical examination and setting of fractures which follow ; to facilitate the reduction of herniae and dislocations and the passing of catheters, and to detect feigned disease; these are its chief surgical uses. But its benefits are not confined to the abolition of pain; there is great reason for hoping that it renders operations less mortal; it enables the surgeon to proceed with his dissection in a more leisurely manner; it does away with the scruples of the over-modest woman, to whom the shame of exposure is worse than the pain of the knife ; and it circumvents the opposition of the timid and unruly. CHLOROFORM. 5 93 In military surgery it has special uses. " In the prolonged searches," says Dr. Macleod,1 " which are sometimes necessary for the extraction of foreign bodies, it not only prevents pain, but restrains the involuntary con- traction of muscles which otherwise would throw great obstacles in the way of both search and extraction. In field-practice, too, when a number of men come in quick succession during a general engagement, to be operated upon, the brave fellows who are waiting for their turn are spared the depres- sion which the groans of their comrades under the knife would otherwise inflict upon them." In the case of children, many things can be done nicely with chloroform, which could be but most ill done, if at all, without it. Take, for instance, the case of wounds of the eyelids or eyebrows, which, if not most accurately sewn up, are sure to be followed by frightful seams, or by inversion or ever- sion of the lids, and perpetual overflow of tears. By a little chloroform, not merely the pain and fright of the injury, and the severe smarting caused by the needle, but the struggles also, which render quickness and nicety of adaptation impossible, are done away with; the patient sleeps tranquilly during the process, and wakes composedly soon after, absolutely without any ill consequences whatever. The writer administered it day by day for a fortnight to a child of four years, who had been severely scalded, in order to prevent the screams and struggles which accompanied the dressing of the wound. No ill effects whatever resulted. The child slept through the dress- ing, and awoke without sickness. But the uses of chloroform are far from being confined to the practice of surgery. In midwifery the uneasiness and spasms which attend the early stages, and the distension and rigidity of the later, together with the anxiety and fears, are so tranquillized that, although fortunate and healthy women need it not, yet those who have ever experienced the comfort of it, are never willing to forego it in another confinement. Moreover, in ordinary cases, its good effects may be obtained with the smallest doses, without scarcely passing the first or second degree of narcotism, and without the slightest danger at the time, or ill effect on mother or child afterwards.2 In the ope- rations of midwifery its effects are admirable ; and not the least happy cir- cumstance is, that it works so well with opium. In general physic its use is great; not so great, perhaps, as the writer was led to hope in preceding editions of this work. In the last edition we said, " In general terms, it may be said to achieve perfectly, and at once, what opium is an hour or two in doing gradually. Moreover, it has the happy property of being so quickly and entirely eliminated from the system, that there are in most cases no ill effects afterwards ; none of the checked secretions for which opium is, justly or unjustly, so often blamed. Hence, in violent pain and spasms, especially in colic, in spasmodic asthma, and spasmodic cough, dyspnoea, dysuria, dysentery, dysmenorrhoea, and almost every other compound of 8i>s, in hysteria and convulsions not depending on fulness of the nervous centres, this remedy may be resorted to. In the violent colic of infants, for example, the sagacious physician, instead of letting the patient shriek itself to death, whilst he is waiting for the effect of remedies, will, by this vapor, stop the pain, which is the element of danger, and remove the causes of the illness radically at his leisure." Increased experience compels the writer to say, that although his former opinion stands good with regard to cases of sudden painful illness, in pre- viously healthy persons, yet that it is not eliminated quickly; and that it often 1 Notes on the Surgery of the War in the Crimea. By G. H. B. Macleod, M.D., F.R.C.S., &c, Lond. It58. 2 The writer has an Essay on the Causes, Varieties, and Prevention of Pain in Labor, which he hopes to publish ere long. 38 594 MEANS OF PRODUCING INSENSIBILITY TO PAIN. leaves a deadly amount of sickness and headache, and feverishness, which are great drawbacks to its use in cancer, neuralgia, and dysmenorrhoea, cases in which the writer has tried it. Cases in which it is inapplicable.—It is generally considered better not to use chloroform in cases of extraction of cataract, in elderly persons. There are two reasons for this. First, lest the vomiting which often happens afterwards might force out the whole contents of the eyeball. But Mr. Haynes Walton has shown that this accident may be prevented if the proper amount of gentle pressure be exerted on the eyelid by means of strips of plas- ter. Another more serious objection, is the interruption which chloroform may possibly occasion to the functions of the stomach in aged persons. In operations on the jaws, or fauces, there is no serious fear that the blood will run into the glottis and suffocate the patient, provided the patient's head be turned on one side repeatedly to let it run out freely. Full narcotism should be induced before these operations, and it should be kept up as well as it can by inhalation at intervals from a sponge wetted with cold water, on which twenty minims of chloroform have been poured. The cases in which on general principles it should be given with hesitation, are those of chronic organic disease of the brain, atrophy or dilatation of the heart, and embar- rassed circulation through the lungs. But since the shock of an operation is in itself extremely formidable to patients so affected, it is probable that a cautious administration of the anaesthetic might diminish the danger instead of adding to it. Epileptic patients are liable to have their fits induced by the inhalation. It should never be given to a woman without a witness. Moreover, it never should be administered by any person to himself, nor yet be used as a plaything or a luxury. If pain is bearable, and not injurious, let it be borne. Accidents from Chloroform.—The commonest is vomiting, which, how- ever, is of very little consequence. If it occur during the inhalation, the patient's head must be turned to one side to let the vomited matter escape. If very troublesome afterwards, a little brandy and soda water, or an aperient, may be administered. The patient, if chilly, should be wrapped up warmly. When the patient is an adult, and particularly if old, the chloroform may not be entirely eliminated for some hours, and may occasion nausea and giddi- ness, and haunt the patient disagreeably with its smell and taste. Abstinence from food beforehand will diminish, but will not infallibly prevent vomiting in all persons; since it is either an eliminatory act, for the purpose of puri- fying the blood, like the vomiting on the day after a debauch, or else, like sea-sickness, the result of brain disturbance. The prolonged insensibility, and other frightful symptoms which affected some persons, especially young women, after inhalation, when the remedy was a new one, were probably due to hysteria. Death from Chloroform.—That a remedy so powerful should be capable of extinguishing life, follows as a matter of course from the details which we have given. The manner in which life is extinguished has been the subject of controversy, and is probably not always the same : nor yet always simple ; but may combine more than one mode of dying. In the first place, chloroform may kill by apnoea, or suffocation; by inter- fering with the passage of the blood through the lungs ; by giving the blood such a quality that the pulmonary capillaries refuse a passage to it; or by acting'upon the medulla oblongata in such way as to stop the reflex act of inspiration. This mode of death seems to occur often in the case of animals poisoned experimentally; sometimes in man. Possibly spasm of the glottis may be produced by a concentrated vapor. In such a* case, the symptoms would be those of "congestion of the head and face, staring eyes, turgid veins, struggling, or convulsive spasms, ineffectual efforts to expand the CHLOROFORM. 595 chest," preceded by a sense of choking, and irresistible propensity to strug- gle against further inhalation. After death, congestion of the lungs, and fulness of the right side of the heart would be found.1 There is a capital experiment recorded by Dr. Chapman,3 in which the heart of a cat poisoned by chloroform, full and motionless, was set beating by the loss of blood which ensued from division of the aorta and pulmonary artery, and beat for an hour and a half. Hence it is evident that.this heart was stopped because overloaded, and unable to force the blood through the lungs : not paralyzed intrinsically. But, secondly, there can be no doubt, that chloroform usually kills man by syncope or angina, that is, paralysis of the heart. And the order of phenomena is usually this :—The patient all at once raises his body and struggles, the face is noticed to be deadly pale and the limbs relaxed, blood ceases to flow from cut arteries, no pulse is felt at the wrist, the heart can- not be felt to beat, the breathing continues slowly and gaspingly for half a minute or more, then all is over. Of deaths belonging to this category, no better example can be given than the following :—A gentleman, aged 73, with intermitting pulse, and arcus in each eye, had been chloroformed six or eight times for the purpose of under- going lithotrity. On Dec. 4, 1851, he was again chloroformed ; during the operation he exhibited considerable faintness, though he recovered himself before it was over. A few minutes after the operation he had what was de- scribed as alarming syncope. Spite of this, the patient was chloroformed again on the 15th and 19th Dec. by Dr. Snow; whose large experience had given him no room to anticipate bad results. On Sept. 15th, 1852, there was occasion for another operation. Chloroform was again given by Dr. Snow. The patient became insensible in three or four minutes, without struggling. The operation was begun. A little of the vapor was given twice or thrice to keep up the effect. After a few minutes great paleness of lips and face was noticed ; but immediately afterwards the face reddened, and the patient strained as though he felt the operation. Hereupon, a little more vapor, largely diluted, was given. But now after two or three inspirations the breathing ceased. It seemed as though the patient were holding his breath a little, as sometimes happens ; but on feeling the wrist there was no pulse. In a few seconds came one deep inspiration;—a few rapid and feeble pulsa- tions of the heart were heard, which then ceased ; one or two very faint inspirations followed at the interval of a quarter of a minute ; then death. Cold affusion and artificial respiration were employed without avail. On inspection the heart was found large, soft, friable, and in a state of fatty de- generation. That death in this, and in other similar cases, is brought about by para- lysis of the heart, and not by suffocation, was successfully shown by the late Dr. Snow. He showed that death from pure suffocation is never so quick as death from chloroform has always been ; that in cases of death from priva- tion of air, the heart goes on beating for some few minutes after breathing has ceased; whereas, as a matter of fact, in most cases of death by chloroform, the breathing has been proved to go on up to the time the pulse stopped, and after it;—that patients have breathed it freely without struggling up to the instant of death; and that sudden paleness is a more frequent phenome- non in these cases, than turgescence of the face ; although neither is incom- patible with palsy of the heart. The writer may add, that in the only case in which any unpleasant symptoms occurred whilst he was administering chloroform, the patient complained afterwards, not of choking, but of the 1 We quote almost verbatim from Dr. Black's verv able pamphlet. 2 How Chloroform Kills, Med. Times, lbth Oct. 185U. 596 MEANS OF PRODUCING INSENSIBILITY TO PAIN. unmistakable symptoms of angina—fixed pain, great oppression, and feeling as of a load in the region of the heart. Thirdly, chloroform may cause death by what the French call by the classical term sideration, to wit, a star-struck or blasted state of the ner- vous system; or, in plain English, by a sudden annihilation of the life of the brain and spinal cord. Hence the syncope may be caused by the state of the brain, and not merely by the direct action of the poison on the heart. That the poison has an injurious operation on the nervous centres, is mani- fest from the nature of the thing, and from the vomiting. In an uncertain number of cases, too, chloroform may have added to the general exhaustion, which has caused patients to sink from the shock of operations. Yet all the accounts concur in establishing the fact that in the infinitely greatest number of cases in man, it is by direct paralysis of the heart that death is produced. A remarkable circumstance is the apparent capriciousness of the accident. It has been suggested that in some cases the chloroform has been impure; but of this there is no proof. In others, that the patient's heart was weak, or in a state of oily degenera- tion. Yet in some cases after death the heart has been found quite sound. In others, that the vapor was given from a handkerchief, and not with an apparatus. But the writer does not hesitate to say, that if the administra- tor keeps one eye on the breathing and a finger on the pulse, a handkerchief is quite as safe as an inhaler, or safer, provided that but little chloroform be put on at a time. It is worth noticing that Mr. Todd, the inventor of the ingenious inhaler of which we have spoken, describes Snow's as imperfect and deceptive. In other cases, again, it has been suggested that the administration was hurried, or careless. And this is no doubt true. The administrator, puz- zled or annoyed by the persistence of the second or intoxication stage, gives a sudden increase, and the heart-stops. But the same apparent capriciousness attends the other instances of sud- den death. We do not always know, why any given soft and thin heart should stop suddenly at a given time ; but we do know enough to put us on our guard. In the first place, our object should be, to obtain the greatest effect from the smallest quantity, and to avoid sudden increase. Then, to avoid all cir- cumstances which disturb the heart; and, above all, mental agitation. The sitting posture is to be avoided. The patient should be as nearly as possi- ble under the circumstances that induce sleep. Some good soup should be given an hour before, and some brandy just before the operation. Account must be taken of exposure to cold and loss of blood during long operations. The air which reaches the patient should be pure ; and lastly, if the pulse be very soft, and the heart's impulse feeble, and the patient subject to breath- lessness on slight exertion, it will be wise to give enough merely to abate mental disquietude, without entire insensibility. Moreover, the writer suggests the previous administration of morphia, as in midwifery, so as to produce a certain amount of sleepiness before the chloroform is administered. The signs of danger of narcotism from protracted inhalation are, respira- tion too slow, or pupil dilating, or pulse very feeble. The remedies are pure air, cold affusion, and stimulants by mouth or rectum. But supposing that symptoms of heart-failure show themselves ? The ordinary plan is, to excite the respiratory acts by opening the windows and dashing cold water on the face; by pulling the tongue forwards, so as to unstop the glottis; by inflating the lungs from mouth to mouth ; or by forcible compression of CHLOROFORM. 597 the chest and abdomen once in three or four seconds ; injecting brandy and beef-tea into the rectum ; and holding ammonia to the nostrils. Moreover, Dr. Chapman's experiment, in which the distended heart of an animal was set beating by loss of blood would suggest the propriety of opening the jugular vein, and letting some blood flow, especially if the face were turgid. At all events the efforts should not be hastily abandoned. But since it is the heart that requires stimulation—necessary as respiration is—the author would not hesitate to stimulate it directly by pricking it with a fine needle plunged rapidly twice or thrice through the sixth intercostal space. There could be little danger in this, under any circumstances : fine needles, iu the days when acupuncture was in vogue, were run in everywhere without harm ; and in such a case as the present it would be quite justifiable. Besides this, Dr. Sibson has suggested to the author, in conversation, the expediency of injecting into a vein, towards the heart, some stimulating liquid. The heart will beat a long time in warm water : and the injection of warm water with a little salt, or of pure fresh blood from the veins of a bystander, would be a most desirable experiment. The number of deaths caused by anaesthetics has been computed by Dr. Chapman at 74, up to Dec. 1858.1 During 1858, and the first six months of 1859, fourteen cases are reported from all parts of the world ; two from the American continent; one from Germany; six from France ; two from Scotland (in which the chloroform was given without medical aid, during labor); two in the provinces in England ; two in the Royal Ophthalmic Hospital, Moorfields. Dr. Chapman calculates that anaesthetics have been administered to 1,200,000 persons for surgical purposes in the whole civilized world during the last ten years, and that one in 16,216 has lost his life thereby. Now comes the very serious question, Has chloroform, on the whole, increased the mortality of operations'? Dr. James Arnott asserts that the mortality of amputation has increased from 21 to 34 per cent, since the introduction of chloroform, and in consequence of the use of it. Mr. Fen- wick shows that in the Newcastle Infirmary, the gross mortality is the same before and since ; to wit, 24 per cent.: but that, if like be compared with like, the mortality of amputations from disease has been reduced from 19 to 13 per cent.; and from injury, to 31 instead of 32. Mr. Coates of Salis- bury, in a pamphlet, the candid and practical tone of which renders it of the greatest authority, declares that the mortality of amputations at his hospital in six years under chloroform, has been 9.259 per cent.; in the six previous years 22.58. But it must be confessed that this question is a most large and intricate one, and that the solution of it demands a most minute analysis of the facts. We do not know yet, whether, comparing like things with like, the mortality has or has not increased ; and if it has, whether the increase is due to chloroform. But it is very unlikely. [From a table given in the review of the Transactions of the American Medical Association, contained in the American Journal of the Medical Sciences for April, 1852, it appears, according to the statistics then avail- able, that the mortality with anaesthetics in the American Hospitals was 1 in 2^, or 43 per cent., in cases where amputation was performed for injuries, and 1 in 4|, or about 20 per cent., when performed for diseases. Without anaesthetics the mortality was 1 in 3||, or 29 per cent., for injuries, and 1 in 1 Westminster Review, Jan. 1859. Deaths from chloroform, sixty-eight: from ether, two ; from mixture of chloroform and ether, one ; from mixture of chloroform and alco- hol, one ; from amylene, two. We believe that Dr. Chapman overrates the number of operations, and underrates that of the deaths. Perhaps one in eight thousand is nearer the truth. 598 MEANS OF PRODUCING INSENSIBILITY TO PAIN. 6f, or 15 per cent., for diseases. More facts on this very important point are very much to be desired.] Chloroform compared with other Anaesthetics.—Very many experi- ments have been made on substances analogous in composition to chloroform, and on various combinations of them. Ether is much less pleasant than chloroform, more irritating to the air-passages, and more apt to be followed by headache and other unpleasant symptoms, of which the persistent taste and smell of it in the breath are not the least. But it is much safer, less rapid in its action, and only one-third as powerful. Besides, it produces complete muscular relaxation more perfectly, so that it is perhaps preferable in cases of hernia, dislocation and spasm. The Dutch liquid, or compound of chlorine and olefiant gas, so called because discovered by the Dutch chemists in 1795, resembles chloroform in its general effects, and is only about one- half so powerful or rapid in its action. It is not easy to procure. A mix- ture of equal parts of chloroform and alcohol is said to be safer, but has caused death in America. [In this country a mixture of chloroform and sulphuric ether, in the proportion, generally, of one part of the former to three of the latter, is preferred by many surgeons. It appears to be more safe than chloroform alone, and equally efficacious.] Amylene, a liquid hydrocarbon, was used by Dr. Snow in 238 cases : its anaesthetic powers were satisfactory, and it caused vomiting in two only out of the 238 cases, although chloroform caused it in 22 per cent. But its odor is abominable, and it destroyed life in two out of the 238 cases. Bisulphuret of carbon is a powerful, but uncertain and disagreeable agent. Undoubtedly, of all anaesthetics yet discovered, chloroform is the best. But we are not necessarily committed to it; and other means may yet be found to induce perfect local with slight central anaesthesia. It is even not impossible that we may yet go back to the experiment of Beddoes, with his reservoirs. Dr. H. Bigelow, of Boston, removed a breast, with the aid of sixty quarts of nitrous oxide gas, " consumed during six minutes, and pro- ducing a most tranquil and complete insensibility." Means of producing local Anaesthesia.—Something is desired which shall produce perfect insensibility of the part to be operated on, and yet leave the brain in possession of its faculties. Very many experiments to this end have been made by Dr. Simpson, who has found that the strongest preparations of opium, aconite, belladonna, tobacco, and Indian hemp pro- duce no appreciable insensibility when applied to the human skin; and although prussic acid rubbed on the gums, and the vapor of chloroform applied continuously to the skin, produce some numbness, yet still they are not sufficient to render a cutting operation, or the extraction of teeth, pain- less. Galvanism and electricity have been tried, and failed ; and a combina- tion of narcotic applications with galvanism has been tried by Dr. Richardson, with very unsatisfactory results. A small quantity of chloroform put into a spoon, and evaporated over a candle, will allay the pain of an ulcer. But the only efficient local anaesthetic we are at present acquainted with, is— Intense Cold, the properties of which have been explored by Dr. James Arnott. The writer has witnessed his mode of applying it, and has applied it himself, thus :— The operator must be provided with about a quarter of a pound of ice, broken quite fine, which may be effected by putting it into a small canvas bag, and using a mallet or flat iron. " The pounded ice having been placed on a large sheet of paper, any loosely cohering particles may be separated by a paper-folder, and the unreduced larger bits removed. Beside it, on the paper, about half its weight of powdered common salt is placed, and they are then thoroughly and quickly mixed together, either by the folder while on the paper, or by stirring them in a gutta-percha, or other non-con- chloroform. 599 ducting vessel. If the mixture be not quickly made, the extreme cold of part of it may again freeze other parts of it into lumps." There must be in readiness a small net of thin gauze, into which the mixture is put; and as soon, says Dr. Arnott, as the action of the salt upon the ice appears by the dripping of the brine, it is ready for use. The part to be benumbed should be held horizontally, and the net should be laid over it; but it is as well to raise the net once in every three or four minutes, in order to watch the effects, and render them equal. A sponge should be held so as to catch the briny fluid that escapes. The process requires a little nicety, which one or two trials will give. If it be nicely performed, it makes the skin immediately pale and be- numbed, but gives no disagreeable sensation. This effect gradually in- creases, till the skin is shrunk, of a peculiar tallowy corpse-like paleness, perfectly insensible, and stiffish. Dr. Arnott believes that, by protracted application of the ice, the fat is congealed. The process, as the author can testify, is rapid and painless ; and when the effects of the cold have passed off, if the part be bathed with cold or iced water, or covered with a bladder containing it, there will be very little tingling or inflammation; possibly a little redness. Unquestionably, if the application be continued for an unreasonably long time—say for an hour or two—or if heat be incautiously applied too soon afterwards, the same effects may ensue as those which we have described at p. 162, under the head of frost-bite, particularly if the patient be of a bad or weakly constitution. But the moderate and judicious use of cold is fol- lowed by no ill consequence whatever, and it seems to promote the process of healing. As an anaesthetic remedy, it appears amply sufficient, and well adapted for most of the minor operations, such as those on small tumors, abscesses, warts, inverted toe-nails, fistula, piles, varicose veins, application of the actual cautery, formation of issues, and the like. For extensive and deep operations, and those in which perfect quiet is requisite, it is insufficient. Besides its use as an anaesthetic before operations, it has been employed to check the growth of cancer and naevus, and to assuage the pain of boils, carbuncle, gout, and neuralgia. The writer has used it in whitlow, and it gave relief to the pain, but did not hinder the formation of matter. For the application of the freezing mixture to ulcerated surfaces, a fine India-rubber bag or gut may be used. Dentists employ a modification of a process invented by Dr. James Arnott, for passing a stream of water of any temperature through a membranous bag over a diseased part. In the apartment over the operating-room is an apparatus, by which at first a stream of water of the temperature of the body, and then a saline solution, gradually cooled down to about 15° of Fahrenheit, or lower, is made to pass through an India-rubber tube. At one part of this tube there is in- serted a tube of the thinnest possible India-rubber, which is wrapped around the condemned tooth and the adjoining gum, and through which the cold current acts upon those parts. The writer has seen the process conducted by Mr. Quinton, and can testify that the success of it was complete ; that is to say, it occasioned no pain itself, and it allowed a tooth to be pulled out without suffering. The gum was blanched, and did not bleed, but the tooth and inside of the socket did. Rinsing the mouth for some time with cold water takes away all unpleasant consequences. The writer's objection to the process is, that it is more troublesome than the result is worth ; especially if many teeth are to be operated on.1 1 See Dr. James Arnott's pamphlet on benumbing cold as a preventive of pain and inflammation from surgical operations, with minute directions for use, 1854. Pamphlets 600 MEANS OF PRODUCING INSENSIBILITY TO PAIN. Mesmerism.—There is no doubt but that the manoeuvres which are called mesmeric passes, if practised long enough upon susceptible persons, are ca- pable of producing a kind of cataleptic condition accompanied with insensi- bility to external impressions, and that in this state surgical operations have, in many instances, especially amongst the natives of India, been performed without the patient's consciousness. But ample objections to mesmerism, as a medical agent, may be gathered from the works of its advocates. The writer has most carefully analyzed the works of Dr. Esdaile, a surgeon of great experience in India ; in which it is asserted, 1st, as to the nature of mesmerism :—" That it is the transmission of nervous matter to the brain of the patient from the brain of the agent, through the nerves of the latter." Which is nowhere proved. 2dly, as to the process:—That it consists in touching some part of the patient's body, breathing on it, and making stroking movements, called passes; but it is alleged that the intention or will of the operator is the chief agent, no matter how the passes are made. 3dly, as to the effects:—That they consist of various degrees of insensi- bility, delirium, and muscular rigidity; during which it is asserted that the patient is completely under the control of the operator; his bodily sensa- tions, his actions, and his very thoughts being exactly those which the mesmerizer may will his passive victim to experience. We do not mention certain other alleged phenomena, such as the power of seeing without eyes, of prophesying, &c. &c, which do not concern us. On the other hand, there is the admission, 4thly, that mesmerism is only one of six powers, each capable of producing the same effects on mind and body; the other five being—religious fanaticism—exhaustion of the brain by long contemplation—exhaustion of any one organ of sense—narcotic medicines—and last, not least, hysteria. Where so many known causes exist to explain the phenomena of mesmerism, it seems unnecessary, to say the least, to go out of our way to imagine a transmission of nervous power. It is confessed further by Dr. Esdaile, 5thly, that all the mesmeric pheno- mena, like the hysteric, if once induced, may occur in paroxysms, without any mesmeric passes, whenever willed by the patient, especially if the nerv- ous centres have been rendered morbidly sensitive by the mesmeric process. If these things be properly weighed, and if the reader consider further that the mesmeric state (or in plain English hysterical catalepsy), is one which cannot be induced in persons of sound vigorous mind ; that, if free from all objection, it could seldom be available at the time and place requi- site ; and that it is confessed that a person susceptible of it is, to use Dr. Esdaile's words, " at the mercy of any foolish or unprincipled person,"—he will agree with the writer, that it has no claim to be received into the rank of therapeutical agents. " It is often," says Dr. Esdaile, " very difficult and laborious to excite the mesmeric action in the constitution ; but being once felt, a very slight recurrence to the original process will often bring on the mesmeric paroxysm ; and if the excitement of the nervous system is kept up by frequent mesmerizing, an independent diseased action is set up in the constitution; we have, in fact, inoculated the system with a nervous disease, acting spontaneously, and obeying natural laws we do not understand."1 [Hypnotism.—Quite recently, hypnotism has been employed for the pur- pose of rendering patients insensible during the performance of surgical by Mr. Quinton, Mr. Blundell, and others on Anaesthetic Dentistry. Mr. Butcher, in his Observations on Hare-Lip, Dublin, 1856, speaks briefly on the use of cold, but com- plains that it causes pain in the case of children with hare-lip ; as much pain as the operation itself. Possibly the process requires Arnott's current apparatus. 1 Esdaile on Natural and Mesmeric Clairvoyance, Lond. 1852, p. 235. Introduction of Mesmerism into the Hospitals of India, 1852, p. 42. Brierre de Boismont on Hallu- cinations, by Hulme, p. 216. EXTIRPATION OF TUMORS. 601 operations. Hypnotism is the name given by Dr. Braid to a proceeding employed by him to throw persons into a somnambulic sleep. A bright ob" ject is held at a distance of eight or ten inches before the person to be hyp- notized, in such a position that the eyes must be forcibly turned upwards to regard it. When the eyes are thus kept constantly fixed, a kind of cataleptic condition accompanied with insensibility to external impressions is induced in a very short space of time. The effects on mind and body of hypnotism are very much the same as those produced by mesmerism, and the judicious remarks just made by Mr. Druitt in regard to the one, may be applied to the other.] CHAPTER III. THE MINOR OPERATIONS. I. Extirpation of Tumors.—A different proceeding is to be adopted in the case of cancer and of other growths. In the former it may be neces- sary to remove a portion of skin by two semi-elliptical incisions, if it appear to be contaminated by the diseased growth. But in extirpating wens or fatty or fibrous tumors, however large, it is a general rule not to remove any of the skin, unless it is much inflamed or ulcerated, or so entirely adherent to the tumor that its separation would be very tedious and difficult. Again, in the former case, it is necessary to cut quite wide of the diseased mass, and remove plenty of the surrounding tissue ; in the latter case the incisions should be carried through the cellular cyst of the tumor. Then, after a free incision through the cyst, the tumor may often be squeezed or twisted out, and its connections be torn, with the assistance of one or two touches of the knife. In all cases it is a better plan (unless the tumor is exceedingly large) to carry the dissection at once boldly to the deepest part where the largest vessels enter than to tie the different branches as they are divided, by which means some vessels may perhaps be tied more than once. Again, it is requi- site in every case that the extirpation be complete, because if the smallest portion is left, it may become the nucleus of a fresh growth. If, therefore, it is found that there is any portion of a tumor which cannot be cut out Fig. 362. Fig. 363. [Serrefines.] [Small forceps for temporarily checking hemorrhage.] without fear of dangerous hemorrhage, a double ligature should be passed through its base, and be tied tightly on each side of it. The serrefines of wire and the small forceps here depicted, which hold on by their own elasti- city, may be of service to check bleeding in extensive operations II. The Ecraseur.—As the act of biting the umbilical cord by an ani- mal is to the cut of the knife or scissors, so is the effect of this instrument to that of the knife. It is a machine, consisting of a fine chain (perhaps wire or whipcord), and of a screw or rack for tightening it; so that when the chain is made to surround any tumor it is made slowly to crush or bite its way through. The advantage of the instrument is, that it causes little 6 0-2 VENESECTION. or no bleeding. The cases in which it is applicable are those of cancer of the tongue, piles, polypes and other tumors of the womb and rectum, and the division of the pedicle of an 364. Fig. 365. H i ovarian cyst. In the case of a tu- mor with a pedicle, its application is easy ; if the mass is solid, or it is desired to extirpate a portion of the side of the tongue, for example, the chain may be passed through the centre and be made to cut one line of a V incision first, and the other afterwards. Or two instruments may be used together. The ecraseur was invented by M. Chassaignac, and in- troduced into England by Mr. Price. III. Venesection at the bend of the arm should always, if possi- ble, be performed in the median- cephalic vein. A ligature being placed a little above the elbow (but not tightly enough to stop the pulse at the wrist), the operator takes the forearm in his hand, places his thumb on the vein a little below the intended puncture, and then (using the right hand for the right arm, and vice versa) pushes the lancet obliquely into the vein, and makes it cut its way directly outwards. When suffi- cient blood has been taken, the sur- geon should untie the ligature above the elbow, and place his thumb on the bleeding aperture. Next he should put a little bit of lint on the wound, and secure that with a strip of plaster, only removing his thumb sufficiently to admit of the application. Then he should remove his thumb enough to Fig. 366. [Ecraseur.] This cut shows the veins of the bend of the elbow, to- gether with the relation of the brachial artery to the me- dian basilic vein. [Bandage after venesection.] put on a little square compress of linen, and over that the middle of a band- age. This is to be passed round the elbow in the form of a figure of 8, and the two ends are to be crossed and turned backwards over the compress. arteriotomy—CUPPING. 603 Fig. 366 is intended to show the way in which the surgeon should grasp the arm, and keep his thumb over the bleeding aperture till the bandage is secured. The jugular vein is sometimes opened in cases of apoplexy in adults, and in children if the veins at the elbow are hidden by fat. The patient, if a child, being laid in a nurse's lap, with his head towards the surgeon, the latter puts his left thumb on the vein a little above the clavicle, and then opens it with a lancet, cutting towards the thumb, and in a direction down- wards and inwards, so that the incision may cross the fibres of the platysma. When blood enough has been taken, the wound should be closed with lint and plaster, and not till then should the thumb be removed. The veins in the leg, scrotum, or neighborhood of the eye or ear, can readily be opened in the same manner, instead of the ordinary mode of venesection, or leeching, or cupping. Abscess in the areolar tissue, inflammation of the fascia, phlebitis, neu- ralgia, varicose aneurism, and aneurismal varix, are occasional ill conse- quences of venesection. IV. Arteriotomy.—The temporal artery should be opened above the outer angle of the eyebrow—not just above the zygoma. The surgeon feels for the largest branch, steadies it with two fingers, one placed above, and the other below, the intended puncture—then pushes in the lancet in the same manner as in venesection. The incision should be directed across the vessel, and should cut it about half through. When sufficient blood has flowed, the best plan is to introduce the lancet, and cut the vessel completely across, so that the ends may retract. A firm graduated compress should then be applied, and be confined with a bandage passing round the head ; and some degree of pressure should be kept up on the wound for a week or ten days. Any subsequent bleeding or spurious aneurism must be treated by completely dividing the artery, if it has not been done already, and by pres- sure ; but if the wound is much inflamed or ulcerated, so as not to admit of pressure, a transverse incision should be made on each side of it, and the artery be tied in both places. V. Cupping.—The patient being placed in a comfortable position, with towels arranged so that his clothes may not be soiled by the blood, and being moreover protected from cold, so that the flow of blood to the surface may not be checked, and the operator having his scarificator, glasses, torch, spirits of wine, lighted candle, hot water, and sponge, conveniently arranged on a table close by ; the first thing is to sponge the skiu well with hot water, so as to make it somewhat vascular. The operator next dries it with a warm towel, and adapts his glasses to the part. Their number must depend on the quantity of blood to be taken—from three to five ounces is a fair calculation for each glass. In the next place, he dips the torch in the spirit, sets it on fire, introduces it for half a second into one of the glasses, and immediately claps the latter on the skin—and the same with the other glasses in succes- sion. As soon as the skin has become red and swollen, he charges the scarificator, and takes it between the right forefinger and thumb, at the same time holding the lighted torch between the little and ring fingers of the same hand. He then detaches one glass by insinuating the nail of his left fore- finger under its edge—instantly discharges the scarificator on the swollen skin, and as expeditiously as possible introduces the torch into the glass and applies it again. The same process is repeated with the other glasses. When they become tolerably full, or the blood begins to coagulate in them, they must be detached in succession and reapplied, if blood enough has not been taken—and when the operation is finished, the wounds should be closed with lint and plaster. There are several points connected with this opera- tion that require notice. In the first place, the glasses must not be exhausted 604 TRANSFUSION OF BLOOD. too much; if they are, the pressure of their rims will occasion severe pain —the blood will not flow—and the operation will very probably be followed by a considerable ecchymosis. Secondly, the position of the glasses must be slightly varied each time they are applied, so that their edges may not again press on the same circle of skin. Thirdly, the expediency of not burning the patient need scarcely be hinted at. Fourthly, in taking off the glasses, the upper part of each should be detached first, so that the blood may not escape. Lastly, the length of the scarificators must be adjusted to the thickness of the skin ; for if the incisions are too deep, the fat will pro- trude through them, and prevent the flow of blood. The direction of the incisions should correspond to the course of the muscular fibres beneath; but this is of no great consequence. For cupping on the temples smaller glasses and scarificators are employed. A branch of the temporal artery is generally wounded, and the flow of blood may be expedited by slightly lift- ing the lower part of the rim of the glass. Pressure should be kept up on the wounds for some days afterwards, in order to prevent secondary hemor- rhage or false aneurism.1 VI. Transfusion of Blood.—This is an operation which may be per- formed in two sets of cases. In the first place, whenever death seems immi- nent from profuse loss of blood; especially after flooding in labor; after operations, wounds, and injuries of all kinds, and the bursting of varicose veins. In every such case, it is the surgeon's positive duty to perform this operation. Secondly, there are some cases in which death is creeping on from slow starvation through disease, such as cases of cancer, and of any other organic disease that is causing exhaustion, in which it may be a ques- tion to be decided by the patient whether the attempt shall be made to pro- long life for a few days or even hours. Besides these cases, the surgeon may think it expedient in cholera, to inject water containing the saline constituents of the serum. In flooding and other sudden accidents it will almost certainly happen that no elaborate apparatus is within reach, and the surgeon will have to use what- ever he can lay his hands on. It is consolatory, therefore, to know that most of the successful cases of transfusion have been performed with common pewter or brass syringes. The operator must of course find some healthy person who is charitable enough to spare some of his blood. Then supposing that he has nothing but a common syringe, he must immerse it in hot water, and thoroughly rinse it out so as to cleanse it from dirt. The next thing is to open a vein in the patient's arm, or if there is no prominent vein there, in the leg. It may, if large, be opened with a lancet, as in venesection, and then a probe be passed into it, to serve as a director for the nozzle of the syringe. The probe ought to pass up freely along the canal of the vein. If there is any difficulty, an incision an inch and a half long should be made over a vein, which should be gently raised on a probe passed under it, and be opened sufficiently. The operator next takes out the piston of the syringe. Then, the arm of the person who is to give the blood having been, meanwhile, bound up, he opens a vein freely, and catches the blood in the syringe, closing the nozzle with one forefinger. When he has taken as much blood as the syringe will hold, he desires the blood-giver to put his finger on the wound to stop the blood ; then puts in the piston, holds the syringe with the nozzle upwards, presses the piston so that all air and a little blood may escape, then, whilst 1 Messrs. Weiss have shown the writer a French instrument, ventouse, as it is called, in which an elastic suction-bottle, with valves, is used to exhaust the air. It appears to be very efficient, and much less troublesome than the torch and spirit of wine appa- ratus, as the amount of suction can be regulated with the greatest nicety. ACUPUNCTURE — ISSUES. 605 a little blood is escaping, he inserts the nozzle into the vein, and gently drives in the blood. Three or four ounces may be injected twice, or thrice, at intervals, according to the effect produced. If the surgeon has time for choice of instruments and for a deliberate operation, he may use the very ingenious apparatus invented by Mr. White- house, of Brighton, constructed by Weiss, and here depicted. It consists Fig. 367. [Whitehouse's instrument for the transfusion of blood.] of a cup of glass or of metal plated, a flexible tube a, and a tube b, which is to be inserted into the vein. This last has an air-trap connected with it, so constructed that any bubbles of air would be detained in it, and be rendered visible to the operator. The blood is received into the cup, and allowed to fill the flexible tube and air-trap (which is emptied of air by being turned upside down), then the nozzle can be inserted into the vein. By raising the cup the force of the stream is increased, and it can be stopped in a moment by the finger and thumb of the operator.1 VII. Acupuncture is easily performed by running in five or six needles with a rotatory motion. It is certainly very efficacious in some cases of neuralgia ; but it is by no means easy to explain its operation. Acupunc- ture is also resorted to in anasarca, when the skin is much distended ; and we have spoken of its utility in hydrocele, ganglion, hydrothorax, and ascites, for the purpose of permitting the serum to exude into the cellular tissue. VIII. Issues may be made by caustic, or by incision, or by the actual cautery. The first may be made either by rubbing a portion of skin of the requisite extent with the potassa fusa, or by making a paste with equal parts of the potass and soft soap, and laying it on the skin till the latter is con- verted into a black slough. The parts immediately around the issue should be protected with several layers of sticking-plaster. After the application of the caustic, the part should be poulticed till the slough separates, and then the sore may be prevented from healing, either by binding several peas firmly on its surface, or by touching it occasionally with the caustic. The second species of issue is made by pinching up the skin, and slitting it up with a lancet, and then introducing some peas to prevent it from healing. It may be remarked, that issues should never be made over projecting points 1 The writer has to thank Mr. Whitehouse for much valuable information on the subject of this instrument. It may be mentioned that about the year 1836, Mr. Philpot, his partner, performed transfusion successfully with a common pewter syringe. Mr. Whitehouse recommends that the blood should be defibrinated, by being beaten up with a fork, before it is injected, so as to avoid embarrassment with clots. G06 CAUTERY—SETONS—MOXA. of bones, nor over the bellies of muscles, for they might degenerate into most obstinate sores. Thus, for diseased vertebrae, the issues should be made between the spinous and transverse processes; for diseased hip, behind the great trochanter, and not over it; for diseased knee, just below the inner tuberosity of the tibia. Issues, if indolent or irritable, should be healed up. They are only of use, says Mr. Vincent, when the actions carried on in them are vigorous and healthy. IX. The Actual Cautery is certainly a very efficient, and it is very far from being the most painful, manner of effecting counter-irritation. On the contrary, its effects are speedy, and not attended with very much suffering. It is easily effected by means of an iron rod with a knob of the size and shape of an olive at one end of it, and a wooden handle at the other. The knob being heated red hot, is rubbed on the skin so as to make two or three blackened lines about half an inch wide, and an inch asunder. Then the cold-water dressing or a poultice may be applied till the shallow eschars separate ; and it appears to be better to keep the sores open by touching them occasionally with the cautery, than by the ordinary irritating dressings. We have spoken in more than one place of the efficacy of the cautery for closing fissures and fistulae. The surgeon will require instruments of various sizes and shapes for these purposes, Marshall's galvanic cautery is a very convenient instrument for cauteriz- ing the interior of sinuses, or fungous granulations. A current from a galvanic battery of half-a-dozen cells is passed along the metallic rods and through the handle ; the rods are isolated by an intermediate strip of ivory, and the current passes through the wire at the end, raising it to an intense heat. The wire can be arranged in any convenient shape. There are other modifications, some having an apparatus in the handle for making and break- ing contact at will. Fig. 368. [Marshall's galvanic cautery.] X. Setons are introduced by pinching up a fold of the skin, and pushing a needle through it armed with a skein of silk or cotton, or a long flat piece of India-rubber. As soon as one or two inches of the thread are brought through, the needle is cut off. A fresh portion of the thread is to be pulled through the wound every day, so as to keep up a constant irritation and discharge. If the discharge is insufficient, the thread may be covered with some irritating ointment before it is drawn under the skin. XI. The Moxa is a peculiar method of counter-irritation long practised in the East, and occasionally employed in Europe, for the relief of chronic nervous and rheumatic pains, or for chronic diseases of the joints. One or more small cones, formed of the fine fibres of the Artemisia chinensis, or of some other porous vegetable substance—such as German tinder, or linen impregnated with nitre, are placed on the skin over the affected part, and then are set on fire, and allowed to burn away so as to form a superficial eschar. The surrounding skin must be protected by a piece of wet rag, with a hole in it for the moxa. It is convenient sometimes to use the moxa as a rubefacient or vesicant, and not as a cauterant. A roll of German tinder ignited may be held with dressing forceps at a little distance from the skin, the surgeon at the same time blowing upon it with a blowpipe till the skin becomes red. BANDAGING. 607 XII. Vaccination.—The matter should be taken on the seventh or eighth day, before an inflamed areola is spread around the vesicle ; and it should be lymph, clear and transparent, not purulent. The operator, with the point of a lancet—a sharp-pointed tenotomy knife is better—should puncture, scratch, or abrade the cuticle in five spots, on the outside of the left arm below the shoulder: each spot may be the size of 0 and the five may be arranged in the form of a cross. Then taking a drop of clear lymph on the point of the knife, he inserts it into one of the spots, taking care that the abraded skin absorbs it; and so with the others. The lymph should be applied directly from one child to another, and should not be carried about on points or lancets. But if the lymph for the first patient is on points, the surgeon should hold them in the steam of warm water so as to liquefy it, and then wipe one on each abraded spot. XIII. Electricity and Galvanism.—In certain cases of defective cir- culation and nervous influence ; when the thigh is weakened and benumbed after sciatica; in cases of atrophy of the extremities after fever; when the extensors are paralyzed from long disuse, as after disease of joints; in deficient menstruation ; in loss of voice from relaxation of the mucous mem- brane of the fauces ; in hysterical neuralgia,—these powerful agents may be resorted to with every prospect of benefit. But the cases to which they are most applicable, are those of asphyxia from poisoning or hanging, when the affusion of cold water and other stimulants fail to excite the action of respira- tion. The best method in these cases is, to place one wire in front of the neck and the other at the pit of the stomach ; or, if the sensibility is so feeble that this fails to take effect, a needle may be inserted deeply between the eighth and ninth ribs on either side, so as to reach the diaphragm, and the current be passed between them. The most convenient apparatus seems to be a large single-cell battery on Smee's or Daniell's principle, with a coil wound around a piece of soft iron, which is thereby converted into a tem- porary magnet, and with a contrivance for interrupting the circuit, and giving a stream of gentle shocks. XIV. Galvano-puncture.—In obstinate neuralgia it is a good plan to insert two needles deeply, at two points in the course of the nerve, and to pass a galvanic current through them. CHAPTER IV. BANDAGING. I. Bandages usually consist of strips of linen, calico, or flannel, varying in breadth from one to three, five, or more inches, and in length from one to six, eight, or twelve yards. Sometimes they are made of India-rubber web, or of a substance like stockings; but, for most purposes, stout unbleached calico, or thin fine calico, will answer. They are generally rolled up longi- tudinally for use, and hence have received the name of rollers. Besides the simple roller, there are many compound bandages, as the T bandage, and the many-tailed bandage (described at p. 259); but the latter are not now much in use, and, like other special bandages, are generally prepared by professed bandage-makers. Lastly, bandages may often be made out of handkerchiefs, or square pieces of linen. II. The chief uses of bandages are, 1st, to keep on dressings, to protect a diseased part from injury, and put some little restraint upon its motions ; 2dly, to afford a support to relaxed muscles, ligaments, and vessels. De- prive any part of its normal support, and varicose veins and dropsical 608 BANDAGES. effusions are sure to occur; and conversely many cedematous and other chronic swellings of the limbs and joints may often be cured by the proper application of bandages alone. III. The Roller.—In applying this to any limb, the surgeon should hold it as represented at p. 88, or in Fig. 370, and should pass it from one hand to the other as he encircles the limb with it. He should begin at the extremity of the limb, applying it most tightly there, and a very little more loosely as it ascends. He should unfold very little of it at a time, and should make each fold overlap about a third of the pre- vious one. When the limb increases in size, he must turn the bandage on itself after the manner de- Fig- 369. picted in the cuts. IV. Bandage for the Finger.—This is a simple strip of linen, that may be wound round- the finger a few times with the requisite tightness. We introduce the figure in order to show how to fasten it neatly without pins or stitches, by merely splitting up the end of the bandage into two tails, which may be turned opposite ways round the finger, and be tied in a bow. This is a most convenient way of keeping dressings on the penis. V. For the Hand.—A bandage about two inches wide may be passed in a figure of 8 round the Fig. 370. hand and wrist, excluding the thumb, and may be finished by one or two circular turns round the wrist. VI. For the Forearm.— After applying it about the hand and wrist as just de- scribed, carry it up the fore- arm, and in every turn fold the bandage sharply and smoothly back upon itself, in such a way that it may lie smoothly on [Bandage for the hand and wrist.] the limb. [Bandage for the finger.] Fig. 371. [Bandage for the forearm.] BANDAGES. 609 VII. For the Foot.—Let the roller be first passed round the metatar- sus, and then be carried up round the ankle, and back again round the foot • exactly as depicted at p. 88. The bandage should always be brought up on the inner side of the instep, as there shown, in order to support the arch of the foot. VIII. For the Leg.—After the foot and ankle have been well enveloped, let the bandage be carried up the leg, and be turned sharp on itself on the calf, in order that it may lie closely, and the folds not be separated. Fig. 372. [Bandage for the leg.] IX. For the Knee.—To support the knee, in ordinary cases, a bandage may be passed round it in a figure-of-8 form, excluding the patella. If that bone is to be covered, the band- age must be passed lightly Fig. 373. over it afterwards several times, making turns when necessary to procure smoothness. X. Four-tailed Knee Ban- DAGE.-When it is merely wished to keep on dressings, or to give slight support, the four-tailed bandage devised by Dr. West- macott, may be used. A piece of linen a yard and a half long, and eight or nine inches wide, is split up in the middle at each end to within a few inches of the centre. The centre being then placed on the patella, the four tails brought under the knee, crossed, and tied two and two. Fig. 374. [Bandage for the knee, figure-of-S.] [Four-tailed bandage of the knee.] XI. For the Groin.—Having passed a roller round the lower part of the abdomen, and secured it with a stitch, bring it in front of the affected groin, then round the back of the thigh, next round the abdomen ; and so on in'a figure-of-8 form, with the folds crossing each other over the groin. [Or the triangular bandage of Yelpeau makes a very neat and simple dressino- for the groin. It consists of a triangular piece of muslin, having 39 610 BANDAGES. a band attached to its base, for the purpose of securing it around the waist, and another strip secured to its apex, which passes around the upper part of the thigh—as in Fig. 376.] Fig. 375. [Fig. 376. [Bandage for the groin.] Velpeau's bandage for the groin.] XII. For the Axilla.—In order to keep on dressings or poultices, &c, put the centre of a common handkerchief folded cornerwise under the [Bandage for the axilla.] axilla, cross it over the shoulder, and carry the ends one before, the other behind, the chest, to tie under the opposite axilla. XIII. For the Head.—A roller having been carried horizontally round the forehead and occiput, and secured by a stitch, let it be carried vertically over the head and under the chin. At the point of crossing on either side let it be secured by a stitch. XIV. Four-tailed Head Bandage.—A four-tailed bandage having been prepared as directed for the patella, and the centre of it having been placed on the top of the head, inclining either to the front or the back, as circumstances may require, two of the tails may be carried back round under BANDAGES. 611 the occiput, and be either tied there or be brought round the neck ; and the other two be tied under the chin. Fig. 379. [Bandage for the head.] [Four-tailed bandage for the head.] Fie. 380. In bandaging the head, care should always be taken to comb the hair so that it may lie smoothly and comfortably; and likewise to arrange the bandages so that the pressure may tell exactly where it is required. XV. Bandage for the Perineum.—This consists of a circular girth, buckled firmly round the pelvis; and of a piece that descends perpen- dicularly, and that is provided with a pad, formed of pieces of flannel, covered with oiled silk, in- tended to press on the perineum. The perpen- dicular piece is divided to inclose the scrotum, or labia, and lastly, is brought up in two portions to be attached to the circular girth in front. The pad must be made capable of being slipped backwards or forwards, on the straight strap, so that it may be made to bear with nicety on the exact spot required. The circular girth may be kept up in its proper place by means of a pair of braces passing over the shoulders. This bandage is highly useful in prolapsus ani; and in prolapsus uteri from relaxation of the vagina ; in which firm pressure on the perineum gives the greatest possible comfort. [Bandage for the perineum.] 612 OPERATIONS FOR TYING ARTERIES. CHAPTER V. OPERATIONS FOR TYING ARTERIES. SECTION I.—THE CAROTIDS, LINGUAL AND FACIAL. [In all operations for tying arteries there are certain general rules to be carefully observed. By strictly following these rules the surgeon will find the difficulties of the operation in every case vastly lessened, and by disre- garding them, from ignorance or neglect, he is always in danger of making ridiculous and serious mistakes. Before proceeding, therefore, to describe the ligature of particular arteries, it seems to us to be well, in a work like this, to state the most important of these rules. In every operation for ligature there are three steps: in the first the sheath of the vessels is reached; in the second the artery is isolated; and in the third the ligature is applied and tied. To reach the sheath of the vessels, the operator must not commence his incisions by hunting the artery, but by finding what Malgaigne calls the first rallying point, or landmark; then he must find the second, then the third, if there be one, and so on, until he meets the sheath containing the artery, or the artery alone, in case it has no common sheath with a nerve or vein. To give an example : to find the lingual artery we are told that " after dividing the skin, platysma, and fascia, by making a transverse incision along the os hyoides, the artery must be looked for where it lies upon the greater cornua of the os hyoides, below the digastric muscle and ninth nerve." A much safer and surer way of reaching the artery would be to make an incision about an inch and a half long, two lines above the great horn of the os hyoides, and parallel to it, through the skin and platysma muscle ; the lower border of the submaxillary gland is thus reached, aud this is the rallying point. The gland should be turned up as a muscle would be, and beneath it is seen the shining tendon of the digastric, which is the second rallying point, embraced by the stylo-hyoides. Detaching these mus- cles from the hyoid bone and turning them up, the hypoglossal nerve is reached, which is the third rallying point. Divide transversely the hypo- glossus muscle, just below the nerve, and the artery is found. To isolate the artery when it is accompanied by a vein or a vein and a nerve, the common sheath of the vessels should be seized with dissecting forceps and a small incision made with a bistoury; then, by means of a di- rector held as a pen, and taking care that the sharp edges of the concave portion are never turned towards the vein, the forceps in the left hand still holding the sheath, the artery must be separated from its connections for a space of rather less than half an inch. To pass the ligature the curved needle, or whatever instrument is used, must be first pushed between the artery and the vein, and then carried round the artery ; in this way the vein cannot be torn by the point of the instru- ment as has occurred more than once. Before tying the ligature, it should be tightened in order to see, from the pain thus produced, if a nerve be not included.] I. The Common Carotid Artery of either side, follows a course as nearly as possible represented by a line drawn from the sterno-clavicular ar- ticulation to a point midway between the angle of the jaw and the mastoid COMMON CAROTID ARTERY. 613 Fie. 3S1. process. Each artery lies against the anterior spinal muscles, the longus colli, and rectus capitis anticus major. Each is contained in a dense cellular sheath, which includes, besides the artery, the internal jugular vein on its outer side, and the pneumogastric nerve between the artery and vein. In front of the sheath, and connected to it, lies the descendens noni nerve, which sweeps downwards, and about the middle of the neck unites with a branch of the cervical plexus, to form a loop from which branches are given off to the muscles that pull down the larynx. Behind the sheath lie the sympathetic and cardiac nerves, and at the lower part the inferior thyroid artery and recurrent nerve cross behind it towards the larynx. Yet it must be recollected that occasionally the descendens noni has been found within the sheath, or behind the artery; and that the inferior thyroid artery has been found in front of the carotid. On the inner side lie the trachea and larynx, and the thyroid gland, which last somewhat overlaps the artery. On the outer side are chains of lymphatic glands. The left artery and the right differ in their origin, and in their relations during the first part of their course. The left arises from the arch of the aorta, and rests at first on the trachea, thoracic duct, and oesophagus. Both termi- nate opposite the upper bor- der of the thyroid cartilage by dividing into internal and external carotids. The left jugular vein lies rather in front of the left carotid, as it goes to empty itself into the left brachio-cephalic vein, which crosses the artery at its origin. The right carotid arises from the arteria innominata, and ascends more perpendicularly. The right internal jugular vein is more external than the left, and near its termination diverges from the artery, leaving an interval of half an inch between them. This makes a material difference in tying these arteries low down. Each artery is covered by the sterno-mastoid, sterno-hyoid, and sterno- thyroid muscles, and is crossed by the omo-hyoid, almost two inches above the clavicle. A dense fascia is connected with this muscle. In the upper part of its course, corresponding to the larynx, the sterno-mastoid leaves the carotid, which is then covered only with skin, platysma, and fascia. Both common carotids terminate opposite the upper border of the thyroid cartilage, by dividing into internal and external carotids. " The carotid artery, in the lower part of its course, may require to be tied for aneurism in the upper part of the trunk. In the upper part, the opera- tion may be necessary for hemorrhage or for erectile or other tumors about the face or orbit; moreover, it may be expedient, on Brasdor's principle, in aneurism too low down to admit of a ligature between the disease and the To tie the Carotid in its lower part—The patient being placed on his [View of parts concerned in tying the common carotid.] 614 OPERATIONS FOR TYING ARTERIES. back, with the shoulders raised, and with the head thrown back and slightly turned towards the opposite side, an incision three inches in length is made on the inner margin of the sterno-mastoid muscle. This incision should be carried through the skin, platysma, and superficial fascia, and should extend from opposite the cricoid cartilage, to a quarter of an inch above the sternum. The head should now be turned to the side operated on, and be brought a little forwards, so as to relax the sterno-mastoid muscle, the edge Fig. 382. [Ligature of common carotid and of subclavian.] of which is to be exposed, and a vein that usually runs in this direction to be looked for and avoided. With slight use of the finger or handle of the scalpel, the sterno-mastoid must be separated and drawn outwards, and the sterno-hyoid and thyroid muscles inwards. If it will at all make matters more easy, the lower and inner portion of the sterno-mastoid may be divid- ed, and the same may be said of the omo-hyoid, which should now be sought for near the upper part of the incision. The dense fascia which unites this muscle to the sheath must now be scratched through, and the sheath will be seen, with the descendens noni upon it, which should be drawn to the inner side.' The greatest care should be taken throughout, and more particularly now, to avoid the numerous thyroid and other veins to be met with. The sheath must be pinched up with forceps, and opened with a cautious touch . of the knife, whose flat surface should be held towards the artery. The aperture is to be enlarged on a director, and an aneurism needle—a curved blunt needle with the eye near the point—armed with a ligature, to be passed round the vessel from without to within, the point of the needle being kept close to the vessel in order to avoid the vagus nerve. When its point ap- pears on the inner side, the surgeon seizes the ligature with forceps, and withdraws the needle ; ascertains that the nervus vagus is not included in the ligature, and then ties tightly a double knot as represented at page 139. One end of the ligature may then be cut off close to the knot, and the other EXTERNAL CAROTID ARTERY. 615 be left hanging out of the wound, which is to be closed with plaster when bleeding has ceased. The patient must be kept at perfect rest in bed till the ligature separates. As a rule, on the right side the ligature should be applied as high as possible : on this side too there may be no trouble with the internal jugular. On the left side, this vein will, in all probability, get in the way and require to be drawn outwards. On this side too the relation of the oesophagus in- ternally, and of the thoracic duct posteriorly and externally must be remem- bered, as these parts must be avoided carefully. To tie the Common Carotid in its upper part.—The patient is placed in the same position as before, but with the head more thrown back. An inci- sion of three inches is made through skin and platysma, on the anterior edge of the sterno-mastoid muscle, from a little below the corner of the lower jaw to opposite the cricoid cartilage. The deep fascia, here very dense, is to be pinched up, opened, and further divided on a director most carefully, in consequence of its intimate connection with the sheath of the artery and with the veins. The edges of the wound are now to be drawn asunder, the pulsation of the artery sought for, and the sheath opened over it, in the manner and with the precautions before described ; a small portion of the vessel must be exposed, and the ligature be passed as before directed. The jugular vein will be more difficult to avoid here than in the lower part of the neck. II. The External Carotid may, if wounded, require a ligature ; or if any of its branches are wounded, and cannot be tied; but such an opera- tion is very rarely, if ever, practised, ligature of the common carotid being * preferable. An incision of the same length and direction as in the two pre- ceding operations should be made through the skin, platysma, and sheath, so as to tie the vessel near its origin, below the part where it is crossed by the digastric muscle and ninth nerve. To tie the external carotid above the digastric muscle, before it has gained the parotid gland, the head should be well extended, and an incision made from the lobe of the ear to the great cornu of the os-hyoides, successively through the skin, platysma, and superficial fascia. The student must not expect to meet with the deeper parts in this situation disposed, as they ap- pear in the dissecting-room, after they have been dissected, when in fact they are completely displaced and pulled down. The parotid gland first comes into view, by raising the border of which the anterior edge of the sterno-mastoid is exposed, and also the posterior bellies of the digastric and stylo-hyoid muscles. Along the upper edges of the latter the vessel may be found entering the parotid. Considerable venous hemorrhage will be en- countered in this operation, which is very difficult to execute well, even on the dead body. III. The Internal Carotid is sometimes wounded by gashes, stabs, or shot from without, or by punctures from within, as may happen when a per- son falls down with a tobacco-pipe in his mouth, and drives it through the back of the pharynx. In such cases, ligature of the common carotid is a very uncertain remedy, and Mr. Guthrie proposes (in compliance with the rule of always securing a wouuded artery by two ligatures, one above and one below the wounded part) to reach the wounded vessel by operation. The leading feature of this operation is, the removal of the second molar tooth, and division of the lower jaw-bone, so that the angle of that bone may be everted, and room be given for reaching the vessel. Mr. Mayo once tied this artery, and in order to reach it cut through the styloid process of the temporal bone.1 1 For further particulars of Mr. Guthrie's operation, see Lancet, 1S50, vol. ii. p. 143. 616 OPERATIONS FOR TYING ARTERIES. IV. The Lingual Artery may be tied by making a transverse incision along the os hyoides, from a little below the symphysis of the jaw to near the border of the sterno-mastoid muscle. The skin, platysma, and fascia being divided, the artery must be looked for where it lies upon the greater cornu of the os hyoides, below the digastric muscle and ninth nerve. This artery has been tied in cases of tumors and wounds of the tongue ; but, con- sidering the depth at which it lies from the surface, the irregularity of its origin, and the important parts in its vicinity, it is much better, as a general rule, to tie the external or common carotid. V. The Facial Artery may easily be tied by cutting through the skin and areolar tissue that cover it where it turns over the jaw, at the anterior border of the masseter; but such an operation can hardly ever be requisite. SECTION II.—THE INNOMINATA, SUBCLAVIANS, AND ARTERIES OF THE ARM. I. The Arteria Innominata has been tied in cases of aneurism of the right subclavian, extending inwards as far as the scalenus. The patient being placed on his back, with the shoulders raised and the head thrown back, one incision, two inches in length, is to be made along the inner margin of the sterno-mastoid muscle, terminating at the clavicle, and another across the origin of that muscle, meeting the former at a right angle. The flap of integument thus formed is to be turned up, and the sternal and part of the clavicular origin of the sterno-mastoid are to be divided on a director, which is to be passed behind the muscle, and kept as close to it as possible. The areolar tissue and fat which now appear, being turned aside, the sterno-hyoid, and sterno-thyroid muscles must be separately divided on a director. A strong fascia, which next appears, must be cautiously scratched through, and the carotid be traced with the finger down to its origin. Then the vena innominata being depressed, a ligature may be carried from without inwards, round the artery, close to its bifurcation, taking care to avoid the vagus, re- current, and cardiac nerves. Mr. Guthrie says, that "if the operation be often repeated, it may eventually be successful." Whether the repetition is desirable, is however doubtful.1 In Aneurism of the Innominata it is impossible, or if possible fatal, to place a ligature between the tumor and the heart; and the ligature of the carotid or subclavian, or both, was the only resource, till Mr. Edwards, of Edinburgh, showed the way of giving relief by pressure. An unhealthy woman of 50 had a tumor the size of an apple situated between the sterno- mastoid muscle and the middle of the neck, pulsating violently, soft and compressible, feeling like a vulcanized India-rubber ball, which, though compressible, expands the moment pressure is withdrawn. Another pul- sating tumor rose in front of the trachea : they were the evidently distinct bulgings of one aneurism, as pressure on one increased the size of the other. These tumors were of two months' growth, increasing rapidly, and attended with great dyspnoea. Brasdor's operation was contemplated, but abandoned because aneurism of the aorta was suspected. Then Mr. Edwards determined to apply pressure to the carotid and subclavian arteries. This was accomplished by two conical pads of cork; one attached to an arc of steel in which the neck rested, and 1 This operation was first performed by Mott, at the New York Hospital, in lSlfe. The patient walked out on the 20th day, bleeding from the wound occurred on the 21st, and he died on the 26th. The arch of the aorta was extensively diseased. Dr. Graefe performed it in 1822 at Berlin ; the patient died of hemorrhage on the 67th day. See Cooper's Surgical Dictionary, Art. Aneurism ; South's Chelius, vol. ii., contains details of half a dozen other cases. SUBCLAVIAN ARTERY, 617 which was supported by an upright rod, attached to a very firm broad girth round the chest; the other to a band over the shoulder. The instrument was so adjusted as to stop all pulsation in the branches of the external carotid, and of the wrist of the affected side. Every morning for the first two weeks Mr. Edwards roughly manipulated the sac for the purpose of breaking up the fibrine. For the first two days, the tumor seemed to become thinner, and the pulsation more violent; after that it became more solid; and in three months the aneurism of the innominata was virtually cured, whilst that in the aorta had made little progress.1 Dr. William Wright, of Montreal, has published an interesting account of a case in which he prolonged a patient's life for a month, by ligature of the right carotid, when death was imminent from a bursting aneurism of the innominata; and shows that his operation is superior to the ligature of the subclavian in the third part of its course, inasmuch as half the cur- rent of blood through the aneurism is obstructed ; whereas by tying the subclavian only one-sixth is obstructed, because its chief branches are given off on the near side of the ligature. II. The Bight Subclavian Artery, in the first part of its course, that is to say, between its origin from the innominata and the scalenus muscle, has been tied for aneurism in the second and third parts of its course, by an operation almost precisely similar to the foregoing ; but it is the most diffi- cult operation in surgery, and the most unsuccessful. III. The Subclavian Artery, in the third part of its course, is about an inch and a quarter long, and passes from the scaleni muscles downwards and outwards under the clavicle to the lower border of the first rib, where it takes the name of axillary. Its depth will depend on the greater or less curve of the clavicle, the length of the neck, and the position of the shoulder, whether high or sloping. It lies on the scalenus medius and the upper sur- face of the rib. In front are the skin, platysma, supraclavicular nerves and vessels, cervical fascia, and areolar tissue of varied density. The clavicle and the subclavius muscle are also before it. The subclavian vein is on a plane anterior, but inferior, and is nearly concealed by the clavicle. It is here joined by the external jugular, by the posterior scapular, and by other small veins from the shoulder and the side of the neck, which sometimes form a large and intricate plexus. The brachial nerves are above and behind. Some of the irregularities in the subclavian artery are of practical interest. The artery may perforate the anterior scalenus, or lie in front of it, close to the subclavian vein. The vein has been met with accompanying the artery in its usual course between the scaleni. On the right side the artery may come from the back part of the innominata. Both subclavians may rise higher in the neck, an inch or more above the usual position, which is just a little above the clavicle ; and the right is the more subject to this variation. The vessel may readily be felt in the lower division of the posterior triangular space of the neck, immediately behind the clavicle; and here it may be compressed by the fingers. The patient should be laid on a table, with the shoulder of the affected side drawn down as far as possible, and the head turned to the other side. An incision must then be made above and parallel with the clavicle, three or four inches in length. It should cut through the skin and platysma, and should extend from over the outer edge of the sterno-mastoid to the trapezius. 1 Case of Mrs. Denmark, by Wardrop (ligature of subclavian), quoted in Cooper's Sur"-. Diet. : case by Mr. Evans, of Belper, in which the carotid was tied, ibid. ; case in which Mr. William Wickham, of Winchester, tied the carotid and then the sub- clavian, Med.-Chir. Trans, vol. xxiii. 618 OPERATIONS FOR TYING ARTERIES. The preliminary incision may be conveniently made by drawing down the skin, and cutting through it while it is steadied on the clavicle. The external jugular vein will probably now be seen, and should be drawn with a blunt hook, to whichever side is the more convenient, and if need be, tied with a double ligature, and cut. The clavicular portion of the mastoid muscle, if unusually broad, should be severed. Perhaps it will be best to do so in all cases. The knife must now be used very sparingly to divide the fascia, and if it can be dispensed with altogether, so much the better, and the dissection continued by tearing, scratching, and picking with directors and probes, some of which should have points like knitting-needles. The omo- hyoid muscle must be sought and drawn up. Here, in a space bounded externally by this muscle, anteriorly by the sterno-mastoid, and below by the clavicle, are the artery and the brachial plexus of nerves. The omo-hyoid varies in its position ; sometimes it runs close to and parallel with the cla- vicle, and then without great caution the dissection might be made above the muscle. It may have a partial attachment to the clavicle, or get its entire origin from this bone ; or may be very high, or altogether absent. The supra-scapular, and even the transversalis colli arteries may be met with, and must be drawn aside. The great landmark, the anterior scalenus muscle, must be searched for with the forefinger, and be traced to its insertion in the rib. The precise position of the artery will then be ascertained, and the fascia and areolar tissue that cover it should be carefully torn through. It is now that the use of dividing a portion of the sterno-mastoid is apparent. Some of the lower branches of the brachial plexus of nerves always appear first, and are very likely to be taken up instead of the vessel; but the peculiar aspect of the artery should be well looked for in order to avoid this mistake. Indeed the appearance of the artery alone should be trusted to; for sometimes when its coats are thickened, pulsation cannot be detected. Venous hemorrhage is often most troublesome, and when pressure on the smaller veins does not readily stop it they must be tied. If the subclavian vein is wounded, pressure alone can be employed. The act of passing the needle under the artery has been attended with almost incredible difficulties, and so has the tying of the ligature, and many ingenious instruments have been devised to render both of these proceedings more easy. IV. The Axillary Artery is that portion of the main trunk of the arm, which extends from the lower border of the first rib, to the lower edge of the tendons of the latissimus dorsi and teres major in the axilla. Its entire course is that of a gentle curve, with the convexity outwards and up- wards. For surgical purposes it may be divided into two portions, the in- accessible, and the accessible ; the former being the upper part of its course, where it lies thickly covered by muscle, and the latter being the lower part, where it can be felt against the humerus in the axilla. In the upper part of its course the artery lies upon the first intercostal space, and on the second digitation of the seratus magnus; its vein lies internal, the brachial plexus is above and behind it; afterwards it encircles the artery. It is in the case of wounds only that an operation is likely to be attempted in this situation : in the .case of aneurism, the subclavian must be tied above the clavicle. In the case of wound, the dissection must be carried down to the bleeding spot, through any muscle that may be in the way, and according to the cir- cumstances of the case. But the following operation may be practised in the dissecting-room. To tie the Axillary Artery in the upper part of its course.—The shoulder should be thrown back, and the arm drawn back, so as to put the pectoral muscle on the stretch. An assistant should be at hand to compress the sub- brachial artery. 619 clavian artery if necessary. An incision should be made from the sternum half an inch below the clavicle, to the edge of the deltoid muscle ; recol- lecting that the cephalic vein and thoracico-acromialis artery, which run in the interval between the pectoral and deltoid muscles, should not be injured. The pectoralis major should then be divided to the same extent. Now there may be a pause to check hemorrhage, which being accomplished, and the lower border of the wound being well drawn downwards, the areolar tissue is to be carefully cut through, and then the edge of the pectoralis minor will come into view, going upwards and outwards over the vessels and nerves to be inserted into the coracoid process. Any branches of the thoracic arteries that may be wounded should at once be tied. The next point is, to scratch through the costo-coracoid, or coraco-clavicular fascia: a dense fascia extend- ing from the first rib to the coracid process, and from the upper edge of the pectoralis minor muscle, to the subclavius. At this stage of the proceed- ings, the arm should be brought to the side, to relax the pectoralis major. And now some touches with a blunt director will probably expose the axil- lary vein, which should be pressed inwards and there kept with a blunt hook. The beating of the artery must now be sought for, the vessel be isolated, and an aneurism needle be passed from below upwards, with all care not to in- clude any of the nerves, either along with the artery, or instead of it. It would be possible to tie the artery below the point where it is crossed by the pectoralis minor, by extending the incision downwards. To tie the Axillary Artery in the axilla.—The patient being placed on his back, the arm must be as widely as possible separated from the trunk, and the forearm supinated, and the whole limb rotated in the same direc- tion. The surgeon will then make out the anterior and posterior boundaries of the axilla, the anterior constituted by the pectoralis major, the posterior by the latissimus dorsi and teres major, which go to their respective inser- tions at the edges of the bicipital groove. Between these muscles the axil- lary vessels and nerves lie, and can be felt against the upper extremity of the humerus ; with the upper part of the coraco-brachialis between the ves- sels and the pectoralis major. The surgeon will recollect the relation of the nerves of the axillary plexus to the artery at this point. The external cutaneous nerve (which perforates the coraco-brachialis muscle) with the outer root of the median lie to the outer side ; the inner root of the median, the ulnar and internal cutaneous, on the inner side, and the circumflex and inusculo-spiral behind. (See p. 620.) The operator makes an incision two or two and a half inches long, over and parallel with the upper extremity of the humerus, between the pectoralis major and latissimus dorsi, but rather nearer the latter. It should cut through the skin. Then a cautious dissection through fascia will reveal the axillary vein and median nerve,1 and the former of which should be drawn inwards, and the latter outwards, whilst the artery is cleared by careful scratches with probes of various degrees of bluntness, else the thoracic and subscapular veins may be wounded. The aneurism needle is passed between the vein and artery. There are frequent irregxdarities in the relation of this artery to the nerves and veins, the knowledge of which should make the surgeon careful. Instead of one vein, there may be two or three. There may also be irregu- larities in the course and distribution of the branches of the artery. V. The Brachial Artery runs obliquely down the inner side of the humerus, to the middle of the bend of the elbow; it runs along the inner border of the coraco-brachialis and biceps respectively, which muscles suc- 1 In case of difficulty, find the inner border of the coraco-brachialis, between which and the artery lies the median nerve. Malgaigne, Operative Surgery, by Brittan, p. 130. 6 20 OPERATIONS FOR TYING ARTERIES. cessively overlay it a little, and form the best guides to it. Its pulsations may be felt along the whole of its course, and it is covered only by skin and fascia, though the operator may not find it so superficial as he may imagine it to be. It is accompanied by two venae comites, whose numerous branches encircle it; and by the median nerve, which first lies on its outer side, be- tween it and the coraco-brachialis, then crosses over it, so as to be quite internal to it at the elbow, where both become covered by the semilunar fascia of the biceps. There are several irregularities not very unusual, which the surgeon should be prepared for. The median nerve may run parallel with the artery, over it, under it, or on the outer side. The internal cutaneous nerve, instead of being superficial, may be deep ; and the basilic vein which lies beneath the skin, over and parallel with the artery, in its lower third, may ascend super- ficially up the arm. The radial artery may arise from the upper third of the brachial, or even from the axillary. The ulnar may also have a high origin, and run either superficially or deeply to the wrist. The same may happen to the interosseous artery. There may be a double brachial; and the supe- rior profunda may have a common origin with the posterior circumflex, and form a branch large enough to be mistaken for the brachial. To tie the brachial in its upper third.—The limb is to be drawn from the side and supinated. The surgeon makes out the coraco-brachialis muscle, endeavors to ascertain the course of the basilic vein, and to feel the pulsation of the artery. Then he makes, carefully, an incision three inches in length over the artery, recollecting that the skin is here very thin, and taking care not to cut the internal cutaneous nerve. The fascia should next be divided to the same extent; and under it probably the basilic vein will be found, to the inner side of the artery. Now the forearm may be bent to relax the parts, and the coraco-brachialis be drawn outwards. Any veins or nerves in the way may be drawn aside with a blunt hook; the sheath of the artery Fig. 383. [Ligature of the brachial, in upper, middle, and lower third.] be opened, and the median nerve which comes into sight be drawn outwards. Now the operator must carefully identify the artery by its pulsation, or by the appearance of its coats ; but it may not pulsate unless the muscles of the limb are relaxed. The needle must be passed in whatever direction the operator finds most convenient for avoiding the veins. Should a large branch be exposed, the trunk must be tied above and not below it. Should two large arteries be found running parallel, it must be ascertained by pressure which of them communicates with the aneurismal sac, or the wound, and that one tied; but if no effect be produced, except both be compressed, then both must be secured. Should it happen when only one vessel is apparent, that compression on it does not check bleeding BRACHIAL ARTERY. 621 Fig. 384. or pulsation below, search must be made for a second one. When the liga- ture is applied very high, the proximity of the origin of the superior pro- funda artery must not be forgotten. To tie the Brachial Artery in the middle of the arm, the incision should be along the inner side of the biceps. The basilic vein will probably be found passing from its superficial to its deeper course. The median nerve will, if regular, be seen lying over the vessel, and should be drawn either outwards or inwards, and the biceps be well relaxed. The operator should be on his guard not to mistake the inferior profunda artery and the ulnar nerve, for the brachial and the median nerve, an error liable to be made if the profunda has become enlarged, and best avoided by dissecting towards the biceps, or rather towards the centre of the limb, and not getting too far internally. The middle third of the artery should be tied, when such an operation is required for hemorrhage from the hand, or from the interosse- ous vessels. To tie the Brachial Artery in its lower third.—This operation has been most frequently done for aneurism, produced by careless venesection, and there can be no doubt that in the large majority of small circumscribed aneurisms, it will be suffi- cient to tie the artery just above the tumor, and as near it as possible. In the case of traumatic aneurism, the difficulties of the surgeon will be increased by the infiltrated and swollen state of surrounding parts, and possibly the tumor may be the only guide to the vessel. An incision from two and a half inches long to three inches, should be made obliquely about half an inch internal to the tendon of the biceps, the posi- tion of which should of course be first ascertained. The basilic vein must be held aside if in the way, as well as any twigs of nerves. The fascial expansion of the biceps must not be needlessly cut, as con- traction of the arm might ensue, or the healing of the wound become tedious. Should it be considered necessary to tie the brachial very low down in consequence of the radial having been wounded, the vessel lies in a triangular space, bounded by the pronator radii teres internally, and by the supinator longus ex- ternally, having the median nerve, when regularly placed, on the inner side. Very great care should be taken to conduct the operation with delicacy and despatch. It may be observed that when the artery is wounded in venesection, the surgeon has the choice of three measures :—1st. To enlarge the wound upwards and downwards, and tie the vessel above and below the injured part. 2dly. To attempt cure by pressure; placing a graduated compress on the wound : bandaging the whole limb : compressing the artery above, and so endeavoring to get the wound in the vessel closed, without traumatic aneu- rism resulting. Should this aneurism result, and be diffused, that is, without a sac, the wounded part must be secured. Should the traumatic aneurism have a sac, either this tumor may be cut into and both ends of the vessel tied ; or recourse may be had to, 3dly, ligature of the lower part of the brachial. [View of the relative ana- tomy of the uluar and radial arteries.] 622 OPERATIONS FOR TYING ARTERIES. VI. The Radial Artery pursues a course corresponding with a line drawn from the middle of the bend of the elbow to the base of the meta- carpal bone of the thumb. It winds over the external lateral ligament of the wrist joint, and between the first and second metacarpal bones sinks into the palm of the hand to complete the deep palmar arch. Although in the upper part of its course it lies deeply and is overlapped by muscle, it is not crossed by any. In the upper third of its course it lies deeply between the pronator teres and supinator longus, and is overlapped by both. In the lower two- thirds it lies between the supinator longus and flexor carpi radialis. It is accompanied and embraced by venae Fig. 385. [Ligature of the radial on outer side of the wrist.] comites and their ramifications, and in the lower two-thirds by the radial nerve, which lies on the outer side. It sometimes happens, as an irregu- larity, that the artery runs superficial to the supinator longus, or even to the fascia; and at the wrist may pass outside the extensor tendons. To tie it, the forearm must first of all be properly fixed by assistants on a table. Then an incision three inches in length must be made over its course. The superficial fascia should be divided ; the deep fascia must be slit up ; and if the vessel is tied in the upper third, care must be taken to cut between the muscles without wounding them. To tie the Radial Artery on the outer side of the Wrist, an incision should be made through the skin, from opposite the styloid process of the radius, to the commencement of the first interosseous space. The tendon of the extensor secundi internodii pollicis, which crosses the artery just before it dips into the palm, is the best guide to it; and it will be easier to tie the vessel on the ulnar side of the tendon. VII. The Ulnar Artery, larger than the radial, passes from the middle of the bend of the elbow obliquely inwards forming a slight curve with the concavity outwards, and then nearly vertically along the ulnar side of the forearm to the wrist; where it passes over the annular ligament on the radial side of the pisiform bone and enters the palm. In the upper half of the arm it is covered by the four superficial muscles which arise from the internal condyle. In the lower half it is nearly superficial, and lies between Fig. 386. [Ligatures of the radial and ulnar arteries.] the flexor digitorum sublimis, and the flexor carpi ulnaris, the latter of which is on the ulnar side. Except in very thin persons, the tendon of the flexor carpi ulnaris overlaps the artery, within two or three inches of the wrist, and so does the inner tendon with more or less of the muscular fibres of the flexor digitorum sublimis; so that, in fact, the vessel is not quite superficial. external iliac artery. 623 Like the radial it is accompanied by two veins. The median nerve is connected to it above for about an inch, is then separated by the ulnar origin of the pronator radii teres, and descends along the middle of the limb. The ulnar nerve becomes attached to the artery at about the lower part of the upper third of the forearm, lying to the ulnar side. On the annular liga- ment, it lies next to the pisiform bone, and rather posterior to the artery. When there is a high division of the ulnar, the vessel almost always passes superficial to the muscles, generally under the fascia, sometimes above it. To tie the Ulnar Artery in the upper third of its course, a longitudinal incision, as shown in the woodcut, a quarter of the width of the arm from the inner edge, which will of course cross the artery, will be preferable to one more in the direction of the vessel; as the edges of the wound can be better separated, and what is of more consequence, the natural division that exists between the flexor carpi ulnaris and the next muscle, can be easily found. Should it be requisite to cut between the muscular mass more ex- ternally, the division should be made very low, and, if possible, between the tendons of the muscles, and carried upwards. The ulnar nerve should be looked for, as when seen it may serve as a guide to the artery. To tie the Ulnar Artery just above the wrist, requires rather more care than to tie the radial. An incision, two inches long, should be made, and it should be about three-quarters of an inch from the inner edge of the limb. The operator should endeavor to feel the tendon of the flexor carpi ulnaris muscle, and when he can to cut just external to it. If he cuts too internally, the muscular fibres of the lower part of this muscle will bulge, and perhaps perplex him. After the skin and fascia have been divided, the artery must be sought for, covered by the tendon of the flexor carpi ulnaris, which is internal, and the inner tendon of the flexor digitorum sublimis, and the fibres of that muscle, which is external. The venae comites are to be separated. As the ulnar nerve lies to the inner side of the artery, the needle had better be passed from within to without. VIII. The Superficialis Vol^e, the artery which continues in the course of the radial, and goes to join the superficial palmar arch, is usually small, but yet a frequent source of troublesome hemorrhage when the ball of the thumb is wounded. But it may be a very large artery and bleed pro- fusely, and then must be tied at the seat of injury. Hemorrhage in the palm of the hand should, when practicable, be stopped by tying both ends of the bleeding vessel; yet it is seldom that this can be done, on account of the manner in which the vessels retract, and of the density of the surrounding parts. The propriety of enlarging the wound, with the object of effecting this, must depend on the circumstances of the case, and can rarely be admissible about the centre of the palm. Yet if the blood spirts out with a jet, the exploration may be justifiable, as it would thus be shown that the bleeding orifice was near. Otherwise pressure should be tried first on the wound, and next, on the radial and ulnar arteries at the wrist, and on the brachial; and if all these fail the brachial should be secured. SECTION III.--THE AORTA, ILIACS, AND THEIR BRANCHES. I. The External Iliac Artery, is not unfrequently tied for aneurism, or wounds high up in the femoral. The process for tying it, as well as the internal or common iliac, is to cut through the abdominal muscles and fascia transversalis, and to get behind the peritoneum without wounding it, so as to reach the point desired. Before any of these operations, the bowels should be well cleared. (See p. 303.) The bifurcation of the aorta corresponds as nearly as possible with a spot a finger's breadth below and to the left of the navel. From this point, a 6 24 OPERATIONS FOR TYING ARTERIES. Fit line drawn to the middle of Poupart's ligament, will coincide with the course of the iliac; the upper third to the common, the lower two-thirds to the external iliac. The common iliac extends from the bifurcation of the aorta, on or about the body of the fourth lumbar vertebra, to the sacro-iliac synchondrosis. Its length may vary extremely in different subjects: it is usually two inches; but if the aorta bifurcates higher up than usual, or if the common iliac bifurcates lower than usual, its length may be increased to 3.5 inches. Under the opposite conditions, it may be only .T5 inch. Each common iliac is covered by peritoneum, and crossed near its bifurcation by the ureter; each, too, is in close relation with its vein; but in this respect there is a difference, for both left and right common iliac veins pass behind the right iliac artery to reach the cava, and the artery is closely connected to them both. Whereas the left common iliac artery has a slight space between it and its vein, which lies more internal to it. The rectum and superior haemor- rhoidal artery also cross the left common iliac artery. The external iliac artery runs in the course we have described, along the inner border of the psoas muscle (see p. 48T), having its vein on the inner side. The genito-crural nerve, which pierces the psoas, lies on it for a short distance, and there is a chain of lym- phatic glands surrounding both artery and vein, which, if enlarged, may give great trouble. To tie the External Iliac, the pa- tient should lie flat on a table, in order that the abdominal muscles may be rendered rather tense. An incision, three and a half or four inches long, should be made above and parallel to Poupart's ligament, beginning about half an inch outside the external abdo- minal ring. It should be carried through skin and the superficial fascia, and be completed so as to lay bare the external oblique tendon. If the ex- ternal epigastric artery be divided, as is probable, it should be secured. The tendon of the external oblique should next be cut through to the same ex- tent, either on a director, or not! The internal oblique and transversalis mus- cles are now to be similarly divided ; and as they vary in thickness, and as the peritoneum is close behind, this part of the operation must be conducted with great delicacy. A portion of the muscle should be lifted with forceps, and be carefully cut through, to form an opening into which the finger, or a large blunt director may be insinuated, and upon which the muscle may be divided. The edges of the wound should now be gently drawn asunder by bent spatulae; the fascia transversalis be exposed and scratched through, and the opening be enlarged by tearing with the fingers. And next the peritoneum should be most deli- cately stripped off, from the walls of the abdomen and from the iliac fossa, till the finger reaches the artery, as it gradually rises from the pelvis. The sheath must be scratched through with the finger-nail or a director at the point selected, and the artery separated from the vein ; the aneurism-needle should be passed between them, and the genito-crural nerve be excluded [Plans for making imeisions to> seenre the arte- ries in the pelvis.] COMMON ILIAC ARTERY. 625 from the knot. The wound should be brought together by sutures, the trunk be bent forwards to relax the muscles, and pressure be applied by means of a bandage and pads of cotton wool. Sir Astley Cooper, of whose method of operating the above is a modifica- tion, separated the internal oblique and transversalis muscles from Poupart's ligament, instead of cutting through them rather higher up, as described above. The advantages of the latter plan are, that the epigastric and cir- cumflexa ilii arteries, and the circumflexa ilii vein which crosses the artery low down, are not interfered with, neither is the spermatic cord, nor the abdominal ring. Moreover, if it should seem expedient to tie the vessel higher up, it might be done without much difficulty, by drawing up the upper edge of the wound. The circumflexa ilii and epigastric arteries are of importance for the collateral circulation. But, on the other hand, it must be confessed that the peritoneum is rather more interfered with. In the method of operating recommended by Abernethy, the incision is made in the course of the artery, instead of across it, as in Sir A. Cooper's method. It extends upwards and inwards about three inches, from an inch above the centre of Poupart's ligament, towards the umbilicus; being longer in proportion to the stoutness of the patient. The subsequent steps are those of Sir A. Cooper's plan. This operation is convenient for cases in which it is doubtful beforehand whether the external or the common iliac should be tied. Its disadvantages are, that the peritoneum is very much disturbed, and that there is greater liability to hernia afterwards.1 II. The Common Iliac Artery.—In order to tie this artery, an opera- tion has been proposed similar to that of Cooper for the external iliac ; but it would be very difficult in a thin patient, and almost impossible in a fat one. It is better to make the formidable curved incision shown in the cut (p. 624). An incision is made from six to eight inches in length, the lower third being about an inch and a half or two inches above Poupart's ligament, and parallel with it. The muscles must be divided, and the transversalis fascia torn through, according to the rules given for exposing the external iliac artery. In fact, there is no practical surgical difference between them, ex- cept that the operation under consideration is more difficult, and requires more care and more assistants. The intestines are sure to bulge more or less into the wound directly that the fascia transversalis is divided, and here is the chief difficulty to be encountered. With the greatest gentleness they must be drawn upwards, while the operator separates the peritoneum from the iliac fossa. There need be no apprehension about the fate of the ureter, as it is always raised along with the peritoneum, the two being closely uni- ted. Having gained the soft brim of the pelvis, the operator may seek the external iliac, and if not very much diseased, it will be readily found, and form a good guide to the common trunk. The sheath of the vessel must be opened just above the bifurcation, and the needle be passed, if possible, from within to without.9 1 This artery was tied by Mr. Partridge, in the King's College Hospital, in November 1S46, for aneurism of the common femoral, in a patient only 23 years old. It was tied by Mr. Thomas Nunn, in January 184!.), for aneurism of the common femoral, and by ,\Ir. H. Smith, in August 1850, for aneurism of the superficial femoral high up. The ligature came away on the twenty-eighth day. All three patients did well. Mr. Smith lias at different times tied the external iliac on one side, and the superficial femoral on the other, in the same patient. 2 The common iliac artery was tied by Mr. A. M. Edwards, of Edinburgh, in a case in which an aneurism of the external iliac artery had burst internally, and the patient was bleeding to death. Mr. Edwards made the incisions described in the text, and with •jreat difficulty reached the common iliac artery through a mass of clots, with his left forefinger. Having commanded the artery, the clots were turned out, and a ligature pissed. Unluckily the patient died of secondary hemorrhage from the ruptured aneu- lism. Possibly he might have recovered had a ligature been placed also below the 40 626 OPERATIONS FOR TYING ARTERIES. Another, or posterior operation, was proposed by Sir P. Crampton.' It has not yet been successful, but is certainly not without apparent merits. By it the peritoneum is very much less disturbed, and the vessel is fully ex- posed. The walls of the abdomen, too, are opened at a part where it is less likely that hernia will ensue But further trial must determine its merits. The following is the manner in which it was performed by M r. Stanley at St. Bartholomew's Hospital in 1846, as detailed by Mr. Skey. The patient, a middle-aged man, was placed on the operating-table, with his body inclined over to the right or sound side. The shoulders and trunk were bent a little forwards, for the purpose of rendering the lumbar integu- ment tense. The line of the last false rib having been ascertained, an inci- sion of three or four inches in length was made from its cartilage or nearly its point, in a line downwards, and somewhat forwards, to the crista ilii. The skin and fascia, then the external oblique, internal oblique, and trans- versalis muscles were singly and successively divided. The external incision was then carried along the line of the crista ilii, to the extent of about three inches more, and the division of the three muscles from the bone completed. There was but little blood lost. Beturning to the situation of the first inci- sion, Mr. Stanley then divided the transversalis fascia to the entire limit of the external wound. He then raised the mass of intestine enveloped in the peritoneum, and pushed it inwards, bringing into view the psoas magnus, left ureter, and finally the common iliac artery, around which he passed a liga- ture, without apparent difficulty.9 III. The Internal Iliac Artery.—Of the seven cases in which this artery has been tied for disease of its branches four have recovered. The operation is necessarily attended with the greatest difficulty, on ac- count of the position of surrounding parts. The internal iliac vein is closely in contact with the artery, each vein being a little posterior to the corre- sponding artery and to its right side, while each artery crosses the course of the external iliac vein. Then the internal iliac veins have their coats very thin, they lie loosely about the artery, and are joined by other veins of large size, so that no sharp instruments should be used in the latter part of the operation. It has been found in old subjects that the peritoneum has not escaped laceration, while being separated from its connections, even with the greatest care. Taking these circumstances into consideration, together with the fact that the artery may be shorter than usual (it is very irregular), and that it may lie deep in the pelvis, several very excellent surgeons have ex- pressed their conviction that under most circumstances it will be more pru- dent to tie the common iliac, although the direct supply of blood to the leg should be cut off. The artery and vein are covered by, or surrounded with, a proper sheath. The ureter is, in some subjects, closely connected with the artery; usually it is placed internal and a little posterior. The operation described for tying the common iliac is that by which this vessel may be the most readily reached, and it has the advantage of ena- bling the common trunk to be tied in case the operator should afterwards desire it. While the vessel is being secured, it should not be immoderately pulled, as the ilio-lumbar artery may be torn through. In all these opera- tions the advantage of the patient being under the influence of chloroform, whereby respiration goes on tranquilly, and the descent of the intestines is to a great extent prevented, must be obvious. We may add, that the aorta may be reached by the same operation by aneurism ; but at all events, imminent death was averted, and life prolonged for twenty- four days. Edinburgh Med. Journal, Jan. 1858. 1 Med. Chir. Trans, vol. xvi. 2 [For the operation of deligation of the primitive iliac we would call attention to the very valuable article of Dr. Stephen Smith, in the Am. Jour. Med. Sci. for July, 1860.1 FEMORAL ARTERY. 627 which the common iliac is tied, should it be necessary to do so, and that, as M r. Guthrie suggests, it may be possible to reach either common iliac from the opposite side of the pelvis, should the position and size of an aneurism render it impossible to do so on the same side. IV. The Gluteal artery may be tied by placing the patient on his face, with the toes turned inwards, and making an incision from an inch below the posterior spinous process of the ilium, and an inch from the sacrum, towards the great trochanter. This incision should be about four inches long. The fibres of the gluteus maximus having been cut through or separated to the like extent, and a strong fascia beneath having been cut through, the vessel will be found emerging from the upper part of the sciatic notch. The Sciatic artery may be found by making an incision through the same parts and for the same extent, but an inch and a half lower down. Both these operations are extremely difficult, from the great depth to which the dissec- tion must be carried, the unyielding nature of the surrounding parts, and the hemorrhage from the numerous blood-vessels that must necessarily be wounded. They should be attempted, however, in case of wounds ; but for aneurisms of these arteries, it is necessary to tie the internal or common iliac. SECTION IV.—THE FEMORAL AND ITS BRANCHES. I. The Femoral Artery extends from Poupart's ligament to the junc- tion of the middle with the lower third of the thigh, where it passes through the adductor magnus muscle Fig. 388. into the ham, and receives the name of popliteal. Its course is as nearly as possible indicated by a line drawn from the middle of Poupart's ligament to the inner edge of the patella, supposing the knee to be bent and the thigh turned outwards. It is accom- panied by its vein, which lies first to its inner side and then behind it, and still further down to its outer side. In its upper half it is covered by no muscle ; in its lower half it is concealed by the sartorius, be- hind which it lies against the bone in a dense fibrous sheath, formed by an interweaving of the tendinous expansion of the adductor with that of the vastus internus. The long saphenous nerve, a branch of the crural, enters this tendinous sheath, and lies on the outer side of the artery. The saphena, the great cutaneous vein of the leg, the homologue of the cephalic in the upper extremity, ascends the thigh in a course parallel to that of the artery, but internal to it, and enters at the saphenic opening two inches below Poupart's ligament. In the case of stabs in the thigh, it is well to bear in mind the possibility that the profunda may be the vessel injured.1 It arises from the femoral, about two inches below Pou- part's ligament, and runs down the thigh behind the femoral, and separated from it, first by the femoral vein, then by the adductor longus tendon. Aneurism of the profunda is not unknown. Nor must surgeons forget the possibility of varieties in the femoral artery, and that there may be two branches of nearly equal size, instead of one trunk. 1 See the cases at p. 300 and p. 303. [View of the relative ana- tomy of the femoral artery] 628 OPERATIONS FOR TYING ARTERIES. The best place for the application of ligature, in cases of popliteal aneurism, is the lowest part of the upper division of the artery, just before it is crossed by the sartorius. It is far enough from the aneurism for the vessel to be healthy, and low enough to avoid embarrassment with the profunda. To tie the Femoral Artery in its upper division.—The course of the vessel having been ascertained by its pulsation, an incision three or four inches in length should be made over it, about two or three inches below Poupart's ligament. The fat and superficial fascia must next be divided to the same extent. Some lymphatic glands will be met with here, and the saphena vein may be seen, but it generally lies much to the inner side of the in- cision. The fascia lata may now be divided to the same extent as the skin ; the sartorius should be gently drawn outward (the sheath of this muscle should not be opened, as it would complicate the operation), and the pulsation of the artery felt for —its sheath should be opened at the lowest part of the wound sufficiently to admit the aneurism-needle. There is always a risk of transfixing the vein and passing the ligature through it—an accident liable to be followed by fatal pyaemia. The best way of avoiding this accident, is to use a blunt aneurism- needle, stiff enough not to bend ; to pass it frouj the inner side, and to hold the inner cut edge of the sheath with forceps, and make it tense. Greater care will, of course, be necessary, if there has been an extension of inflammatory action to the sheath, with infiltration or thickening.1 To tie the Femoral Artery in the lower part of its course.—Turn the limb a little outwards, bend the knee, and raise the leg on a pillow. Make an incision three inches long, half in the upper third of the thigh, half in the lower, and in a direction midway between the front and back surfaces, through the skin and superficial fascia, taking all care to avoid the saphena vein. Divide the deep fascia on a director to the same extent. Now will be exposed the tendinous interweaving of the adductor muscles and vastus internus, that forms the tendinous sheath for the artery ; which is covered with more or less areolar tissue. At the posterior part of the wound lies the edge of the sartorius muscle. When this muscle is not seen, it should be searched for, because it forms a good landmark. Let the edge of the wound be drawn aside, then clear away the areolar tissue with care, and at the upper part of the space seek for the long saphenous nerve as it is passing through the aponeurosis of the adductors to gain the tendin- ous sheath of the vessels. Introduce the director where the nerve enters, and when the sheath is divided, the artery will very readily be found in a posterior position. The femoral vein is behind it. Sometimes the aponeu- rotic expansion of the tendinous sheath is higher than usual, and in this case the nerve may perhaps not be readily found. It is hardly necessary to allude to the possibility that the anastomotica magna might be taken up instead of the femoral artery; this branch arises from the trunk just before the latter perforates the adductor magnus to become the popliteal. 1 It may be mentioned as a fact, that in two patients, in whom Mr. Haynes Walton tied the femoral artery for popliteal aneurism, after it had been subjected to piessure unsuccessfully—in one instance for more than six weeks—there were no structural changes in the parts that had been compressed. [Ligatures of the femoral artery.] POSTERIOR TIBIAL ARTERY. 629 Fig. 390. The ligature should be applied on the upper portion of the artery. II. The Popliteal artery may be tied by cutting through the skin and fascia lata for the extent of three inches on the outer border of the tendon of the semi-membranosus muscle, the patient being placed on his face, with his knee straight. On pressing that tendon inwards, the artery may be felt. Its vein, which lies superficial and rather external to it, must be cautiously separated and drawn outwards, and the needle be passed between them. This operation is very seldom performed. The writer lately witnessed an accident in the person of his friend Dr. Norton, by which it would be very possible for the popliteal vessels to be wounded. In drawing a tight cork, by means of a common corkscrew, from a bottle held between the knees, the bottle was crushed, and the sharp edges driven between the inner hamstrings and the bone into the popliteal space. The patient was most kindly and skilfully attended by Mr. Hodgson and Dr. E. Smith, and made a good recovery ; but the hemorrhage was immense, and the danger for a time great. III. The Posterior Tibial Artery. As we have often said, a wounded ar- tery should, if possible, be tied at the wounded part; and in most cases the wound may be enlarged, and its track pursued till the bleeding vessel is reached. Yet there are exceptions to this latter rule ; for example, the poste- rior tibial or peroneal artery may be wounded by a narrow instrument thrust through from the front of the leg ; and to meet such cases, as well as others in which these vessels may require ligature for naevus, the surgeon must be pre- pared to cut down upon them from the calf. To tie the Posterior Tibial in the upper part of the leg.—The course of the artery corresponds with a line drawn from the middle of the popliteal space to the middle of the space between the heel and inner ankle. The patient should lie on his back, with the injured limb resting on its outer side, the knee half bent, and the foot on a pillow, and the heel raised, in order to relax the muscles of the calf to the utmost. Supposin..- the leg to be divided into thirds, an incision four inches long, half in the upper, half in the middle third, and an inch from the inner edge of the tibia, should be made through the skin and superficial fascia. AVhen the calf is very large, the cut should be taken more than an inch from the tibia'and less when'the calf is very thin. If possible, the saphena vein should be avoided. In the illustration are shown two converging branches of this vessel that were met with at the upper part of the wound. The deep fascia having been divided, and the muscles exposed, the edge of the gastrocnemius is to be drawn aside, in order to expose the solaeus. The fibres of the solanis are next to be severed to the extent of the first incision, until the fascia covering its anterior surface is seen, and then this is to be [Ligatures of the posterior tibial.] 630 OPERATIONS FOR TYING ARTERIES, pinched up, perforated, and divided on a director. The cellular fascia, which intervenes between the superficial and deep muscles of the calf, and surrounds the vessels, must now be torn through, and the artery will be exposed lying on the tibialis posticus. Its two veins, of uncertain size, are in very close contact with it, and not unfrequently surround it by anastomoses. The nerve is on the outer side of the artery. If the artery is not readily found, and there should appear to be want of room to look for it, some of the fibres of the solaeus may be cut across. Instead of directing the solaeus to be cut, some operators have proposed to separate its tibial origin from the bone. If this be done, the first inci- sion should be made higher up, and nearer to the tibia. The objections to it are, that in case of injury, when the muscles are swollen and infiltrated with blood, it would be very difficult to distinguish between the attachments of the soloeus and those of the flexor longus digitorum and tibialis posticus; so that all the muscles of the leg might be detached, and the interosseous membrane reached, instead of the artery. Again, supposing the solaeus to be correctly separated from the bone, it is no easy matter to draw the muscle sufficiently aside to expose the artery. This operation is considered by Mr. Guthrie to be so "painful, difficult, bloody, tedious, and dangerous," that he proposes to reach the artery by making a perpendicular incision six or seven inches in length, at the back of the leg, through the skin, gastrocnemius, plantaris, and solaeus; then the fascia will be exposed with the artery beneath it, and the nerve to the outer side. Perhaps this operation cannot be spoken of in much more compli- mentary terms than the preceding one. To tie the Posterior Tibial in the middle of the leg.—An incision must be made three inches long, half in the middle third of the leg, half in the lower, and midway between the inner edge of the tibia and the inner border of the tendo Achillis. It is often impossible to avoid cutting through the internal saphena vein. The fascia covering the edge of the tendo Achillis must be divided on a director. A second fascia, the deep one of the tendo Achillis, is often met with, Fig. 391. and must be treated in like manner. Whether one or two of these structures be seen, depends on the line of the incision, for at a little distance from the tibia, the two are, to use an anatomical expression, blended. The artery sur- rounded more or less by fat, which is a peculiarity in this situation, will be found along the inner edge of the flexor longus digi- torum, accompanied by its two veins. The nerve is to the outer side. It must be remembered that, in the upper part of the leg, [View of the relative anatomy of the posterior tibial.] the posterior tibial nerVC lies to the inner or tibial side of the artery; it soon, however, passes over, and inferiorly lies to its outer or fibular side. To tie the Posterior Tibial at the ankle.—The vessel is here compara- PERONEAL ARTERY. 631 tively superficial. An incision is made two and a half inches long, in the groove, midway between the anterior edge of the internal malleolus and the extremity of the heel, commencing near the tendo Achillis. The superficial fascia having been divided, the strong and dense fascia which adheres to the sheaths of the tendons, and covers the vessels and nerves in this situation (which is, in fact, the internal annular ligament), must be very carefully divided on a director, as well as the origin of the abductor pollicis ; and the artery should be looked for, surrounded by the venae comites. The fol- lowing is the order of the muscles, vessels, and nerves in this situation :— The tendons of the tibialis posticus and flexor digitorum communis are close to the malleolus internus. At about a quarter of an inch behind, there is the posterior tibial artery, on each side of which is a vein ; a little behind is the posterior tibial nerve, and half an inch nearer to the heel is the tendon of the flexor longus pollicis. Much pains should be taken to avoid opening the bursae around the tendons of the tibialis posticus and flexor longus digitorum respectively, or interfering with the sheath of the flexor longus pollicis The line of incision advised is, on this account, to be preferred to that across the direction of the artery, that in a circular form around the malleolus, or that parallel to the tendo Achillis. IV. The Peroneal Artery.—The trunk of this vessel is often absent, its place being supplied by branches from the posterior tibial artery. Some- times, on the contrary, it is very large at the lower part of the leg, and supplies the place of the posterior tibial. To tie it, an incision should be made four inches long, almost in the centre of the leg, being about half an inch nearer the upper part, and an inch behind the external edge of the fibula. The border of the solaeus is to be sought for and sepa- rated from the peronei which encircle the outer side of the fibula, and it may be requisite to detach a portion of this muscle from the fibula, to expose the flexor longus pollicis; the fibres of which must be separated longitudinal- ly, first with the direc- tor, then with the handle of the scalpel, and the artery sought for about the centre, where it will be near the edge Of the [Ligatures of the peroneal artery.] fibula. At the lower portion of the incision, the vessel is covered by the bone. Directly that the flexor proprius pollicis is exposed, the great toe should be bent to the 632 OPERATIONS FOR TYING ARTERIES. utmost, in order to relax the muscle and facilitate the separation of its fibres. If in the case of wound, with arterial hemorrhage, the posterior tibial is cut down upon, and found intact, the incision may be extended, so as to allow the peroneal to be reached, by separating the superficial from the deep muscles of the calf, and raising the flexor proprius pollicis. V. The Anterior Tibial Artery.—A line drawn from the head of the fibula to the base of the great toe will be parallel to the course of this artery. To tie the vessel in the upper part of the leg, an incision four inches long, or even longer, should be made through the skin, midway between the spine of the tibia and the external edge of the fibula, half of which should be in the upper third of the leg, and half in the middle. The intermuscular septa, between the tibialis anticus and extensor longus digitorum, must be sought for, raised on a director, and divided. It will facilitate the future steps of the operation to cut the fascia a little trans- versely at one or both extremities of the incision. The heel should be fully brought down, and the muscles then separated with the finger, from below upwards. It must not be forgotten that at the lower part of the incision, the ex- tensor proprius pollicis is to be separated from the tibialis anticus, as about the centre of the leg it intervenes between the extensor communis digitorum and tibialis anticus. The artery is deeply seated, lying on the interosseous membrane, accompanied by its two veins, and having the nerve in front and in close contact. The nerve is superficial in its entire course, and often changes its situation from one side to another. To tie it in the lower part of the leg.—An incision three inches in length, commencing at about the junction of the middle with the lower third of the leg, just half an inch external to the spine of the tibia, must be made obliquely upwards and outwards, as is shown in Fig. 394. The fascia covering the tibialis anticus must then be divided, and the artery will be found lying on the lower portion of this muscle which separates it from the external surface of the tibia, surrounded by the venae comites, and with the nerve directly in front. Should it be found necessary to tie the artery lower down, the tendon of the extensor proprius pollicis had better be drawn to the outside, while that of the tibialis anticus is drawn in the contrary direction, and the connecting fascia divided. Here the vessel rests on the tibia. XI. The Dorsal Artery of the Foot can rarely require to be tied. This vessel, superficial as it be, is, from its diminutiveness and the tightness of the fascia on the dorsum of the foot, very difficult to be taken up even in the dead body. The posterior extremity of the interosseous space, between the first and second metatarsal bone, being found, an incision should be carried directly upwards for two inches or more. The fascia having been divided on a director, the tendon of the extensor longus pollicis and the inner tendon of the extensor brevis digitorum will be exposed, between which the artery lies. The last-named tendon is a certain guide, as it is first external to the vessel. In wounds of the arteries in the sole of the foot (except perhaps of the external plantar, opposite the base of the little toe), before enlarging the wound with the view of securing the bleeding point, methodical pressure should be applied after the manner recommended at p. 301; if that fails, the posterior tibial artery should be tied behind the inner ankle, and the anterior tibial on the dorsum of the foot likewise, if necessary. In wounds also of either of the tibial arteries inflicted on children in the operation of dividing the deep tendons for club foot, pressure should have a fair trial. DORSAL ARTERY OF THE FOOT. 633 Fig. 393. Fig. 394. [View of the relative anatomy of the anterior tibial.] [Ligature of the anterior tibial, and dorsal of the foot.] [As a substitute for the ligature, as a means of effectually closing arte- ries, and arresting hemorrhage, acupressure appears to be fast coming into use among British surgeons. The instrument used for the purpose of acupressure is a slender needle of passive iron, headed with wax or glass. This needle is passed so as to com- press together and to close, by its middle portion, the tube of the bleeding artery a line or two, or more, on the cardiac side of the bleeding point. It should be passed over the artery in such a way as to compress the tube with sufficient power and force against some resisting body. Such a resisting body will be most frequently found, 1st, in the cutaneous walls and compo- nent tissues of the wound ; 2d, sometimes in a neighboring bone, against which the artery may be pinned and compressed by the acupressure needle ; and 3d, in a few rare cases it may possibly be found in practice, that a sec- ond needle may require to be introduced to serve as a point against which the required compression is to be made. Dr. Simpson, of Edinburgh, the author of this plan of acupressure, illustrates the action of the needle upon the artery, by the way in which the stalk of a flower is attached to the lapel 6f a coat by means of a pin. Acupressure is more simple of application than the ligature, it is far surer in its results as regards all the chances of obtaining the reunion of wounds 634 AMPUTATION OF THE THIGH. by the first intention, and therefore far safer as respects the avoidance of the occurrence of purulent infection. Although but very recently brought into notice, it has already been used, with extraordinary success, in amputations of the extremities and the removal of diseased glands, and of large tumors.] CHAPTEB V I AMPUTATIONS. I. Amputation of the Thigh.—It will be convenient to describe this amputation first; and to embody in the description of it such general pre- cepts as are applicable to the Fig. 395. other amputations. In the first place the surgeon should have his tourniquets, am- putating knives, saws, artery- forceps and tenacula, ligatures, bone-forceps, sponges, and curved needles threaded (or wired), close at hand on a tray, arranged in due , order ; and he should see with his own eyes that every requisite is at hand before he begins. In this, as in every other ope- ration, it is necessary to place the patient in a convenient posture, so that the operator may not be obliged to stoop. For amputation of the thigh, the patient may be placed on a bed, or on a table covered with a folded blanket; the diseased leg should project sufficiently over the edge, and should be supported at the knee by an assistant, who sits on a low stool in front; and the sound limb may be secured to one of the legs of the table with a handkerchief. For amputation of the thigh, in an adult, the surgeon should have a long, straight, sharp-pointed knife. Instead of the common amputating saw, he may, if he pleases, use the instrument here depicted, and invented by Mr. Butcher of Dublin, although it is in excision of the ends of bones that it is most particularly useful. It will be seen that the blade, which is 8 inches long, and only .25 inch in breadth, is most tensely stretched between two upright bars, by a screw in the middle of the uppermost cross bar. The tension, combined with the firmness of the teeth, renders it a capital cutter, whilst from the outset of the teeth, and narrowness of the blade, it cannot well become locked. More- over it can, when the screw is reversed, be turned in any direction, and be there fixed, so as to cut backwards or sideways.1 1 The saw depicted here differs in some respects from that described by Mr. Butcher, Dublin Journ. Med. Sc, Feb. ls>55. Weiss has another modification of it, suggested by Mr. Busk. [Tourniquet.] AMPUTATION OF THE THIGH. 635 Then measures must be adopted for compressing the main artery, and preventing too great loss of blood. This may be done, either by pressure with the hand, or with the tourniquet. • Fig. 396. [Saw for amputations.] Pressure with the hand on the main arterial trunk, if effected by a steady assistant who can be trusted, is sufficient in most cases ; and if the limb is amputated so high up that the tourniquet cannot be applied, there is of course no choice ; the femoral artery must be compressed against the ramus of the pubes. Both hands should be used for this purpose. Either the thumbs, or else the tips of the fore, middle, and ring fingers in a line should compress the vessel, and when one hand relaxes a little, the other should press more firmly. The handle of a key covered with lint is sometimes used. The common tourniquet consists of three parts : a pad, to compress the artery, which should be firm, narrow, and flattish; a strong band which is buckled round the limb ; and a bridge-like contrivance, over which the band passes, with a screw, by turning which the bridge is raised, and the band tightened. The pad should always be placed so as to compress the artery against the bone. Instead of a pad attached to the band, it is preferable to use a small, firm roller, about an inch thick; to put this lengthwise over the main artery, and secure it by a turn of bandage ; and to apply the band of the tourniquet over this. The band should first of all be buckled tightly ; then by turning the screw a very powerful degree of force is exerted. The screw may be put over the pad, or on another part of the limb ; but it should always be put opposite the buckle of the band. The advantage of the tourniquet is, that it compresses the smaller arteries as well as the prin- cipal trunk; its disadvantage is, that it arrests the venous circulation, and causes a greater loss of venous blood ; wherefore, it should never be con- stricted tightly until the incisions are just commencing. Amputations maybe performed either, 1, by cutting from the skin towards the bone with a circular sweep of the knife, or with two oval semicircular sweeps ; or, 2, by transfixion and cutting flaps outwards ; or by a combina- tion of either method. The flap operation has been of late the favorite ; it is more brilliant; and it enables the surgeon to select a flap where he pleases, so that when the flesh on one side of the limb is destroyed by disease or injury, the end of the stump may be covered with a flap taken almost en- tirely from the sound side, and greater length of limb may be preserved. But it is generally admitted that the circular, although a slower and less showy operation, produces on the whole better stumps than the flap opera- tion, as usually performed. The aim of the surgeon should be to produce a good, useful stump ; and not to execute a pretty-looking manoeuvre. He must be careful to have skin enough to cover the flesh, and flesh enough to cover the bone. If the bone 63 6 AMPUTATION OF THE THIGH. is inclined to project it should be shortened at once ; and the same with muscle or tendon, and especially with nerves, which should always be cut short if they project. Mr. Teale, of Leeds,1 declares that the mortality of the amputations of the thigh and leg is nearly one in three ; and that the stumps of those who es- cape are generally unsatisfactory, and unable to bear pressure. In order to diminish the mortality, and produce a more useful stump, he proposes to amputate by means of a long and a short rectangular flap. (See p. 638, 642.) The long flap is to be formed out of such parts as do not contain the prin- cipal blood-vessels and nerves, and is to be long enough to fall easily over the end of the bone. Its length and breadth are equal to half the circumfer- ence of the limb; it is therefore a perfect square. The short flap is one- fourth its length. The long flap is folded over the end of the bone, and united by suture, as shown at p. 638. No dressing is used by Mr. Teale; and he orders the stump not to be lifted for many days. He believes the advantages of this plan to be, that tension is avoided by the ample size of the long flap ; that this, folding over the end of the bone, soon acquires organic union with it, and seals up its veins ; that the limb is not disturbed by lifting and dressing, and the veins consequently are early closed; and that the end of the bone is covered by parts free from large vessels and nerves, and that the cicatrix does not adhere to it. In this, as in all other operations, we suppose the patient to be under the influence of chloroform; unless there is some rare and special reason to the contrary. 1. Circular Method.—The surgeon stands on the outer side, and uses his left hand to grasp and steady the part which he is to amputate. The artery must be compressed by one of the methods before described, and an assistant must grasp the limb with both hands, so as to draw up the skin as high as possible. Then the surgeon commences by putting his arm under the thigh, and makes an incision at one sweep, completely round the limb, through the skin and fat down to the fascia. The knife of course cuts from heel to point. The assistant is now to draw the skin further up, the retraction being aided by a few touches with the knife ; and then the knife, being put close to the edge of the retracted skin, is to be made to divide everything down to the bone by another clean circular sweep. The next thing is to separate the muscles from the bone for another inch or two with the point of a knife, especially those connected with the linea aspera; and then the periosteum having been divided by one more sweep, the muscles are to be well drawn up from tne bone, either by the hands of the assistant or by the retractor, a piece of linen with a longitudinal slit in it. The saw must be used to divide the bone : it should be held perpendicularly or nearly so : it should be used very lightly, and the last few strokes should be excessively short and gentle, that the bone may not be splintered. If it is, the irregular part must be removed by the forceps. The femoral artery should now be tied, its orifice being seized and slightly drawn out by forceps; and afterwards any large branches that appear in the muscular interstices. Then all compression should be suddenly ceased, so that any arteries that are liable to bleed may do so, and be tied at once. Hemorrhage from large veins is to be restrained by elevating the stump, and making compression for a short time with the finger. If, however, nothing else will do, they must be tied. Any obstinate oozing from small vessels should be restrained by sponging with cold water, or perhaps by a touch with arg. nitras. So soon as bleeding has ceased, a light bandage may be passed round the limb above the stump, and the edges of the wound should be nicely adapted with sutures and strips of plaster. 1 On Amputation by a long and a short Rectangular Flap, Lond. 1858. AMPUTATION OF THE THIGH. 6 31 The edges are to be brought together in a straight line, which may be made either perpendicular or horizontal, the latter, however, being the better plan. The patient should then be removed to bed, and the stump be supported on a pillow covered with oil-cloth or gutta-percha. No other application will be needed save a good flake of fine wadding to exclude the air, and absorb discharge. Pain may be allayed by an opiate. The stump may re- main as it is for some days, the cotton being changed, and the discharge wiped occasionally from its surface. But after from four to six days, sooner or later, according to the quantity of the discharge and the feelings of the patient, the dressings "should be changed, the straps being taken off and re- placed one by one, with care not to disturb the ligatures, and the hands of an assistant being employed to support the edges, and prevent their falling asunder. At the subsequent dressings, the points to be attended to are, to renew the light bandage occasionally, which was passed round the stump soon after the operation, in order to support the muscles, and prevent their retraction—to bring together the edges of the wound with adhesive straps, to press gently out all collections of matter, and take care that there is no bagging;—to use some antiseptic if need be—to remove the ligatures when loose—(that on the femoral artery should not be disturbed for a fortnight) —and to accelerate cicatrization by the nitrate of silver, or other stimulants, if the granulations appear languid. If the patient is very emaciated, the circular incision may be carried down to the bone at once without ceremony, because in such patients the muscles always retract greatly. Sir C. Bell recommended the skin not to be divided Fig. 397. This cut represents the surgeon as standing on the inner side ; it is, however, more convenient on the whole that he should stand on the outer side. The knife should be carried along close to the bone for an inch or more before it is made to cut the flap. Mr. Haynes Walton says that it is better to make the lower flap first, since thus, the integuments being relaxed, it is easier to shape out the upper flap accurately. quite circularly, but the knife to be inclined a little, so as to make two oval flaps. The same may be done also in dividing the muscles. 2. Flap Operation.—The flaps may be made, either from the inner and outer, or from the anterior and posterior aspects of the limb. The latter way is the more convenient if the amputation is low down ; but the former, if it is in the middle or upper third. In performing this operation, the sur- geon, standing as before, grasps the flesh on the anterior surface of the limb with his left hand, and lifts it from the bone ; then passes his knife horizon- 638 AMPUTATION AT THE HIP-JOINT. tally through it—carries the point over the bone, pushes it through the other side of the limb as low as possible ; then makes it cut its way out upwards and forwards, so as to make the anterior flap. In amputating the ri»-ht thigh, the knife should be passed behind the saphena vein. It is again entered a little below the top of the first incision, passed behind the bone, brought out at the wound on the other side, and directed so as to make a posterior flap in the direction of the dotted line. Both flaps are now drawn back; the knife is swept round the bone to divide any remaining muscular fibres, and the bone is sawn through. In the same manner flaps may be made from the inner and outer sides of the limb, the surgeon first grasping the flesh, and transfixing it, and cutting a flap on one side of the bone, then passing the knife close to the bone on the other side (without again piercing the skin), and making another flap. 3. Teale's Operation.—The surgeon is recommended to begin by marking out the flaps with ink. Taking the circumference of the limb at the point where the bone is to be sawn, half Fig 398. of this will be the length and breadth of the flap. One line is to be traced on the inner side, as near as may be to the femoral ves- sels, without including them in the flap ; a similar parallel line on the outer side, and a line of equal length joining their lower extre- mities. A transverse line may then be drawn to show the place of the short flap, which should be one- fourth the length of the long one. " The operator begins," says Mr. Teale, " by making the two lateral This cut, copied from Mr. Teale's book, shows the incisions of the long flap through flaps put together by sutures. the integuments only. The trans- verse incision of this flap, sup- posing it to run along the upper edge of the patella, is made by a free sweep of the knife, through the skin and tendinous structures, down to the femur." But should the lower transverse line fall across the patella, the skin must be dissected off, and the cut be carried down to the femur, above its upper edge. " This flap is completed by cutting the fleshy structures from below upwards, close to the bone." The posterior short flap, con- taining the large vessels and nerves, is made by one sweep of the knife down to the bone ; the soft parts being afterwards separated from the bone close to the periosteum, as far upwards as the intended place of sawing. SECTION II.—AMPUTATION OF THE HIP-JOINT. This operation is requisite in cases in which the upper extremity of the thigh-bone is smashed, and in which the soft parts are so injured that it is of no use to attempt excision. " No man," says Mr. Guthrie, " should suffer amputation at the hip-joint when the thigh-bone is entire. It should never be done in cases of injury when the bone can be sawn through immediately behind the trochanter major, and sufficient flaps can be preserved to close the wound thus made. An injury warranting this operation should extend to the neck or head of the bone, and it may be possible, as I have proposed, even then to avoid it by removing the broken parts."1 1 Guthrie, Commentaries, 6th edit. p. 63. AMPUTATION AT THE HIP-JOINT. 639 It is generally by flaps ; either anterior and posterior, or lateral. The writer saw it performed in the year 1835 by Mr. Herbert Mayo, at the Middlesex Hospital, in the following manner :— The femoral artery was first tied immediately below Poupart's ligament. This was the rule of that day, but was quite unnecessary. The artery should be compressed during the operation, and its cut orifice be tied imme- diately afterwards. The patient being in the recumbent posture at the edge of the table, and the limb held out horizontally, a long knife was thrust through the limb immediately on the inner side of the joint, and carried forwards and inwards, [Fig. 399. Amputation of the hip-joint.] and made to cut the inner flap from the abductor muscles. This flap should be immediately grasped by an assistant, who should compress the femoral artery. In the next place, Mr. Mayo cut into the hip-joint with a short strong curved knife, and severed the ligamentum teres and the muscles attached to the digital fossa. Lastly, putting in the long knife over the trochanter, he cut downwards and outwards to make the outer flap. This amputation, excluding the preliminary tying of the femoral artery, was most brilliantly accomplished in twenty-eight seconds; yet would scarcely in the present day be justified, since it was performed upon a young woman to get rid of neuralgia from a stump, which had undergone two previous amputations. Of the method by anterior and posterior flaps, a very good example is afforded by a case of Mr. Tatnum's at St. George's Hospital in July, 1855. The thigh having been slightly bent and abducted, the knife was entered at the outside at the junction of the upper and middle thirds of a line drawn from the anterior superior spine of the ilium to the great trochanter. It was carried obliquely inwards and downwards immediately in front of the joint, and brought out about two inches below the tuberosity of the ischium. " Cutting my way out," says Mr. Tatuni, " I made a large anterior flap, which was at once firmly grasped, so as to prevent the possibility of hemor- rhage, and drawn upwards. The anterior part of the capsular ligament being laid bare was easily divided ; the head of the bone was then partially dislocated by rotating the limb outwards and extending it backwards ; the ligamentum teres was at once cut through, and the dislocation of the thigh- bone completed. The knife was then carried through the joint and over the trochanter, and the posterior flap was made. In doing this I took care to 640 AMPUTATION AT THE KNEE-JOINT. have this flap somewhat small and thin, well knowing by experience that a large posterior flap tends by its weight to drag the cut surfaces apart in the progress of healing. As I completed the posterior flap, dry sponges were stuffed into the wound by assistants, and thus all hemorrhage was at once stopped." Plenty of ligatures securing every bleeding vessel including the femoral vein ; sutures and plasters, completed the operation. The pa- tient, a lad of 16, left the hospital in a month. In this case, as in one operated on by Mr. C. G. Guthrie, the entire thigh- bone was removed in order to give the patient a greater chance of security from the return of cancer than would have been given by amputation through the affected bone. In any such case, the surgeon probably will be able to plan his lines of incision as he pleases ; and the limb can be moved in any direction, to facilitate his proceedings. Not so in cases in which there is extensive destruction of soft parts and smashing of the neck of the bone. Here the surgeon must be guided by the direction in which he can secure the best covering of skin.1 SECTION III.--AMPUTATION AT THE KNEE-JOINT. This operation may be substituted for amputation in the lower third of the thigh, in cases in which excision of the knee-joint is impracticable. [Fig. 400. Amputation at the knee-joint, Syme's operation.] 1. Syme's Operation.—A semicircular incision is made through skin and fascia over the patella; next, the knife is thrust horizontally across immedi- ately behind the joint, and is made to cut a long flap from the calf of the le"1; next, the anterior flap being lifted up, the extensor muscles are severed from the upper border of the patella ; the remaining soft parts are divided, and the femur sawn through the condyles, immediately above the joint. 2. If circumstances permit it, an anterior flap may be made including the patella, by a semicircular incision through the tissues in front of the joint, beneath the patella from the posterior part of one condyle of the femur to the other. Then the ligamentum patellae is cut through, the patella lifted with the anterior flap, the joint opened by cutting through the lateral and crucial ligaments; and lastly, a sufficiency of under flap cut from the calf. The interarticular cartilages should always be removed, and the surface of the patella, or femur, if diseased. The popliteal artery should not be wounded above the part at which it is severed. The patella should be brought down over the end of the femur. 1 For details of other modes of performing this operation, see Guthrie's Commentary•* and South's Chelius, vol. ii. AMPUTATION OF THE LEG. 641 SECTION IV.—AMPUTATION OF THE LEG. 1. Oval Amputation through the calf.—An oval incision is made in the direction shown in the cut, through skin and fat; these are thoroughly drawn Fig. 401. [Oval amputation of the leg.] back ; the incision is carried upwards obliquely through the gastrocnemius to the bones, so as to make a posterior flap ; this being well pulled up, the remaining soft parts around and between the bones are divided ; lastly, the bones are sawn through. [Here, as also in the forearm, in sawing the bones, the surgeon should take care that the most movable bone be the one first divided by the instrument.] The integuments are brought together in a transverse line. 2. The flap operation is performed by Mr. Fergusson in an elegant and expeditious manner, thus :—He first places the heel of the knife on the side of the limb furthest from him, and draws it across the front Fig. 402. of the limb, cutting a semilu- nar flap of skin; when its point has arrived at the op- posite side, it is at once made to transfix the limb; this stage of the operation is represented in Fig. 403 ; and then the posterior flap is cut. The surgeon must take care not to get his knife between the two bones. When the operation is performed high up, the popliteal artery will be divided instead of the two tibials. The tibia, however, should never be sawn higher than its tuberosity, or the joint will be laid open. The fleshy mass of the gastrocnemius may require to be cut out, to make the flap thin- ner. If low down, the tendo Achillis will require to be shortened after the flap is made. The flap is to be brought forwards, and confined by a stitch or two, the line of junction being horizontal. 3. Circular Method.—The artery being under command, as in amputa- tions of the thigh, and the leg being placed horizontally, one assistant sup- porting it at the ankle, and another holding it at the knee and drawing up the skin, the surgeon makes a circular incision through the skin, four inches below the tuberosity of the tibia. The integuments are next to be dissected 41 [Oval amputation of the leg, after separation of the limb ] 642 AMPUTATION OF THE LEG. up for two inches, and turned back ; and the muscles are to be divided down to the bone by a second circular incision. Then a long slender double- edged knife, called a catline, is passed between the bones to divide the inter- Fig. 403. [Flap amputation of the leg.] osseous ligament and muscles, and both bones are sawn through together, the flesh being protected by a retractor, which should have three tails. The spine of the tibia, if it projects much, may be removed with a fine saw or bone nippers, and care should be taken not to leave the fibula longer than the tibia, or'it will give much trouble. The anterior and posterior tibial and peroneal arteries, and any others requiring it, being tied, the stump is to be treated as directed after amputation of the thigh. The teguments should be put together transversely. Fig. 404. [Teale's amputation.] 4 Teale's Operation.—-The length and breadth of the anterior flap are to be determined and marked out as before described, p. 635. The two lateral incisions are first made through the skin; and the transverse one down to the bone ; then the long flap is dissected up, and with it, all the tissues in front of the bones and interosseous membrane ; including the anterior tibial vessels which are divided once only. The short posterior flap is then made by one'cut down to the bones, and is to be dissected clean from the bones and interosseous membrane up to the point of sawing. The cuts are reduced from Mr. Teale's book. AMPUTATION OF THE ARM. 643 [Stump after removal of the limb in Teale's operation on leg.] SECTION V.—AMPUTATION OF THE ARM. In amputations of the upper extremity, the flow of blood may be suffi- ciently commanded by compressing the artery above the clavicle, or in the Fig. 406. [Circular amputation of the arm.] arm. If it is thought pro- per, however, the tourniquet may be applied so as to com- press the artery against the humerus. 1. Circular.—The arm being held out, and an as- sistant drawing up the skin, one circular incision is made through the skin, which be- ing forcibly retracted, an- other is made down to the bone. These incisions should be made with two slight divergences, so as to cut the skin and muscles rather longer in front and behind than at the sides. [Fig.'407. Flap operation on the arm.] 644 AMPUTATION AT THE SHOULDER. The subsequent steps are precisely similar to those in amputating the thigh. 2. Flaps.—The knife is entered at one side, carried down to the bone, turned over it, brought out at a point opposite (the vessels being left behind for the second flap), and then made to cut a neat rounded anterior flap two or three inches long. It is next carried behind the bone to make a posterior one of equal length; and is lastly swept round the bone, to divide any- remaining fibres. The division of the bone, ligature of the arteries, and treatment of the stump as before. SECTION VI.—AMPUTATION AT THE SHOULDER. This may be performed in several manners. 1. The patient being seated in a chair and well supported, or, which is better, being placed on a firm [Fig. 408. Amputation at the shoulder on left side.] [Fig. 409. Amputation at the shoulder on left side.] table, with the shoulder elevated, and projecting beyond its edge, and the subclavian artery being compressed, the surgeon enters a long straight knife at the anterior margin of the deltoid muscle, an inch below the aero- AMPUTATION AT THE SHOULDER. 645 mion. From this point he thrusts it through the muscle, across the outside of the joint, and brings out the knife at the posterior margin of the axilla. If the left side is operated on, the knife must be entered at the posterior margin of the axilla, and be brought out at the anterior margin of the del- toid muscle. Then, by cutting downwards and outwards, the external flap is made. The origins of the biceps and triceps, and insertions of the infra and supra spinatus are next cut through, and the joint is laid open. Finally, the blade of the knife being placed on the inner side of the head of the bone must be made to cut the inner flap. 2. The covering for the exposed part of the scapula in the preceding operation was obtained from the deltoid. But it may also be obtained from the muscles in front or behind, supposing the deltoid to be implicated in the disease or injury which demands the operation. One elliptical incision may be carried from beneath the middle of the acromion to the posterior border of the axilla, and another to the anterior border. These flaps being dissected up, the head of the bone may be turned out of the socket, and the remaining soft parts be divided ; or the bone may be sawn through just beneath its neck. An assistant should be directed to grasp the flap which contains the axillary artery so soon as it is divided, because the pressure above the clavicle is generally not sufficient to stop the circulation entirely. SECTION VII.—AMPUTATION AT THE ELBOW. This is performed by passing the knife through the muscles in front of the joint, and cutting upwards and forwards, so as to make a flap from the fore- arm. Then the operator makes a transverse incision behind the joint. He next cuts through the external lateral ligament, and enters the joint between the head of the radius and external condyle, then divides the internal lateral ligament, and, lastly, saws through the olecranon, the apex of which, with the triceps attached to it, is of course left in the stump. SECTION VIII.—AMPUTATION OF THE FOREARM. This operation should always be performed as near the wrist as possible. 1. Circular.—The limb being sup- ported with the thumb uppermost, and an assistant drawing up the skin, a circular incision is made through it down to the fascia. When the skin has again been retracted as much as possible, the muscles are divided by a second circular incision ; the interos- seous parts and the remaining fibres are next cut through with a catline ; the flesh and the bones are then to be sawn through together, the saw being worked perpendicularly. The radial, ulnar, and two interosseous arteries require ligatures. 2. Flaps.—The limb being placed in a state of pronation, the surgeon makes a flap from the extensor side, just as is represented in the annexed cut; and he then transfixes the flexor side, and makes the other flap ; taking Care not tO paSS the knife between the [Flap amputation of the forearm.] 646 AMPUTATION OF THE HAND. bones whilst performing either transfixion. The interosseous parts are next divided, the flesh drawn upwards, and the bones sawn through. If the tendons project, they must be shortened. Teale's operation is performed, mutatis mutandis, like that of the leg; and that of the upper arm like the thigh. SECTION IX.—AMPUTATION AT THE WRIST. 1. Circular.—The skin being pulled back, a circular incision is made a little below the level of the line that separates the forearm from the palm of the hand. The external lateral ligament is then cut through, and the knife carried across the joint, to divide the remaining attachments. Fig. 411. [Flap amputation of the wrist.] 2. Flaps.__A semilunar incision is made across the back of the wrist, its extremities being at the styloid processes, and its centre reaching down as far as the second row of carpal bones. This flap being dissected up, the joint is opened behind, the lateral ligaments are cut through, and the knife, being placed between the carpus and bones of the forearm, is made to cut out a flap from the anterior surface of the palm, as represented in the above figure. The tendons must be shortened, and the skin brought together by sutures. SECTION X.--AMPUTATIONS OF THE HAND. I. Amputation of the fingers or thumb at their last joint may be per- formed thus :__The surgeon holds the phalanx firmly between his finger and thumb, and bends it, so as to give prominence to the head of the middle phalanx. He then makes a straight incision across the head of the middle phalanx, so as to cut into the joint, and takes care to carry it deeply enough at the sides to divide the lateral ligaments. The joint being then thoroughly opened, the bistoury is carried through it, and made to cut a flap from the palmar surface of the last phalanx, sufficient to cover the head of the bone; and it is better to leave too much than too little. If, however, the joint cannot be bent, this operation may be performed thus: The surgeon holding the phalanx firmly, with its palmar surface up- wards, first passes his knife horizontally across the front of the joint, the flat surface towards it, and cuts out the anterior flap; then divides the lateral ligaments and the remaining attachments with one sweep of the knife. II. Amputation at the second joint of the fingers or thumb may be performed in the same manner. AMPUTATION of the hand. 647 [Flap amputation of the finger.] III. It is always expedient to save as much as possible of the fingers and thumb ; consequently in cases admitting of it, flaps may be made from the soft parts wherever practi- cable, and then the bone cut Fig- 412- with forceps. Teale's plan of making a flap from the dorsal surface has been V / V * adopted by Mr. S. Hey, \A // f with great advantage. IV. Amputation of a FINGER AT THE METACARPAL joint may be effected thus: The surgeon should make out accurately the situation of the joint between the head of the metacarpal bone or knuckle and the base of the first phalanx. If he looks for the transverse lines on the palmar aspect, that mark the flexure of the joint and divide the finger from the palm, he may calculate that the metacarpo-phalan- geal joint, at which he is to amputate, is about half an inch nearer to the wrist than this line is. Then he may begin by making a semilunar incision on one side of the prominence of the knuckle, a quarter of an inch beyond the joint, and should carry it round in front of the joint to the web on the other side, thus encircling two- thirds of the joint. The finger should now be drawn to the other side, the extensor tendon cut through, and the point of the bistoury passed into the joint, and made to divide its ligaments. This will allow the head of the bone to be turned out, so that the bistoury being placed behind it may cut through the remaining attachments and make another flap. This operation may also be performed by making an incision on one side of the joint (as in the method just described), and then bringing it across the palmar surface, and round the other side to terminate where it began. The tendons and ligaments are now to be divided, and the head of the bone turned out. The digital arteries must be tied, and after bleeding has ceased, the wound may be closed by confining the adjoining fingers together. V. Amputation of the metacarpal bone of the thumb is performed thus : The thumb being held out, a bistoury is inserted near the metacarpo-phalangeal joint, its point is thrust between the bone and the muscles of the ball of the thumb, and as close to the bone as possible, and brought out just above the articulation with the trapezium. This step is shown in Fig. 413. Secondly, the bistoury is made to cut its way outwards. Thirdly, an incision, beginning at the upper extremity of the last, is carried Fig. 413. [Introduction of the knife in amputating the thumb.] 648 AMPUTATION OF THE FOOT. along the bone, and round and behind the metacarpophalangeal joint to meet the other incision at its commencement (see Fig. 414). Fourthly, the bistoury should be passed along the metacarpal bone to clear it from its re- maining attachments ; and lastly the bone should either be cut through, or disarticulated. If the latter proceeding is necessary, the bone must be forcibly abducted, and the ligaments on the inner side of the metacarpo- trapezial joint be cut through first. When the metacarpal bone of the thumb alone is diseased, it should, Mr. Fergusson advises, be extirpated alone, and its phalanges should be pre- served. The bone should be Fig. 414. exposed by means of an inci- sion along its radial margin; //f^TTiim******^^ then its articulation with the inz :' ^"^taa^iyB phalanges should be divided; and lastly, it may be turned out and separated from the trape- zium ; taking care not to wound the radial artery where it passes between the first and second metacarpal bones. VI. Amputation of the [Incisions for amputating the thumb.] METACARPAL BONE OF THE LIT- TLE finger is performed thus: An incision is made along the ulnar border of the dorsum of the bone, and is carried round the root of the little finger. The skin and flesh are dissected off, as closely as possible, and the bone divided. (See amputation of the metatarsal bone of the great toe.) VII. Amputation at the head of a metacarpal bone is effected by mak- ing an incision on each side of it (as in amputation of the fingers at that joint, but extending rather higher up), and then cutting through the bone with the cutting- forceps. Mr. Fergusson recommends the head of the metacarpal bone to be removed in almost every instance where the entire finger is abstracted, because the deformity is much less. But the part need not be removed high enough up to divide the transverse ligament. Care must be taken during the cure to keep the fingers paral- lel, and prevent them from crossing at their tips. If a part or the whole of the shaft of one of these bones is to be removed also, an incision should be made along its dor- sum, to the point where the two former ones meet; and then the flesh being dissected away on either side, the bone may be cut through or disarticulated according to circumstances. Fix 415. [Amputation of the head of a metacar pal bone.] SECTION XL--AMPUTATIONS OF THE FOOT. I. Amputation of the toes at any of their joints is performed in pre- cisely the same manner as amputation of the fingers. In removing a single toe from its metatarsal bone, the surgeon should take care first of all to as- certain the exact situation of the joint, which lies rather deeply. Moreover, amputation of the foot. 649 he should not remove the head of the metatarsal bone, as he may of the me- tacarpal, because it is important to preserve the entire breadth of the foot.1 II. Amputation of ALL THE TOES AT THEIR Flg" 416, METATARSAL J.OINTS-- an operation which may be requisite in cases of frost-bite-is performed by first making a trans- verse incision along the dorsal aspect of the me- tatarsal bones, dividing the tendons and lateral ligaments of each joint in succession; and then, the phalanges being dis- located upwards, the knife is placed beneath their metatarsal extre- mities, and made to cut out a flap from the skin on the plantar surface, sufficient to cover the heads of the metatarsal bones. III. Amputation of the metatarsal bone Fig. 417. [Division of metatarsal bone of the great toe with forceps.] OF THE GREAT TOE IS pCT- Fig. 418. [Fig. 417.—Incisions in amputating metatarsal bone of the great toe.] [Fig. 418.—Result of the operation of removal of the metatarsal of great toe.] 1 Mr Ilavnes Walton has favored the writer with a valuable note, to the effect that it is de'-ii-il'le to explore the real seat and amount of disease about the tarsus, before performing amputation. For example, he had a case in which the head of the metatar- sal bone of the great toe was suspected to be carious, and was condemned to be cut «.ut • a serious operation, inasmuch as it takes away one of the three supports of the arch of "the foot. But a free incision revealed disease in the first phalanx only. This was removed, and the patient recovered with the slightest possible limp. 650 AMPUTATION OF THE FOOT. formed precisely like the operation for the removal of the metacarpal bone of the little finger. An incision down to the bone with a scalpel, is carried along its dorsum and round the root of the great toe, as shown in Fig. 417. Secondly, the knife, which must be kept as close to the bone as possible, ia made to dissect it out from the surrounding parts; thirdly, tjhe bone is cut through with forceps, a part of the operation shown in Fig. 416. Vessels are to be tied, and the wound brought together as shown in Fig. 418. It may be observed that, in lnviding the metatarsal bones of the great or little toes, or the metacarpal bones of the fore or little finger, care should be taken not to leave any prominent angle. IV. Amputation of all the metatarsal bones (Hey's operation) is performed in the following manner:—The exact situation of the articula- tion of the great toe to the inner cuneiform bone (to which the tendon of Fig. 419. [Amputation of all the metatarsal bones (Hey's operation).] the tibialis anticus may serve as a guide) being ascer- tained, a semilunar incision, with the convexity for- wards, is made down to the bone, across the instep, from a point just in front of the aforesaid articulation, to the outside of the tuberosity of the fifth metatarsal bone. The flap of skin thus formed being turned back, the bistoury is to be passed round behind the projec- tion of the fifth metatarsal bone, so as to divide the external ligaments which connect it with the cuboid. The dorsal ligaments are next to be cut through, and then the remaining ones, the bones being depressed. The fourth and third metatarsal bones are to be disarticulated in a similar manner, dividing their ligaments with the point of the knife, and taking care not to let the instru- ment become locked between the bones. The first metatarsal is next to be attacked, and lastly, the second, the extremity of which, being locked in be- tween the three cuneiform, will be more difficult to dislodge. Perhaps it may be convenient to saw it across. When all the five bones are detached, the surgeon completes the division of their plantar ligaments, and slightly separates the textures which adhere to their under surface with the point of the knife, and then, the foot being placed horizontally, he puts the blade under the five bones, and carries it forwards along their inferior surface, so as to form a flap from the sole of the foot sufficient to cover the denuded tarsal bones. * V. Amputation through the tarsus, so as to remove the navicular and cuboid bones, with all the parts in front of them, is commonly called Cho- part's operation. In the first place, the articulation of the cuboid with the os calcis (which lies about midway between the external malleolus and the tuberosity of the fifth metatarsal bone), and that of the navicular with the Fie;. 420. [Stump after removal of the parts, in Hey'* operation.] AMPUTATION AT THE ANKLE-JOINT. 651 astragalus (which will be found just behind the prominence of the navicular bone in front of the inner ankle), must be sought for; and a semilunar in- cision be made from one to the other, as in the last-described operation. Fig. 421. [Chopart's operation, through the tarsus.] The flap of skin being turned back, the internal and dorsal ligaments that connect the navicular to the astragalus are to be divided with the point of the bistoury, recollecting the convex shape of the head of the latter bone. The ligaments connecting the os calcis and cuboid are next divided, and lastly, a flap is to be procured from the sole of the foot. It may be expe- dient after this operation, to divide the tendo Achillis if the heel is drawn backwards. SECTION XII.—AMPUTATION AT THE ANKLE-JOINT. I. Syme's amputation.—The essence of this operation consists in the removal of the entire foot, and in preserving the integument of the heel as the most natural pad for the stump to rest upon. The incisions employed Fig. 422. Fig. 423. [Fig. 422. Incisions for removing the foot at the ankle (Syme's operation).] [Fig. 423. Flap after removal of the os calcis, in Syme's operation.] are different in the hands of various surgeons. But that generally adopted is represented in Fig. 422. The knife is carried round down to the bone. 652 STUMPS. The ankle-joint is laid open in front, and its lateral ligaments divided. The os calcis is then dissected out, in which process, which is not easy, the knife should be kept close to the bone, so as not to wound the plantar arteries if possible. The malleoli are cut off smoothly, and if there is any disease of the ankle-joint, a thin layer of the end of the tibia should be removed; the posterior flap is then brought forward and retained by suture. The skin of the heel is rather liable to slough, and hence many surgeons make the incision more oblique, so as to preserve more skin from the dorsum of the foot, and less from the sole. II. Pirigoff's amputation is theoretically more perfect than Syme's, inasmuch as it is easier to perform, leaves a longer stump better adapted to bear pressure; and does not disturb the tendo Achillis, nor, generally speaking, cause so much injury—nor is there the hollow flap. Instead of dissecting out the entire os calcis, the surgeon removes the anterior part of the bone, which supports the astragalus, and leaves the heel process. M. Pirigoff began his first incision1 close in front of the outer malleolus, and carried it straight down to, and transversely across the sole of the foot, then obliquely upwards and forwards to the front of the inner malleolus. It divides everything down to the bone ; and the incision is brought obliquely forwards on the inner side, in order not to cut the posterior tibial artery before its division into its plantar branches. The ends of this incision are connected by a second semilunar one across it into the ankle-joint, which is to be held with the foot extended. When the front of the joint is thus laid open, the lateral ligaments are divided ; and then the posterior part of the capsule. Now with a narrow saw (such as Butcher's, p. 635) the os calcis is sawn through, from behind forwards and downwards. Then the malleoli are separated from the anterior flap, and sawn off, and a thin slice of the tibia if diseased. Lastly, the cut surface of the os calcis is brought into contact with the tibia; and the wound united with sutures. SECTION XIII.—AFFECTIONS OF STUMPS. I. It sometimes happens that the flesh shrinks away from the end of the bone, which becomes white and dry, and finally exfoliates. The nitric acid lotion is the best application. II. Protrusion of the bone is a very awkward circumstance. It not only greatly retards the healing of the stump, but produces a cicatrix which is thin, red, constantly liable to ulcerate, and unable to bear the least pres- sure or friction. The cause of the conical stump, as it is technically called, is generally a want of skin and muscle sufficient to cover the end of the bone. Sometimes, however, it arises from spasmodic reaction of the muscles, espe- cially if they have not been properly supported by bandages during the cure The remedy is simple ; the bone must be shortened. This may be done in slight cases by making a longitudinal incision over the bone on the side opposite the vessels, and sawing off a sufficient portion of it, removing at the same time any diseased portion of the cicatrix. But if the projection is con- siderable the entire end of the stump must be amputated. III. Neuralgia of the stump is another very untoward event. It some- times arises because the truncated extremities of the nerves (which after amputation always swell and become bulbous) adhere to the cicatrix, so as to be subject to constant compression and tension. Sometimes, however, it is entirely independent of any morbid state of the extremities of the nerves, but arises from some irritation in their course, or from some irritation, > See a very good account of this operation by Mr. Spencer "Wells, Med. Times, 20th March, 1858. EXCISION of bones and joints. 653 centric or eccentric, of the spinal cord. Sometimes, again, no local cause whatever is detectable ; and the pain is evidently connected with an hys- terical state of the system. In any case the symptoms are extreme irrita- bility and tenderness, paroxysms of violent neuralgic pain, and spasms and twitchings of the muscles, which not unfrequently retract, and cause the bone to protrude, and the stump to become conical. Treatment—1. Painting with tincture of aconite, or Scott's ointment, F. 160, spread on lint, and worn as a plaster; or the emplastrum saponis or plumbi, combined with a little belladonna or opium; tonics and aperients, together with change of air, sometimes suffice to remove the extreme sensi- tiveness of these as well as of other irregular cicatrices. 2. If the pain and tenderness are referred to one or two nerves only, their bulbous extremities should be cut down upon and removed. 3. If, however, the whole surface of the stump is implicated, or if the stump is conical, a second amputation may be resorted to. CHAPTER VII. EXCISION of bones and-joints. I. Excision of Bones.—We have already stated that bone when dead must be removed by operation, because nature seems not only to have pro- vided no means of absorption, but the process of repair envelops the dead portion in a sheath of new bone that renders mechanical extrusion most improbable. We also intimated that bone when infiltrated with unhealthy lymph, and softened or carious, has but slow power of recovery, and that extirpation of the diseased part is advisable. Bone may also be invaded by cancer or other tumors, which render removal necessary. Accordingly there are very few bones in the body which have not been removed wholly or in part. Operations for this end are usually exceedingly difficult and laborious, and are anything but attractive to the lookers-on. When the existence of a tumor, or of diseased or dead bone is ascertained, and its extent explored by probes, if there are sinuses which admit of it, a sufficient incision is made through the thickened parts; and it must be made where the bone is nearest the surface, and where important vessels and nerves are not in the way. Then if there is a shell of new bone it must be bored with trephines, or cut with forceps, or chisel, or gouge; and when the diseased part is exposed, it must be removed as it best may. In cutting it out from any adherent tissues, the knife must be kept close to it. Of the removal of portions of the cranium, and of the upper and lower jaw, we have already spoken. The clavicle has been extirpated by Mr. Travers for a tumor; by Mr. Davie because it pressed on the trachea. (See pp. 221, 281.) The scapula was extirpated by Mr. W. Fergusson from a patient who had previously suffered amputation at the shoulder- joint : it has also been frequently extirpated alone for tumors. It is laid bare by a h incision; the acromion sawn through, the levator anguli, tra- pezius," and serratus divided, the mass lifted, the neck of the bone sawn, and the deltoid and remaining muscles divided. The sternum is occasionally perforated, and removed piecemeal. The ribs, when carious, present no difficulty. The pleura is usually thickened, except in the case of tumors. Portions of the ossa innominata have been taken away. The coccyx may require to be cut out for disease, or for neuralgia ; and for the latter malady 654 excision of joints. Fig. 424. it is sometimes necessary to make a subcutaneous incision, so as to isolate the bone from all the surrounding tissues. Portions of each of the long bones are removed from time to time. Mr. Jones, of Jersey, has removed the entire ulna; the whole or greater portion of the fibula and radius, and considerable portions of the femur and tibia have also been taken away, in cases in which otherwise amputation would have been the only resource. II. In like manner, in cases in which joints are hopelesssly diseased, modern surgeons have substituted the cutting out the portions of diseased bone, for the cutting off the whole limb ; and the results have been encouraging. It seems to be established, that excision is, on the whole, safer than amputa- tion ; less violence is done to the body, fewer great arteries and nerves are injured, and, what is of more consequence, fewer large veins are divided, and as the articular end of the bone only is sawn off, and the medullary canal not touched, there is less chance of pyaemia. Lastly, the patient is left with an imperfect limb, it is true, but with one which, in most cases, is highly useful. What we say of excision for disease, applies with double force to excision for injury.1 III. The elbow-joint is one, the excision of which has been now for some years an established rule. The operation is performed thus. The patient is on his back chloroformed, and the arm held out in a prone posture by two assistants, one of whom holds the upper arm, the other the forearm. An incision through skin and subjacent textures is then made on the ulnar side of the dorsum of the joint; its centre about the level of the olecranon; its length from two to four inches ; and it should be so planned as not to go into the groove where the ulnar nerve lies. A second in- cision, parallel to this, is made on the radial side, and a third transversely, severing the triceps from the ole- cranon. The ulnar nerve is gently drawn inwards and protected, the lateral ligaments severed, the elbow forcibly bent, so as to turn out the ends of the bones. The olecranon may now be cut off with forceps, and then it will be seen clearly what other portions of bone are denuded, softened, or necrosed, and they may be cut off with forceps or saw. Mr. Fergusson's Lion Forceps, p. 418, will be of great service in steadying the extremity of bone which is being removed. As much as is necessary, and no more, of the brachialis must be cleared from the coronoid process The lower end of the humerus is next dealt with ; if it requires to be cleared from the soft parts in front, the knife must be kept close to the bone ; then as much as neces- sary, and no more, may be cut off. Arteries are now to be tied, and so soon as bleeding has ceased, the wound is to be brought together by sutures, and the arm laid in a half-bent posture either on an angular splint, well padded and covered with oiled silk, to which it is to be 1 A grenadier before Sebastopol received a wound in the popliteal space. All that was to be seen was a small orifice with inverted edges. On introducing the finger, the direction of the wound was found to be immediately forwards; pain was felt in the inner side of the head of the tibia, the joint was half bent, and could scarcely be moved. Hence it was presumed that the ball had lodged in the joint. On the third day ampu- tation was performed. The ball was found impacted in the semilunar cartilage over the inner head of the tibia. On the third day after the amputation, secondary hemorrhage from the femoral artery came on, and the patient quickly died. Dr. M'Cowan, who reports the case, says, very justly, that if excision had been performed as he himself had intended, at all events the immediate cause of the patient's death would have been avoided.—Medical Times and Gaz., March 1, 1856. , [Excision of the elbow.] excision of the wrist-joint. 655 properly secured by bandages; or Mr. Butcher's box, with movable sides, may be used ; or Mr. Christopher Heath's splint, which secures, in the greatest perfection, the advantages of entire rest; the power of keeping the limb of any desired length, by means of the screws; the power of bending it to any angle by means of the central hinge ; and the convenience of dress- ing the wound without disturbance. The cut explains itself.1 Fig. 425. [Heath's splint, in the excision of the elbow.] When the reparative stage has fairly set in, the joint should be moved from time to time to insure the formation of a flexible uniting medium or false joint. There are many varieties in the plan of the incision and the after steps of the operation which will readily suggest themselves. For instance, the in- cision may be one perpendicular one six inches or so in length—which is theoretically the best—or may be like X or h-, or a simple curved flap from side to side ; or beginning with a single | the surgeon may enlarge it to \- or H as he sees occasion. Gouge forceps may be of service in these and other like operations. IV. The shoulder-joint may be exposed by making a perpendicular incision through the deltoid, three or four inches downwards from the acro- mion ; and another from the extremity of the first incision upwards and backwards to the posterior border of the deltoid. The triangular flap thus formed, is reflected upwards and backwards; the joint is laid open; the capsular tendons divided ; the head of the humerus turned out and sawn off; and the glenoid cavity of the scapula, if diseased, may be removed by the bone-nippers or gouge. But as this operation is most frequently re- quired in cases of gunshot wound, the surgeon may vary his incisions, according to the extent and situation of the wound ; and may make them of a V or T shape, or may make a simple curved flap, by cutting from near the coracoid process to an inch behind and below the root of the acromion. V. Excision of the wrist-joint.—This is an excision which has always been considered one of the least promising, because of the excessive com- plexity of the joints surrounding the diseased bones. Yet the surgeon will always do wisely to make every effort to preserve any part of the hand ; for the removal of diseased parts cannot make the patient's case much worse, and there is always amputation as a last resource. The incisions and other steps of the operation must be various in almost every case, according to the place and extent of the disease, whether, for example, the ends of the radius and ulna, or the carpal bones only are diseased : no precise rules, therefore, can be laid down. But the general principles should be those which guided Mr. Butcher, of Dublin, during that operation on the carpus which is deservedly called by his name.9 In this case the wrist-joint was excessively swollen, with numer- 1 See Mr. Heath's paper, Lancet, 28th Nov. 1857. t On Excision of the Elbow and Wrist-Joints, and the Preservative Surgery of the 656 EXCISION OF THE HIP-JOINT. ous discharging sinuses around ; the radio-carpal articulation grated on motion; a probe introduced into almost any sinus came in contact with roughened, crumbling, and broken-down bone ; but the metacarpal bones and phalanges, the flexors of the fingers, and all the powers of the thumb were unimpaired. Having determined on operating, the first step was to make a curved incision, beginning a little below the wrist, two lines on the ulnar side of the extensor secundi internodii pollicis tendon, going down close to the carpal extremity of the metacarpal bones, and then sweeping upwards so as to finish below the end of the ulna fully half an inch higher than the point where it began. "The flap thus marked out," says Air. Butcher, " was rapidly dissected up, and consisted of the integuments, areo- lar tissue, and extensor tendons of the four fingers, together with large deposits of fibrine." By the elevation of these soft parts en masse the diseased bones were at once brought into view. In the next place, the soft parts were cautiously separated from the ends of the ulna and radius, in- cluding the second extensor tendon of the thumb which was detached from its groove in the radius. Then the few ligamentous shreds which bound the diseased bones together were severed ; their carious ends were made to project by bending down the hand ; the soft parts in front were sufficiently detached by a few cautious touches with the knife, which was kept close to the bones so as not to injure the radial or ulnar artery ; after this the ends of the bones were easily removed by Mr. Butcher's saw. Then the diseased carpal bones were dissected out, except the trapezium, which was sound; some of the thickened soft parts were cut away, the flaps laid down and secured, and the hand and arm put upon a padded splint in the prone po- sition. The advantage of Mr. Butcher's mode of operating is, that it leaves the extensor muscles of the thumb intact; so that although the fingers will be of necessity stiffened in a bent position, yet with the aid of the thumb they will be available for writing and many other purposes. In a recent paper he gives a specimen of the writing executed by a sightly and useful hand, which would formerly have been amputated. Other modes of operating, consist of longitudinal incisions on one or both sides of the wrist-joint; or of incisions on the dorsal and palmar aspects so planned as to go between the tendons without dividing them. No two cases are exactly alike. But the principles which should guide the surgeon are to take away nothing that can safely be left, and to leave the soft parts of thumb and finger, even if obliged to cut out joints or portions of bones. It is useful also to bear in mind the fact which Mr. Butcher has pointed out, of the independence of the muscles of the thumb from those of the fingers, so that either set may be liopelessly injured by disease, leaving the other almost unaffected. VI. Excision of the hip-joint.—We have spoken in a former page of the removal of the carious head of the thigh-bone after it has become dislo- cated by disease. Now for a few words on the much more formidable opera- tion which has been performed in cases of injury. When the head or neck of the femur has been broken by a musket ball, the patient may be seen, says Mr. Guthrie, lying in bed, with a small hole in front or at the back of the thigh, with no bleeding, and no pain, and nothing but inability to move the limb and to stand upon it; and yet thi.-1 man will die inevitably after a few weeks of pain and suffering, unless his thigh be amputated at the hip, or unless the splintered bones be cut out. Mr. Guthrie, in the Addenda to his Commentaries, tells us that this opera- Hand, by Richard G. H. Butcher, Esq., Surgeon to Mercer's Hospital, &c, Dublin, 1855. Also Reports in Operative Surgery, 3d Series, Dublin Quarterly Journ. Med. Sc, Feb. 1859. EXCISION OF THE KNEE-JOINT. 657 tion was performed at least six times before Sebastopol, in 1855, and although not one of the patients survived, yet there were plenty of causes besides the operation to account for their death. Mr. Blenkins, Mr. O'Leary, Mr. Crerar, Dr. Hyde, and Dr. MacAndrew were the operators. The surgeon may, according to circumstance, make a long, straight inci- sion down the outer side of the limb, beginning a little below the anterior superior spine of the ilium, and going down over the trochanter. The at- tachments of muscles having been severed from the trochanter, the bone is turned out of the wound by raising it at the knee, the shattered parts are sawn off, and the neck and head of the bone, if necessary, dissected out of the aceta [Fig. 426. Fig. 427.' Course of the incision in excision of the hip-joint.] bulum. Or, the incision, as recommended by Mr. Guthrie, may be in the shape of a semilunar flap, beginning just over the inner edge of the tensor vaginae femoris muscle, and curving downwards and outwards, so as to cross the bone at least an inch below the trochanter, whence it should turn upwards to the extent of about three inches. This flap, including skin, fascia lata, tensor vaginse femoris, and part of the glutseus maximus, should be turned up, the muscles attached to the injured parts be divided, and the remaining steps of the operation be as be- fore. As Mr. Guthrie observes, it will be pos- sible, if the surgeon finds it desirable, on closer view of the injured parts, to convert this opera- tion into that of amputation at the hip-joint. VII. Excision of the knee-joint was first performed in 1762 by Mr. Filken, of Xorthwich, in Cheshire ; it was subsequently performed twice by Mr. Park, of Liverpool, twice by Sir Philip Crampton, and twice by Mr. Syme. One of Mr. Park's Cases Was [Appearance of a patient, after exci- eniinently successful, so was one of Cramp- Si0n of the knee.] ' The above drawing represents a patient of Mr. Price's, a young woman set. 26 whose left knee was excised in October, 1856. The patella was retained ; but was cut out after a vear, because abscesses continued to form around it. Ihe limb sajs Mr i'lice, August, 1859, "is most serviceable, and the girl in active employment. 42 658 EXCISION OF THE KNEE-JOINT. ton's. Park's patient, who was a sailor, was able to go aloft and perform the usual duties of his calling. Altogether, there are records of 19 cases performed by British aud conti- nental surgeons up to the year 1830. Of these 19 there were only about 8 Fig. 428.l Fig. 429. [Appearance of a patient, after excision of the knee, the disease not arrested.] recoveries; the remaining 11 died, but not from the operation.3 From 1830 to 1850 the operation was in abeyance, and almost universally condemned by teachers of surgery, until, in the latter year, it was revived by Mr. W. Fergusson, a revival which is one of the greatest tri- umphs of modern surgery. Next to Mr. Fergusson, Mr. Jones, of Jersey, whose suc- cess in all departments of operative surgery would be called remarkable, were they not the natural results of great acuteness and energy ; Mr. Page, of Carlisle ; the late lamented Mackenzie, of Edinburgh, who lost his life in the Crimea; Dr. Pritchard, of Filey ; Mr. Evan Thomas, of Manchester; Dr. Cotton, of Lynn; Mr. Holt and Mr. Henry Smith, are entitled to the credit of having early performed this operation with success. Dr. Murray Humphrey, of Cambridge, and Mr. Butcher, of. Dublin, have also been frequent and successful operators. The cases in which it ought to be performed are, generally speaking, such cases of injury or disease as would otherwise be submitted to amputation in order to save the patient's life, or enable him to enjoy it. The object of the operation is to produce a firm and useful limb, slightly 1 This represents a boy, aged 9, whose knee was cut out by Mr. Price, July 20th, 1856 : for a time he did well, but never had good use of the limb, which at the end of two years and three months presented the appearance shown above. The limb was then amputated, and he recovered. After the amputation, the ends of the bones which had suffered excision were macerated and are represented in the next cut. Evidently the causes of failure were the intensely strumous diathesis, the softened and unhealthy state of the bones, and the formation of numerous abscesses in the soft parts, which had been the seat of disease for four years before the excision. See Lancet, Nov. 27th, ISfjS. 2 Vide S. Cooper's Surgical Diet. art. Joints. [Condition of the bones, as found at the autopsy of the above-mentioned patient.] EXCISION OF TnE KNEE-JOINT, 659 shortened, and with entire bony anchylosis, or fibrous union admitting of some small degree of motion at the situation of the joint. But all cases are not suitable for excision. And those cases are unsuit- able, and better adapted for amputation, in which either the quantity of dis- eased bone requiring removal is very great—for then the case will probably not do well—or if it proceed to recovery, and the patient be young, the future growth of the limb may be prevented ; or the quality of the disease may be such as experience has shown to be incompatible with the exudation of healthy material of repair. This last is a point which has been very clearly stated by Mr. Price.1 If the " white swelling" has begun with disease of the synovial membrane (see pp. 265, 270), or so-called ulceration of cartilage, the diseased joint surfaces may be cut off, and the case will do well; or if there be scrofulous exuda- tion into the bone structure, and it be in one or more circumscribed masses,' bounded by a layer of lymph and healthy bone, these masses, when laid bare by the section of the bone, may be gouged out, as a dentist would deal with a carious tooth, and if sound bone be left the case will do well. Not so, if, as Mr. Price remarks, the scrofulous exudation be diffused throughout the cancellous tissue ; if the whole area of the bone be enlarged and softened, with its cancelli filled with strumous deposit, and its perios- teum thickened and separating. In such a case, the whole disease can scarcely be removed, and diseased bone is left, incapable of healthy exuda- tion. Low inflammation, repeated abscesses, and fresh operations to remove carious or necrosed fragments will be the almost certain result, and if the patient do not die of exhaustion or pyaemia, he must go through amputa- tion at least. Here it may be observed, that since there are no absolute diagnostic marks of the various forms and degrees of joint disease, it may happen that the surgeon must sometimes come to a final decision after he has laid the joint open, and has removed a slice of bone. This point is clearly laid down by Mr. Butcher.2 The patient, whilst under chloroform, suffers no prolonged shock; and if the bones are found extensively diseased, amputation should be performed at once. Mr. Fergusson has done this ; and Mr. Hutchinson, a surgeon no less remarkable for his own successful operations, than for his zeal in collecting accurate statistics. In operating on a case which appeared to be suitable for excision, he found the cartilage gone, the joint surfaces carious, deep ulcers excavated in the patella and tibia, the cancellous struc- ture of the femur infiltrated with yellow matter, and containing an ill-cir- cumscribed abscess; and a second slice revealed no better state of things. Amputation, therefore, was immediately performed. The patient had lost nothing by the attempt to save his limb ; and Pedantry only, complaining of such as "disturb her ancient melancholy reign," could object to the proceeding. The operation consists, first, of one or more incisions for laying bare the joint. Mr. Fergusson makes an H incision in front of the joint; the lateral lines about four inches long ; the cross cut running below the patella. The lateral should, as Mr. Butcher says, be placed far enough back to allow the discharge to run out freely, and prevent pouching of matter in the ham. Other surgeons have made a single semicircular flap, running below the pa- tella, with upward extensions at its ends. The next point is to raise the flap, including the patella, bend the joint, 1 Contributions to the Surgery of Diseased Joints, with especial reference to the Ope- ration of Excision. No. 1. The Knee. By P. C. Price, Surgeon to the Great Northern Hospital, &c. &c, London, 1859. . 2 Second Memoir on Excision of the Knee-Joint. Dublin Quart. Journ. Med. Science, Feb. 1857. 660 EXCISION OF THE KNEE-JOINT. sever the lateral ligaments, very cautiously lay bare the popliteal surface of the femur, and cut off the articular surface. Here Butcher's saw will be useful, cutting from behind forwards. The cut should be parallel with the natural surface of the condyles, and all obliquity should be avoided, so that the sawn surfaces of bone may rest flat and evenly against one another. Then any carious spots must be gouged out, or, if need be, another slice removed ; and now, too, the surgeon may convert his operation into an am- putation if the state of the bone seems irreparable. The tibia is then treated likewise. The patella, if healthy, may have its cartilage pared off; if ulcerated a little, the diseased surface may be cut out: if thoroughly soft and strumous, or even if doubtful, it should be re- moved. Perhaps it is the best plan always to do so. Then all diseased synovial membrane, and all thickened and infiltrated areolar tissue, should 'be trimmed off, so that the tissues which remain, both hard and soft, may be as healthy as possible. This is one of the points on which success depends. The next thing is to tie vessels and remove clots. The next, to bring the limb into a straight position; which is to be accom- plished by extension, under chloroform, from the foot, whilst the thigh is held steadily; and as this may be a matter of some difficulty, it may, as Mr. Butcher observes, be facilitated by division of the biceps and other ham- string tendons. This will insure greater freedom from displacement and spasmodic jerking. The cut surfaces of bone should be accurately adapted to each other; and here Mr. Butcher gives the caution to let no soft tissue be allowed to intrude between them. The edges of the flaps are brought together with sutures, and covered with lint or cotton. In the next place the limb must be put up ; and it is upon the details of this, and of the after-treatment, that the patient's safety will mainly depend. The wounded surfaces of bone must be in apposition, and at absolute rest; all possibility must be excluded of their slipping, starting, grating, jerking, or grinding against each other, or of the femur projecting. If they do, the exudation of repair must of necessity be destroyed and decomposed; and fetid suppuration, and possibly purulent absorption, or caries, will result. It is universally agreed that the limb should be put up on the operating table before removal to bed. The leg should be nicely bandaged, and the hollows above the ankle padded. The engraving will show the solid look Fig. 430. [Butcher's box, after excision of the knee.] of a limb, after this operation, done up in the box employed by Mr. Butcher. It is well padded with horsehair; the sides can be let down by hinges, so as to give access to the wound : in other respects the cut explains itself.1 Mr. Price, who, with Mr. Parkinson and Mr. Heath, had great-opportu- nities of perfecting the details of treatment in Mr. Fergusson's cases in the King's College Hospital, before he executed his own operations, uses a Mclntyre's splint, of thin tinned iron, with a footboard. The length can 1 Case of Excision, Dublin Quarterly, Nov. 1857. EXCISION OF THE KNEE-JOINT. 661 be regulated. The portion corresponding to the popliteal space is slightly convex upwards, so as to keep the bones in their place ; and is narrow, so that the wound can be got at. There is an interval between the leg plate Fig. 431. [Apparatus used by Mr. Price after excision of the knee.] and footboard, in order that nothing may press on the heel or tendo Achillis. The foot and leg are confined by rollers to this splint, previously well pad- ded with wool covered with oiled silk; and with additional pads of the same, where needed, especially behind the head of the tibia. A short splint should be laid on the front of the thigh, and compressed by a web and buckle. Then on the outside of this apparatus is used a long side splint, the central part of which is replaced by an iron hoop. It passes up the side, and is provided with a perineal band, as usual (p. 248). Lastly, the whole limb, so put up, may be swung in Salter's apparatus, as represented in the follow- ing drawing made from the life by Dr. Westmacott, from a patient of Mr. Price's in the Great Northern Hospital. The wounded part is uncovered, and the side splint removed, and part of the swing undone to show it. The practical fact is, that the dressings had been duly attended to, that the limb had never been disturbed since the operation, and was convalescent in the fifth week. The drawing shows a small pad placed on the femur, to keep the end of it from tilting forwards. During the first few hours, the patient, as after every other operation, should be watched by a surgeon, to guard against shock, vomiting, spasm, Fig. 432. [Cut showing an excised knee, swung in Salter's apparatus.] and hemorrhage. The end aimed at in the operation has been described ; the time which is required to produce it is uncertain; but after five or six 662 EXCISION OF THE KNEE-JOINT. weeks the limb may often be lifted, and the patient go on crutches, with the firm confidence that after some months he will have a strong and useful limb, adequate for any active employment. To complain of the time required to rescue a patient from mutilation, and give him a useful leg, is absurd. Numerical Results.—From the revival in 1850 to December 1854, 31 cases had been collected by Mr. Butcher: from that time to December, 1S5(5, when he published his second memoir, 51 additional cases; altogether 82; by the end of December, 1858, Mr. Price had collected 79 besides, making 160 in all. Of the 160, 32, or 20 per cent., died ; of whom eight died of pyaemia, and one of erysipelas; these are hospital causes. Exhaustion, irritation, and shock, destroyed 15 : acute phthisis, peritonitis, pneumonia, suppression of urine, and dysentery each destroyed one ; one died after am- putation ; two from unknown causes. In 18 cases, one of which was fatal, amputation was obliged to be re- sorted to, for non-union, abscess, and hectic. In at least 50 per cent, the operation resulted in a good useful limb. It must be added, that during the first six months of 1859, Mr, Price has collected particulars of 24 cases; out of which four died from the opera- tion," and six required amputation, and of these three died; whilst only 14 were cured by the operation ; but it is premature to speak of the whole of them. This would increase the average mortality—taking the whole 184 cases—to 21.2 per cent. But the mortality is not equal to that of amputa- tion of the thigh ; and much of the mortality, and the necessity for amputa- tion depend upon causes which surgeons in time will think it a disgrace to let patients suffer from, especially hospital air. [In a recent publication of Mr. Price, we find that out of 160 cases of excision of the knee, collected from all British sources, both metropolitan and provincial, 32 died, or 1 in 5, giving a mortality of 20 per cent. Mi- Bryant states that out of 167 cases of pathological amputation of the thigh, performed at Guy's Hospital, 1 in 5^ were fatal, giving a mortality of 18 per cent. It should be added, moreover, that in amputations of the thigh for chronic disease of the hip-joint, or those in which excision of the knee might be thought of, as a substitute for amputation, only 1 case out of 7 proved fatal, giving a mortality of about 14 per cent. It must be taken into account, also, that all of these amputations were performed in a large city hospital, where the mortality after operations is notoriously greater than elsewhere; while many of the excisions recorded in the statistical tables of Mr. Price were performed out of London, under decidedly better sanitary conditions. So far, therefore, as we are at present able to decide from ex- perience, excision of the knee must be considered as more fatal than ampu- tation of the thigh. The fact, moreover, must not be lost sight of, that in 17 of the cases marked by Mr. Price as recoveries from excision, amputation became afterwards necessary. Of course in choosing between these two operations the surgeon must be mainly influenced by their relative safety; but there is another considera- tion which is by no means to be lost sight of, and that is the ultimate condi- tion, so to speak, of the patients to be operated upon. As regards the utility of the limb preserved by excision of the knee, there is as yet very little in- formation of importance, in the hands of the profession. What we have been able to learn is almost entirely obtained from a recent publication of Mr. Pemberton, who is, it may be stated, an advocate for the operation.1 In one case, two inches and a half of the femur and an inch of the tibia 1 On excision of the' knee-joint; illustrating the principal complications which are likely to arise after the performance of the operation, and especially the want of sub- sequent growth and development in the limb of young subjects. By Oliver Pembertou. EXCISION OF THE ANKLE-JOINT. 663 were removed by Mr. Pemberton, from a boy, twelve years of age; in the course of eight months all had healed and the boy was walking about with a high-heeled shoe, and a stick, the limb being only three and a half inches shorter than the other. Six years afterwards Mr. Pemberton had an oppor- tunity of examining his patient. He had grown in height and had thickened considerably in figure, but was somewhat diminutive for his age. The lower limbs presented a wonderful contrast in appearance ; the one was strong, with the muscles, bones, and joints, well defined ; the other feeble and blighted. The sound limb from the anterior superior spinous process of the ilium to the outer malleolus measured thirty-four inches ; the one subjected to the operation only twenty-five. There was, therefore, a difference of nine inches, or a deficiency in growth as compared with the other, of more than five inches since the operation. The limb, it is stated, "could not be deemed otherwise than an incumbrance, and with the best appliances to remedy the want of length, proving, after all, little better than a sad deformity." In- formation of a similar kind was obtained by Mr. Pemberton from Dr. Keith. If, therefore, as more extended experience seems to show, excision of the knee is, in all patients, more fatal than amputation of the thigh, and, in young patients, is an operation ultimately productive of disastrous results, it is not worthy of the favorable opinion passed upon it by Mr. Druitt in the present edition of his work.] IX. Excision of the ankle-joint and tarsus.—In disease and injury of the ankle-joint and tarsus, the surgeon should still be guided by the prin- ciples upon which he acts in disease of the wrist; namely, that diseased parts should be extirpated, and that any sound parts that may be even partially useful should be left. The operation in every case must be planned accord- ing to the state of the parts; and in most cases the surgeon will probably content himself with enlarging sinuses, denuding the diseased bones, and scooping them out piecemeal with the gouge, and repeating the operation if necessary until all the carious parts are removed, instead of removing the whole at one coup. The os calcis has been cut out by Mr. Hancock, Mr. Gay, Mr. Page, of Carlisle, and other surgeons. Mr. Page began with an incision down in the bone, from half an inch below the inner ankle, directly under the sole of the foot to the outer ankle ; intending to resort to Syme's operation if the state of things revealed by future dissection should render it necessary. The flap was dissected up from the heel; the tendo Achillis cut at its insertion ; the joint between the os calcis and astragalus opened, the interosseous and other ligaments divided. The incision was then carried forwards along the sole, on each side, and a flap raised from the anterior part of the os calcis, up to its articulation with the cuboid, which was then divided, and the os calcis removed.1 The cuboid bone may be laid bare by a crucial or H incision, and may be gouged out, or separated from its connections by forceps and knife. The os calcis with the cuboid and ends of the tibia and fibula were removed by Mr. Thomas Wakley, in 1847.2 An incision was carried across the sole of the foot from one ankle to the other. A second and third at right angles to this along each side of the sole, so far forwards as the cal- caneocuboid and astragalo-scaphoid joints respectively, so as to enable a flap of the sole about two inches long to be turned forwards. Then a last semicircular incision was made from one ankle to another behind the heel at the level of the insertion of the tendo'Achillis, which was cut through. The 1 Lancet, 1850, vol. i., p. 6'2S. 2 See report and drawings in Lancet, 1S4S, vol. ii. p. 5. ; also in Guthrie's Commen- taries. 664 excision of the ankle-joint. flap made by this last incision was raised, and the os calcis disarticulated from the astragalus and cuboid, and removed together with the integument covering it which was included between the incisions. Then the astragalus was detached from the tibia and fibula, with great care not to wound the anterior tibial artery. The astragalus was next detached from the scaphoid, and the malleoli were removed with forceps. The posterior tibial artery was tied. The patient recovered, with a fair use of the foot. APPENDIX OF FORMULA. § I. Tonics. F. 1. Cinchona with Acid. ty. Acidi sulphurici diluti Vt\v.—xv.; syrupi aurantii f^ss.; infusi cascarilloe (vel decocti cinchonae), f'3x. Misce, fiat haustus, ter die sumendus, ante cibum. For Children. R_. Decocti cinchonae lancifolise f^iijss.; syrupi zinziberis f§ss. acidi sulphurici diluti m_xxx. Misce, sumatur pars quarta ter die. 2. Quinine Draught with Ammonia. R.. Quinse disulphatis gr. ij.; tincturae opii TTl^ij.—v.; spiritus setheris compositi, spiritus ammoniae aromatici, aa f^ss. ; decocti cinchonae f^x. Misce, fiat haustus, ter vel quater die sumendus. In cases of great Debility, with Restlessness or low Delirium. 3. Quinine Draughts with Acid. R.. Quinse disulphatis gr. ij.; acidi sulphurici diluti n\\.—xv.; tincturae aurantii, syrupi ejusdem, aa f3ss. ; aquae f§jss. Misce, fiat haustus, ter die sumendus. R:. Quinse disulphatis gr. ij.; acidi hydrochlorici Tt\,x.; camphorae gr. ij.; spiritus aetheris nitrici f3J-; tincturae cardamomi compositae f'3j-; aquae menthae viridis fgx. Misce, fiat haustus, sexta, quaque hora sumendus. A powerful stimulant and tonic. 4. Liquor Cinchonae. R.. Liquoris cinchonae flavae Battley tt\xx.; aquae pimentae fgj. Misce, fiat haustus quater die sumendus. In atonic erysipelatous diseases.—A prescription of Dr. Farre's. One fluid drachm of Battley's solution is said to be equal to an ounce of the finest bark. The Pharmacopoeial infusum cinchonae spissatum is probably as good. 5. Bark with Ammonia. R.. Decocti cinchonae flavae fgviiss. ; ammoniae sesquicarbonatis :jss.; syrupi zinziberis f^ss. Misce. Dosis, pars sexta, bis vel ter die. 6. Bark with Liquor Potassas. R. Decocti cinchonae flavae f J viiss.; liquoris potassae f^U-; tincturae cinchonae com- positae f3ij. Misce. Dosis, pars sexta, bis vel ter die. 7. Bark with Guaiacum. R.. Tincturae guaiaci ammoniatse, tincturae humuli, aa fjss.; decocti cinchonae lanci- folise f§ij. Misce, fiat haustus, ter die sumendus. In chronic rheumatism, chronic rheu- matic sclerotitis, tincturae cardamomi compo- sitae, syrupi, singulorum f^iii. Aquae f§vi. Misce. Dosis, pars sexta ter die. In de- bility, with acidity and flatulence. 12. Citrate of Iron for Children. R.. Syrupi ferri citratis (Bullock) fluidrachmas duas; aquse destillatae fSjiij. Misce. DosiS, f§ss. ter die. 13. Chalybeate Mixtures. R.. Tincturae ferri sesquichloridi f^ij.; syrupi zinziberis §j.; aquae f^vij. Misce. Sumantur cochlearia duo magna bis die. R.. Liquoris ferri acetatis (Pharm. Dub.) fluidrachmam; aquae pimentae fluiduncias sex. Sumat aeger partem sextam ter die. 14. Steel and Acid Mixture. R.. Ferri sulphatis gr. xij.; acidi sulphurici diluti fjj.; tincturae cardamomi compo- sitae f5ss.; infusi rosae compositi fjvss. Misce, sumantur cochlearia duo magna bis ' vel ter die. 15. Steel, Ammonia, and Quassia. R. Infusi quassiae f^ss.; tincturse ferri ammoniati fgss.; ammoniae sesquicarbonatis gr. vj. ; syrupi aurantii f3j-; aquae destillatae f'3vij- Misce, fiat haustus, bis vel ter quotidie sumendus. For hysterical women. (Brodie.) 16. Sulphate of Iron for Children. R:. Ferri sulphatis gr. iii.; acidi sulphurici diluti tt\xij.; syrupi zinziberis fjiij.; aquoe florum aurantii f3iij.; aquae destillatae fgijss. Misce. Dosis, f^ss. ter die. 17. Syrup of Iodide of Iron (Pharm. Lond.) R. Syrupi ferri iodidi f^j. ; sumat aeger guttas xx.—xl., bis die, e cyatho aquae, vel infusi zinziberis. Iodide of Iron, with Sarsaparilla. R.. Syrupi ferri iodidi, syrupi sarsae, aa f^j. Misce. Sumat seger cochleare parvum bi6 quotidie ex aqua. (Dr. Ferguson.) 18. Mistura Ferri Aromatica, or Heberden's Ink. R.. Corticis cinchonae lancifoliae contusi ^j. ; caryopbyllorum contusorum 3ij.; ferri ramentorum §ss.; aquae menthse piperitae f§xv.; macera per dies tres in vase clauso, subinde agitans, dein cola, et adde tincturae cardamomi compositse f3;iij ; tincturae au- rantii f^iij. Dosis, f§j.—iij. bis vel ter die. A most agreeable aromatic tonic. The Dub- lin Pharmacopoeia, from which this formula is taken, orders Jjiij. of sliced calumba root with the bark: but the preparation is less nauseous without it. APPENDIX OF FORMULAE. 667 19. Griffith's Mixture. R.. Myrrhae contritae 3J ; potassae carbonatis gss.; aquae f^vss.; ferri sulphatis gr. xii.; ppiritus myristicae l§ss.; sncchari giv. First dissolve the sulphate in two ounces of water, and put it into the bottle; then rub the other ingredients smoothly together, and add them. Dose, l§j.—iss. thrice daily. The original prescription is to be seen in Dr. Moses Griffith's Practical Treatise on Hectic Fevers and Pulmonary Consumption, written at Colchester, 1776. New Ed. Lond 1795. Dr. Griffith frequently varied the proportion of the ingredients, and sometimes added tincture of bark, nitre, $c. 20. Steel with Aloes. R.. Misturae ferri compositae, decocti aloes compositi, partes equales. Dosis, f^j. ter die. In chlorosis, constipation with debility, §c. R.. Extracti aloes purificati gr. vj.; ferri sulphatis gr. xij.; extracti glycyrrhizae gr. xij. Misce et divide in pilulas xij.; quarum sumatur una bis die, ante cibum. 21. Nux Vomica and Strychnia. R.. Tincturae nucis vomicae (Pharm. Dub.) fgj. ; acidi nitromuriatici diluti f3\j.; tinc- turae zinziberis f^ij.; syrupi f3iij. ; aquae fgvss. Misce. Dosis, pars sexta ter die. In any form of functional paralysis after all known causes are remedied. In obstinate debility, diabetes insipidus, alkaliHe urine, #c. R.. Extracti nucis vomicae gr. ij. ; mannae 9j. Misce et divide in pilulas viij.; quarum sumatur una ter die. The extract such as is prepared by Squire is quite as efficacious a medi- cine as strychnia itself, and very much safer. Any mistake in dispensing strychnia might be fatal. The dose may be increased by degrees. 22. Dilute Nitromuriatic Acid. R.. Acidi nitrici fortissimi f^j.; acidi hydrochlorici f^ij. Misce et adde, aquae destil- latae f3xv. Dosis, n\x.—xxx. ex aqua. R.. Acidi nitromuriatici diluti f3ij. ; spiritus aetheris nitrici f^ij.; syrupi f§ Pulveris ipecacuanhae compositi, extracti conii, singulorum 5jj.; misce et divide in pilulas xxiv.; quarum sumantur una vel duae subinde. In painful ulcers, chronic rheu- matism, stricture, §c. (C. Mayo.) R_. Extracti hyoscyarai, extracti conii, extracti papaveris, singulorum ^j. Misce et divide in pilulas xij. In similar cases. 31. Pulvis Sudorificus Salinus. R.. Pulveris ipecacuanhae compositi grana quindecim; potassae nitratis grana quindecim; potassae.bicarbonatis grana quinque. Misce, fiat pulvis, hora, somni sumendus, e cyatho ptisanse.' 32. Compound Opiate Mixtures. R.. Liquoris opii sedativi n\xx.; spiritus ammoniae aromatici, spiritus aetheris nitrici, singulorum»f5iss. ; syrupi fgij.; misturae camphorae f^vss. Misce. Dosis, pars quarta, quartis horis. R.. Morphiae hydrochloratis granum; acidi hydrochlorici diluti guttas duas; aquse fgviiss.; syrupi zinziberis f^ss. Misce. Dosis, pars octava. 1 We offer this as a substitute for the original Puhis Doveri, the lecipe for which Is as follows :— "Take opium an ounce, saltpetre and tartar vitriolated each four ounces, ipecacuanha one ounce, liquorice one ounce. Put the saltpetre and tartar into a red-hot mortar, stirring them with a spoon till they have done naming: then powder them very fine ; then slice in your opium, grind these to a pow- der, and mix the other powders with these. Dose from 40 to 60 or 70 grains in a glass of white wine posset, going to bed ; covering up warm, and drinking a quart or three pints of the posset-drink while sweating." Dr. Dover accounts for the largeness of the dose by saying that the properties of the opium are mitigated by the other ingredients ; but in the present day, four, six, or seven grains of opium would be a dangerous dose, spite of the other ingredients. But if this is a true copy of the recipe, it is very difficult to understand how the saltpetre and vitriolated tartar can flame when heated together. Possibly the cream of tartar was used, and not the sulphate of potass.—See " i'be Ancient Physician a Legacy to his Country," by Thomas Dover, M. B. Fifth edition. 1733. • APPENDIX OF FORMULAE. 669 R.. Syrupi papaveris fgiv.; magnesiae carbonatis gss.; spiritus aetheris nitrici; .tinc- turae hyoscyami, singulorum f3ij.; mistur;e camphoraef^vij. ; Misce. Dosis, pars sexta subinde. To tranquillize the system after injuries, operations, accouchements, hemorrhage, violent mental excitement, $c. (Dr. Gooch.) Mr. Cole's Stimulating Narcotic Draught for Delirium Tremens. R.. Extracti opii (Hill) gr. ij. vel iij.; aquae ferventis fgiv.; tere in mortario et adde brandy fgiss. ; sacchari q. s. Misce. The patient should be allowed to sip this out of a tumbler, like a glass of grog. Cole's Mil. Surg. p. 59. § II. Aperients. 33. Calomel. R.. Calomelanos grana quinque; antimonii tartarizati grani £; fiat pilula. R.. Calomelanos grana quatuor; extracti colocynthidis compositi grana sex; fiant pilulae duae. 34. Black Draught. R. Sennae foliorum 3vj.; zinziberis concisi 3ss.; extracti glycyrrhizae gij.; potassae carbonatis 3ss.; aquae ferventis f|ix. Post horas tres cola, et adde spiritils ammoniae aromatici fgij.; magnesiae sulphatis gj; (vel potassae tartratis §j) tincturae sennae, tinc- turae cardamomi compositae, aa fgss. Dosis f^jss.1 Red Draught. R.. Magnesias sulphatis gij.—iv.; syrupi zinziberis, tincturae cardamomi compositae, singulorum f§j.; infusi rosse compositi f^x. Misce. 35. Haustus Magnesiae Sulphatis Acidus. R. Magnesiae sulphatis gj.—giv.; syrupi aurantii fgij.; acidi sulphurici diluti n\x.; aquae fgj. Misce, fiat haustus. To this draught may be added one grain of sulphate of zinc, or of sulphate of iron, or two grains of quinine, in cases of debility. 36. Haustus Magnesias Albus. R. Magnesiae sulphatis gij.; magnesiae carbonatis 9j.; syrupi zinziberis f3j. ; aquae menthaa viridis f3sj. Misce, fiat haustus. This draught will often be retained by the stomach when almost every other is rejected. 37. Cordial Aperient Draught. R.. Tincturae sennae f§ss.; tincturae rhei fgss. Misce. 38. Rhubarb Draughts and Powders. R Pulveris rhei, semiscrupulum ; sodoe bicarbonatis, scrupulum ; sacchari albi, scru- pulum; olei lavandulae guttas quinque. Misce, fiat pulvis, e cochlearibus duobus aquae sumendus. This is the most perfect combination of rhubarb. The lavender hides its flavor completely. . R Pulveris rhei, bismuthi trisnitratis, confectionis aromaticas. aa £)ij.; aquae mentha? piperitae fgiv. Misce. Sumatur pars quarta bis die. In habitual constipation and flatulence. R Rhei gr. xv.; magnesiae carbonatis 9ss.; spiritus ammoniae aromatici fgss.; syrupi fgj.; aquae anethi f3x. Misce. For cases of colic, diarrhoea, with acidity and indigestion, §c. Rhubarb and Polychrest Salt. (Dr. Willigm Fordyce.) R. Pulveris rhei, potassae sulphatis, aa §j. ; pulveris zinziberis gj. Misce. Dosis gr. x.—xl. A capital aperient for children; serving, in most cases, all the purposes of ,• mercury. ty. Rhei, potassae sulphatis, ail 9J.; spiritus Lavandulae compositi fgj.; aquae fgj. Misce, fiat haustus. A warm efficient purgative. ' This dransrht is greatly improved, both in flavor and efficacy, by the addition of a few caraway seeds, one ounce of buckthorn juice, one of tincture of jalap, and six of moist sugar. 67 0 APPENDIX OF FORMULAE. 39. Saline Aperient Draughts. R. Sodae potassio-tartratis giv.; succi limcnum f3ii.; syrupi zinziberis f3j.; spiritus myristicae f§ss.; aquae f§ij. Misce, fiat haustus. A cooling purgative. R.. Sodae potassio-tartratis 5>j- i sodae sesquicarbonatis £)j.; sacchari albi gj.; fiat pulvis, e cyatho aquae sumendus, cum cochleari magno succi limonis, vel cum acidi citrici granis quindecim. 40. Epsom Salts and Tartar Emetic. R.. Magnesiae sulphatis §j.; antimonii tartarizati gr. j.; aquse menthae f§x. Misce; sumantur cochlearia magna tria, quarta quaque hora. An active nauseating aperient, fit for robust persons threatened with acute inflammation. (Sir A. Cooper.) 41. Saline Aperients with Tonics. R.. Magnesiae sulphatis giv. ; ferri sulphatis gr. viii.; quinse disulphatis gr. xii. acidi sulphurici diluti fgjss.; syrupi zinziberis f^j.; tincturae ejusdem fgij.; aquse f5viij. Misce. Dosis, pars octava bis die. R.. Magnesiae sulphatis 3J-! acidi sulphurici diluti f3J-; ferri sulphatis gr. xv.; infusi gentianae compositae f§iij.; tincturae aurantii f3iv.; infusi rosae i§vj. Misce. Dosis pars sexta bis quotidie. R.. Ferri potassio-tartratis 5y- ; sodae potassio-tartratis §vj. Misce; fiant pulveres sex. Sumatur una mane, ex cyatho aquae. Combinations of .saline purgatives with tonics, so as to answer the double purpose of draining congested abdominal veins, and bracing the sys- tem, are of great efficacy in most chronic complaints. The second of these formulas is a pre- scription of Dr. Jephson's, who is famous for such combinations. 42. Pulvis e quatuor Salibus. R.. Sodii chloridi, sodae sulphatis, magnesiae sulphatis, potass* sulphatis, singulorum partes sequales. Optime misceantur, et desiccentur ante ignum'. Dosis 3j-—iv-> ex cyatho aquse. An agreeable saline aperient. A grain of sulphate of iron may be added to each dose, with sugar or ginger, if agreeable. 43. Hospital House Physic. R.. Magnesiae sulphatis !§ij.; pulveris rhei, jalapse, ila 3j' 5 aquae menthae piperita fgvij. Misce. Dosis, pars sexta. 45. Castor Oil and Turpentine Draught. R.. Olei terebinthinse, olei ricini, aa f5vj- » mucilaginis acaciae fgij.; aquae menthae quantum satis sit ut fiat haustus. 46. Aperient Electuaries. R.. Pulveris potassse supertartratis ^ss.; sulphuris prsecipitati gij.—iv.; confectionis sennae 5j. ; syrupi zinziberis, quantum satis sit. R.. Magnesiae ustae, potassae supertartratis, pulveris rhei, aa 3J- 5 pulveris zinziberis 5ss ; thflriacae, quantum satis est. R. Mannae, confectionis sennae, aa §j.; sulphuris giij.; syrupi quantum satis sit. Dosis gj.—iv., omni nocte hora, somni. 47. Pilulae Catharticae. R.. Aloes ^ss.; pulveris colocynthidis, cambogise, aa 5j»; jalapse gij. ; saponis gj ; antimonii tartarizati 9ss.; olei caryophyllorum Tt^xx.; contunde simul, et divide in pilulas, pondere granorum quinque. • 48. Pilulae Catharticce cum Calomelane. R.. Pilulae praecedentis 3'v.> calomelanos gj. Misce et divide in pilulas Ix. Pilulae Hyper catharticae. R.. Extracti colocynthidis compositi J^ij; olei crotonis guttas duas. Divide in pilulas octo, quarum sumantur duae. For threatened apoplexy, oedema glottidis, $c. APPENDIX OF FORMULA 671 49. Blue Pill and Colocynth. R. Pilulae hydrargyri £)ss. ; extracti colocynthidis compositi 9'jss. Misce, fiant pilulae duodecim. 50. Sulphate of Iron with Aloes. fy. Ferri sulphatis, aloes Barbadensis, aa gij. ; pulveris rhei 3j. Misce, et divide in pilulas lx. Dosis, una vel duae hora somni. An admirable aperient for weak constipated persons. 51. Pilulae Aloes Dilutee. R.. Extracti aquosi aloes Barbadensis, saponis, theriacse, extracti glycyrrhizae, aa gj. Solve leni calore in balneo; dein divide in pilulas xlviij. Dosis, una hora somni. A capital eccoprotic aperient, unloading the colon of scybala, but rather irritating to the rectum. The aloes should be of the best Barbadoes kind, purified by solution in water. The formula is attributed to Dr. Marshall Hall. 52. Ipecacuanha and Rhubarb Pills. R Pulveris ipecacuanhae gr. xxiv. ; pulveris rhei ^iv-', saponis £)ss. Misce et divide in pilulas xxiv.; quarum sumatur una ter die. A gentle aperient in piles and other con- gested conditions of the intestines. R.. Ipecacuanhae gr. vj.; extracti aloes purificati gr. vj.; extracti rhei gr. xxxvj. ; olei cajuputi rt\,iv. Misce et divide in pilulas xij.; sumatur una, hora ante prandium. A good dinner pill for constipated persons. 53. P^lls of Aloes and Sulphuric Acid. R.. Aloes Barbadensis gr. xxiv.; acidi sulphurici fortissimi guttas vj. Misce et divide in pilulas vj. ; quarum sumantur duo, quarta qufique hora,. A very powerful aperient, that often succeeds when almost everything else fails. The author is indebted for the prescription to his friend Dr. Dickson. 54. Guaiacum and Jalap Pills. R. Guaiaci pulveris, extracti jalapse, extracti hyoscyami, aa, J)j.; cambogiae gr. iij. Mi-ce ef divide in pilulas duodecim; quarum sumantur una vel duae hora, somni. An active purge, not irritating to the rectum. 55. Gingerbread Electuary. R.. Guaiaci pulveris gij.; sulphuris, rhei, aagj.; zinziberis 3J- '< Treacle quantum satis sit ut fiat e.lectuarium. Dosis, pars sexta. 56. Guaiacum Electuaries. R.. Pulveris guaiaci gr. v.; pulveris cinchonae 9j.; pulveris cinnamomi compositi £)ss. Misce, fiat pulvis bis die sumendus. R. Pulveris guaiaci 3ij.; pulveris rhei gss. ; sulphuris 5i.; pulveris myristicae 3ss. ; theriacae quantum satis est ut fiat electuarium. Dosis, pars sexta omni nocte. In chronic rheumatic diseases. This is commonly called the Chelsea Pensioner. 57. Sulphate of Manganese. R.. Manganesii sulphatis 9J.; magnesiae sulphatis gij.; syrupi zinziberis f3j.; aquae f^j.-s. Misce fiat haustus mane sumendus. In gouty cases, to produce a copious discharge of bile. R. Manganesii sulphatis, pulveris rhei, aa 9j.; spiritus Lavandulae compositi fgj. ; aquae f^iss. Misce fiat haustus. S III. Alterative and Febrifuge Medicines. 58. Saline Draughts. R. Potassae nitratis ^ij. ; sodae sesquicarbonatis 9j.; syrupi croci, spiritus aetheris nitrici, aa f3j.; aquae f^v. Misce. Dosis f^jss. quarta quaque hora,. R.. Potassae nitratis gr. x. ; sacchari Qj. Misce, fiat pulvis, sumendus e cyatho vinario aquae men tine viridis. Green mint water and nitre form a very agreeable mixture, and produce a pungent cooling sensation on the tongue and palate. But the salt should only be dissolved at the 672 APPENDIX OF FORMULAE. moment of administration, and the mint water should be quite cool. Attention to these trifi(s makes a great difference to a patient who is parched with fever. R.. Potassae bicarbonatis P>iv. ; syrupi zinziberis f3ij-; aquae fjvss. Dosis f^jss. quarta quaque hora, cum f^ss. succi limonum recentis. R.. Liquoris ammoniae acetatis f^ij.; spiritus aetheris nitrici f§ss; misturae camphorae fluiduncias quinque cum semisse. Misce. Dosis, pars quarta, quarta, quaque hora,. R,. Ammonise sesquicarbonatis £)ijss. ; tincturae cardamomi compositse f^ss.; aquae f? v. Misce. Dosis f Jjjss. quarta quaque hora, cum cochleari magno succi limonum, vel gr. xv. acidi citrici. In the early stage of erysipelas and low fevers. 59. Digitalis Draught, for Aneurism. R_. Tinct. digitalis tt\xv. ; aceti destillati fgj.; syrupi f3j; aquae f§jss. Misce; fiat haustus ter die sumendus, ad duodecim vices. 60. Borax. R.. Sodae biboratis 3J-! sodse sesquicarbonatis 3ss.; potassae nitratis gss. Misce et divide in pulveres sex; quorum sumatur unus ter die e cyatho aquae. In lithic deposits. 61. Phosphate of Soda. R.. Sodae phosphatisgiij. Fiat pulvis, mane sumendus e cyatho aquse. As an aperient when the urine is red. R.. Sodae phosphatis £)j.; infusi gentianae compositi f^j. Misce, fiat haustus bis die sumendus. 62. Calomel and Opium Pill. R.. Calomelanos gr. i.—ii.; pulveris opii gr. I—|; extracti glycyrrhizae quantum sufficit ut fiat pilula, quartis—sextis horis sumenda. To mercurialize the system in acute inflam- mation. Calomel and Opium with Antimony. R.. Calomelanos i.—ii.; pulveris opii gr. i—i; antimonii tartarizati gr. £; extracti glycyrrhizae quantum satis sit ut fiat pilula. This formula may be used when there is a con- siderable amount of sthenic inflammation. 63. Alterative Pill. R.. Pilulae hydrargyri, granum dimidium ; extracti hyoscyami gr. ij. Misce, fiant pilula bis vel ter die sumenda. 64. Alterative Powders. R.. Hydrargyri cum creta gr. iij.—vi. ; pulveris Doveri gr. j.—v. Sodae sesquicar- bonatis, sacchari albi, aa £)j. Misce, fiat pulvis omni nocte sumendus. R:, Hydrargyri cum creta gr. ij. ; pulveris rhei gr. v.; sacchari £)ss.; pulveris cinna- momi gr. v. Misce, fiat pulvis, omni nocte sumendus. As a gentle alterative in chronic diseases, when the secretion of bile and urine is scanty. 65. Calomel and Colchicum. R.. Calomelanos gr. iv. ; extracti colchici acetici gr. xij.; extracti colocynthidis com- positi gr. xxiv.; extracti hyoscyami gr. xxiv. Misce, fiant pilulae duodecim, quarum sumat unam vel duas hora somni. In rheumatic and gouty inflammations. 66. Plummer's Pill. R_. Sulphurati aurati antimonii, calomel, aa gij.; tere simul donee bene misceantur, dein adde pulveris resinae guaiaci giv.;'balsamicopaibse q. s. ut fiat massa pilularis ex cujus singulis drachmis formentur pilulae xij. Abridged from Dr. Andrew Plummer's original paper in the " Medina! Essays and Observations published by a Society in Edinburgh," vol. «., 1847. Dr. Plummer was Professor of Medicine in the University of Edinburgh at that time. 67. Tartar Emetic with Mercury. R.. Antimonii potassio-tartratis gr. j. ; hydrargyri cum creta gr viij.; extracti conn gr. xvj. Misce et divide in pilulas octo; quarum sumatur una bis vel ter die. 1 In the original, gummi guaiaci :>iij. ; resinse guaiaci 5j. appendix of formulae. 67 3 68. Tartar Emetic. R.. Antimonii tartarizati, granum; aquae destillatae, fluidunciam. Sumatur cochleare pai-vum quarta quaque hora. R.. Antimonii potassio-tartratis gr. j.—ij ; syrupi papaveris f§ss.; aquae destillatae f§vijss. Misce; sumantur cochlearia duo magna ter die.' R.. Antimonii potassio-tartratis gr. iij. ; tincturae opii fgss.; aquae fgvj. Misce. Dosis, cochleare uuum omni semihora, vel majori intervallo donee delirium cessaverit. In deli- rium tremens and other cases of nervous excitement in which depletion is inadmissible.—See Dr. Graves's Clinical Medicine. 69. Colchicum Draughts. R,. Vini radicis colchici fgss.; syrupi f3ss. ; aquae f§i. Misce, fiat haustus quartis— sextis horis sumendus. 70. Colchicum and Magnesia. R.. Vini colchici f3ij., solutionis magnesiae2 f§jss.; syrupi croci f3'J- » misturse cam- phorae fgivss. Misce ; sumantur cochlearia duo quarta quaque hora. R:. Magnesiae carbonatis, sodae sesquicarbonatis, aa Qss.; vini seminum colchici m„xv.; aquae pimentae f^jss. Misce, fiat haustus ter die sumendus. 71. White Purgative Draught with Colchicum. R.. Aceti colchici f3j.; magnesiae sulphatis gij.; magnesiae carbonatis ^j.; syrupi zin- ziberis f3j. ; aquae auethi fgx. Misce. {Sir C. Scudamore.) 72. Antilithic Pill. R.. Extracti colchici acetici, hydrargyri cum creta, aa gr. j.; extracti colocynthidis com- positi gr. ij. Misce fiat pilula omni nocte sumenda. Sir A. Cooper's Prescription for Chronic Gout and Rheumatism. R.. Potassae bicarbonatis 3ss.; tincturae aurantii fgij.; decocti aloes compositi f^viij. Misce ; sumatur cyathus vinarius omni mane. 73. Colchicum and Rhubarb. R.. Infusi.rhei fgx.; vini colchici rt\,xx.; potassae bicarbonatis J^j. ; tincturae carda- momi compositae fgj. Misce, fiat haustus hora, somni sumendus. Dr. Marshall Hall. 74. Turpentine in small Alterative Doses. R. Mucilaginis fgss.; sodae sesquicarbonatis Qss.; olei terebinthinae m^xv.—xl.; aquae destillatae fgj. Misce, fiat haustus. In rheumatism, rheumatic ophthalmia, iritis, passive hemorrhage, £c. 75. Lead Draught. R.. Tlumbi acetatis gr. iij. aceti destillati fgij. ; tinct. opii mj.— x.; syrupi rhceados f5j., aquae destillatae fgvij. Misce ; fiat haustus quarta, quaque hora, sumendus, ad sex vices. In active hemorrhage. > The inventor of the contrastimulant method of administering tartar emetic was Thomas Marryat, born 1730 died 1792; practised at Bristol; a very eccentric person; author of "Therapeutics, or the Art of Healing " a work which passed through many editions, and was very popular with apothecaries at the beginning of the present century. The twenty-fourth edition was published in 1816 by Sherwood. The author says, page 5, " Auy fever may soon be extinguished by the use of the following powders :— Take of tartarized antimony five grains ; white sugar or nitre a drachm. Let them be well rubbed in a class mortar and be divided into six powders; one to be taken every three hours, notwithstanding the nausea the first may probably occasion. If they bring on a diarrhoea they should still be con- tinued and it will soon cease. If these are taken (which is most commonly the case) without any manifest inconvenience, let there be seven grains in the next six powders, and in the next, ten. Here I beg leave to retract what I said in some former editions of this work: viz., that till sickness and vomiting was excited this noble medicine was not to be depended on. For I have seen many instances wherein a DaDer'has been given every three hours (of which there have been ten grains in six powders), without the least sensible operation, either by sickness, stool, urine, or sweat, and though the patients had been nnremittinely delirious for more than a week with subsultus tendinum, and all the other appearances of hastening death, they have perfectly recovered without any other medical aid, a clyster every other day excepted " a Made by Murray or Dinneford. 43 674 appendix of formulae. 76. Tonic Aperient and Antacid Powders. R.. Sodae carbonatis exsiccatae gr. v.; pulveris calumbae gr. x.; pulveris rhei, zinziberis, aa, gr. ij. Misce; fiat pulvis, quotidie ante prandium sumendus. R_. Ferri sesquioxydi 9j.; sodae bicarbonatis gr. iij.; pulveris rhei gr. iij. Misce, fiat pulvis, ter die sumendus. R.. Pulveris cinchonae 9j. ; sodae bicarbonatis gr. iij. ; pulveris aromatici gr. v. Misce, fiat pulvis, ter die sumendus. 77. Antacid and Carminative Mixtures. R.. Magnesise carbonatis 9i.; spiritus ammoniae aromatici f3ss.; syrupi aurantii f5iij.; aquae calcis, aquse destillatae, aa fgiij. Misce, sumantur cochlearia duo magna ter die. After meals. R\ Cretae preparatae 3ss.; liquoris calcis fgiij.; aquae anethi fgiij. Misce, sumantur cochlearia duo magna ter die. R.. Potassae bicarbonatis 9). ; infusi rhei f|ij.; syrupi zinziberis f3ij. ; aquae menthae piperitae fgij. Misce. Dosis, 1§] bis die. The above prescriptions are intended for children with voracious appetites, red tongues, thirst, and loaded urine. R.. Infusi caryophyllorum fgviijss.; sodae bicarbonatis 5j ; spiritus ammoniae aromatici fgij.; tincturae cardamomi compositae fgss. Misce. Dosis f§jss. bis die. R.. Ammonise sesquicarbonatis, potassae bicarbonatis, aa gss.; aquae destillatae fgvyss. Dosis fgjss. bis die. For adults laboring under dyspepsia, acidity, and turbid urine. To be taken after breakfast and at bed-time. 78. Liquor Potassae Mixtures. R.. Liquoris potassae f3iij.; syrupi f^iij.; aquse destillatae fgvij. Misce. Sumatur pars sexta ter die, post cibum. R. Liquoris potassae ; tincturae gentianse; syrupi zinziberis, spiritus aetheris nitrici, aa f3iij.; aquse destillatae fg viss. Misce; sumatur pars sexta bis vel ter die, post cibum. 79. Bismuth. R. Bismuthi trisnitratis, drachmam ; pulveris acaciae 3ij.; potassae bicarbonatis 3'\i.; misturae camphorae fluiduncias sex. Misce. Dosis fgjss. bis die. To be taken an hour after breakfast and dinner in cases of gastrodynia and pyrosis. To this mixture ten minims of Scheele's prussic acid may be added if there is much pain. ' R.. Bismuthi trisnitratis gj.; magnesiae carbonatis 3ss.; pulveris acaciae 3'ij.; aquae fgvi. Misce. Dosis fgjss. bis die. Pulvis Bismuthi Composiius. R. Bismuthi trisnitratis, pulveris acaciae, sodae bicarbonatis, singulorum £)j.; pulveris zinziberis gr. v. Misce, fiat pulvis hora post cibum sumendus, ter die. In all cases of irritable or chronic inflammation, attended with acidity, flatulence, and irritable stomach, these combinations of bismuth and alkali are most valuable. 80. Prussic Acid Mixtures. R. Acidi hydrocyanici diluti (Pharm. Lond.) TT\>.; potassse bicarbonatis gr. x.; syrupi zinziberis fgss.; aquse auethi fgiss. Misce, fiat haustus bis die sumendus. In cases of irritable acid stomach. R. Acidi hydrocyanici diluti {Pharm. Lond.)X(\vi.; misturae cretae fgiss.; sodse bicar- bonatis gr. v. Misce, fiat haustus. In the same class of cases, with irritable bowels. 81. Antilithic Powder. R. Magnesiae gr. vj.; potassae bicarbonate gr. xij. ; potassae tartratis gr. xv. Misce; fiat pulvis, omni vespere sumendus e cyatho parvo aquae. (Brodie.) 82. Sarsaparilla and Nitric Acid. R.. Decocti sarsae compositi fgiv.; acidi nitrici diluti rrtxx.—lx.; tincturae hyoscyami f3ss. Misce, fiat haustus ter die sumendus. appendix of formula. fi7 5 83. Alkaline Infusion of Sarsaparilla. ty. Sarsaparillae Jamaicensis radicis, concisae et contusae gij.; radicis glycyrrhizae coucisie 30- ? liquoris potassae W^xl.—lx.; aquae destillatae ferventis fgx., tincturae car- damomi compositae fgiij. Miscera per horas viginti quatuor, et cola. Sumatur totum quotidie. Sarsaparilla with Iodide of Potassium. R.. Potassii iodidi gr. xl.; extracti sarsae liquidi fgii. ; solve. Dosis gii. bis die, ex aquae. 84. Sarsaparilla and Lime Water. ty. Sarsaparillae gij. ; glycyrrhizae 5'j- 5 liquoris calcis fgx. Macera per horas viginti quatuor, et cola. Sumatur totum indies. 85. Sarsaparilla Soup. To three ounces of sarsaparilla, sliced, add three pints of water; let them simmer on a slow fire until reduced to two pints ; take out the root, bruise it, and return it into the water with half a chicken, or half a pound of beef without fat; boil them for an hour slowly, and pour off the soup for use.—Dr. Colles's Lectures, vol. ii. p. 346. 86. Corrosive Sublimate Pills. R.. Hydrargyri sublimati corrosivi, ammoniae hydrochloratis, aa gr. j.—ij.; aquse des- tillatae guttam ; micae panis quantum satis est, ut fiant pilulae xij., quarum sumatur una ter die. Sir B. Brodie. 87. Corrosive Sublimate and Bark for Children. R.. Hydrargyri sublimati corrosivi gr. j.; tincturae cinchonae (vel tincturae rhei) gij : solve. Dosis fgj. ter die ex aqua. To be taken after meals. (Sir A. Cooper.) 88. Iodine Mixture.1 R.. Iodinii gr. J; potassi iodidi gr. j.; aquae destillatae fgvj. Vel R> Tincturae iodinii compositi (p. l.) n\xx.; aquae destillatae fgvj. Vel R.- Liquoris potassi iodidi compositi (p. l.) fgss.; aquse destillatae fgvss. Misce. Sumatur totum indies divisis dosibus. 89. Iodine Ointment. R.. Iodinii gr. vij.; potassi iodidi ^ij. adipis gj. Misce. Iodine Paint Is composed of iodine with half its weight of iodide of potassium rubbed together with enough spirits of wine to make it of the consistence of paint. Used as a strong discutient for bubo, diseased joints, §c. 90. Iodine Lotion. R.. Liquoris potassii iodidi compositi fgj.; aquse destillatae fgx. Misce. For Scrofu- lous Ulcers, Fistulas, Ophthalmia, $c. 91. Rubefacient Solution of Iodine. R.. Iodinii giv. ; potassi iodidi gj. ; aquae destillatae fgvj. Misce. To touch very indo- lent sores, the edges of the eyelids, ozsena, J-c. 92. Caustic Solution of Iodine. R. Iodinii, potassii iodidi, aa, gj.; aquae destillatae fgij. Misce. To destroy weak granulations, ragged edges of sores, aquse ferventis octarium. 106. Enemata for destroying Ascarides. B- Aloes, saponis, aa^j.; aquae octarium. R.. Aloes, saponis, assafoetidae, aa, £)j.; aquae octarium. Misce. R;. Infusi quassiae octarium; ferri sulphatis gr. v. Misce. N. B. The dilute citrine ointment (one part of the ointment to 12 of hard fat) is a capital remedy. A small piece should be put within the sphincter. § VI. Gargles. 107. Detergent Gargle. R.. Liquoris calcis chlorinatae f3iv.; mellis gj.; aquae destillatae fgiij. Misce. A " tabtespoonful to be mixed with a glass of warm brandy and water, to be used as a gargle. 108. Cooling and Sialagogue Gargles. R.. Mellis, confectionis rosae caninae, ilii 3ij-; aceti destillati fgss. ; acidi hydrochlorici ttlxxx. ; aquse rosae fgj.; aquae purse fgvj. Misce. R.. Potassae nitratis gj.; infusi rosae compositi fgviij. Misce. R.. Oxymellis fgiij. ; misturae camphorae fgv. Misce. R.. Boracis 5j-; mellis gj. aquae rosae fgj.; aquae fgvj. Misce. 109. Astringent Gargles. B- Aluminis gj.; acidi sulphurici diluti n\,xx.; tincturae myrrhae fgij.; decocti ciuchonae fgvj. Misce. R.. Zinci sulphatis gss.; aquse fgviij. Misce. B- Liquoris chloridi zinci {Sir W. Burnett's Disinfecting Solution) fjss. ; aquae fgviij. Misce. An admirable wash for the mouth when the membrane is flabby and the secretion offensive. 110. Stimulating Gargles. R. Tincturae capsici f3'j. ; oxymellis fgss.; aquae fgvijss. Misce. R. Tincturae pyrethri (F. 183) f3 iij.; aquse gviij. Misce. 111. Tannin Gargle. R.. Tannin 3j.; brandy fgss.; misturae camphorae fgvss. Misce. For salivation, spongy gums, relaxed throat, £c. 112. Corrosive Sublimate Gargle. R. Hydrargyri sublimati corrosivi gr. ij. ; acidi hydrochlorici TTLxx.; mellis gj. ; aqu:e destillatae fgvij. Misce. 6 7 8 APPENDIX OF FORMULA. 113. Creasote Gargle. B- Creasoti guttas xx. ; mucilaginis fgss.; terre et adde, aquae fgviij. Soothing Gargle. B- Extracti papaveris, drachmam; boracis, drachmam; aquae, fluiduncias octo. Misce. Glycerine is a capital soothing application, either alone, or in combination. § VII. Lotions, Injections, and Collyria. 114, Frigorific Mixture. B- Sodii chloridi, potassae nitratis, ammoniae hydrochloratis, partes aequales; aquae quantum satis sit ad solvendas. To be put into a bladder. 115. Spirit Lotion. B- Spiritus vini rectificati fgj.; aquse fgxv. Misce. 116. Goulard's Lotion. " This is made by putting two teaspoonfuls, or 200 drops of the extract of Saturn (Liq. Plumbi Diacetatis), to a quart of water, and four teaspoonfuls of brandy." From a Treatise on the effects of Lead, &c.; from the French of Mr. Goulard, Surgeon-major to the Royal and Military Hospital of Montpellier, Lond. 1775. Dilute spirit of wine may be substituted for the brandy. Nitrate of Lead. R. Plumbi nitratis, drachmam; aquse destillatae, octarium. Fiat lotio. A capital deo- dorizing lotion for ulcers, cancers, §c. (Dr. 0. Ward.) 117. Zinc Lotions. B- Zinci sulphatis 3J. j aquae octarium. Misce. Acetate of Zinc Lotion. B- Liquoris plumbi diacetatis fgss. ; zinci sulphatis 3ss ; aquae destillatae, octarium dimidium. Acetate of Zinc with Creasote Lotion. Pp Plumbi acetatis, zinci sulphatis, aa £)ss.; creasoti guttam unam. Tere simul ut fiat pulvis, in aquae octario dimidio solvendusut fiat lotio. The author learned this formula from Mr. Harvey Itmay be supplied to patients in the form of powder, andis an excellent astrin- gent, and corrective of fetor in otorrhoea and other fetid discharges. 118. Lotion of Chloride of Ammonium. B- Ammoniae hydrochloratis gss.; acidi acetici diluti, spiritus rectificati, aafgss. ; mis- turae camphorae fgxv. Misce. 119. Nitric Acid Lotion. R. Bosae petalorum £)j ; aquse ferventis fgviij. ; acidi nitrici diluti f3'ijss. Misce, et cola post horam. 120. Opiate Lotion. B- Pulveris opii gss.; aquse destillatae ferventis fgviij.; macera per horas duas, et cola. 121. Poppy Lotion. R. Extracti papaveris gij. ; aquae ferventis fgiv. Misce. The addition of a drachm of borax, forms a capital lotion for itching eruptions. 122. Conium Lotion. R. Extracti conii 3J- ; aquae destillatae fgiij.; tere simul, et macera per horas duas; dein cola. 123. Belladonna Lotion. B- Extracti belladonnae £)j ; aquse fgiv. Misce, et cola. appendix of formulae. 67 9 124. Arsenical Lotion. R.. Liquoris arsenicalis f3j.; aquae destillatae fgj. Misce. 125. Black Wash. ty. Calomelanos gj.; mucilaginis acaciae fgss.; liquoris calcis fg vss. Misce. 126. Yellow Wash. B- Hydrargyri sublimati corrosivi gr. vj —xij.; liquoris calcis fgvj. Misce. 127. Chloride of Zinc Lotion. R. Liquoris zinci chloridi (Sir W. Burnett's) fgss.; aquae destillatae fgviij. Misce. 128. Iron Lotion. R.. Ferri sulphatis gr. viij.; aquae destillatae fgviij. Misce. See Mr. Vincent's "Obser- vations." 129. Alum Lotion. R:. Aluminis gss. ; aquse destillatae fgviij. Misce. 130. Blue Lotion. R.. Cupri sulphatis gr. viij. ; aquae fgviij. Misce. 131. Tannin Lotion. R.. Tannin 3?S'; spiritus rectificati f3j. ; aquae destillatae fgiv. Misce. 132. Oakbark and Catechu Lotion. R.. Catechu gj. ; aquae ferventis fgviij. Macera per horam et cola. R.. Corticis quercus gij. ; aquae ferventis octarium ; coque ad consumptionem dimidii, et cola. 133. Borax Lotion. B- Boracis 3j.; aquae destillatae fgviij. Misce. 134. Nitrate of Silver Injection for the Urethra. R.. Argenti nitratis gr. ij.; aquae destillatae fgviij. Misce. (Ricord.) 135. Sulphate of Zinc Injection. R.. Zinci sulphatis gr. viij. ; aquae destillatae fgviij. Misce. 136. Acetate of Zinc Injection. R.. Zinci sulphatis gr. v.; liquoris plumbi diacetatis f3ss.; aquae rosse fgiv. Misce, fiat injectio. 137. Acetate of Copper Injection. R.. Cupri sulphatis gr. v. ; liquoris plumbi diacetatis fgss.; aquae rosae fgix. Misce, fiat injectio. 138. Ammoniuret of Copper Injection. B- Liquoris cupri ammonio-sulphatis m^xx.; tincturae opii fgss. ; aquae rosae giv. Misce, fiat lotio. 139. Sulphate of Zinc with Opium. R. Pulveris opii ^ss.; aquae ferventis octarium dimidium; macera per horas duas, dein cola et adde zinci sulphatis 9 ss. 140. Collyria. R. Zinci sulphatis gr. j. ; vel aluminis gr. j.; vel cupri sulphatis gr. |; vel argenti nitratis gr. j. ; vel zinci acetatis gr. j. ; vel liq. plumbi diacetatis TT\v. ; aquae destillatae fgj. Misce. One part of good brandy to six of water makes an admirable collyrium for most cases. 680 APPENDIX OF FORMULAE. 141. Corrosive Sublimate Collyrium. B. Hydrargyri sublimati corrosivi gr. j. ; aquse destillatae fgviij. Misce. (Mackcnzn.) 142. Opiate Collyrium. B- Zinci sulphatis gr. xij. (veZliquoris plumbi diacetatis f3ss.); liquoris opii sedativi f3ij. ; aquae destillatae fgxij. Misce. 143. Opodeldoch, vel Linimentum Saponis. B, Spiritus vini rectificati libras iv.; saponis mollis libram unam ; digere in leni calore donee fiat solutio, cui adde camphorae uncias duas, olei rosmarini, origani, aa, semunciam. Misce, agitando. 144. Stimulating Liniments. B- Liquoris ammoniae fgij.; linimenti saponis (vel linimenti camphorae compositi) fgj. Misce, fiat linimentum. B- Tincturae capsici fgss.; linimenti saDonis fgss. Misce. 145. Pearson's Liniment. R. Olei olivae fgjss.; olei terebinthinae fgss.; acidi sulphurici fortissimi fgjss. Misce gradatim. A painful irritant 146. Chilblain Liniment. !£.. Tincturae cantharidis fgiij.; linimenti saponisfgix. Misce, fiat linimentum. Wardrop. 147. Opiate Liniment. R. Tincturae opii fgss. ; linimenti saponis fgj. Misce. 148. Conium Liniment, or Epithem. B- Extracti conii gj.; glycerine gss. Misce. In neuralgia, and uterine irritation. 149. Belladonna Liniment. R.. Extracti belladonnas scrupulum: glycerine fluidunciam dimidiam. Misce. Glyce- rine is the best vehicle for narcotic liniments, as it does not dry, and so renders absorption by the skin more easy. The extracts of opium and aconite may be used in like manner. Anodyne Camphor Liniment. R,. Camphorae gj. ; spiritus rectificati, glycerine, aa gj. A capital soothing rubefacient fdr chronic rheumatism and neuralgia. 150. Mercurial Liniment. I£. Unguenti hydrargyri fortioris, adipis, aagiv. ; camphorae gj. ; spiritus rectificati f3J.; liquoris ammoniae fgiv. Misce. 151. Croton Oil Embrocation. R,. Olei tiglii guttas xxx.; linimenti saponis fgj. Misce. § VIII. Poultices. 152. Bran Poultice. Make a linen or flannel bag of the size requisite to cover the part affected, and fill it loosely with bran. Pour boiling water on this till it is thoroughly moistened; put it into a coarse towel, and wring it dry; then apply it so soon as it is cool enough. 153. Bread Poultice. "I shall now speak," says Mr. Abernethy, "of the bread and water poultice. The way in which I direct it to be made is the following: —Put half a pint of hot water into a pint basin, add to this as much of the crumb of bread as the water will cover: then place a plate over the basin and let it remain about ten minutes; stir the bread about in the APPENDIX OF FORMULAE. 681 water, or, if necessary, chop it a little with the edge of the knife, and drain off the water by holding the knife on the top of the basin, but do not press the bread, as is usually done; then take it out lightly, and spread it about one-third of an inch thick on some soft linen, and lay it upon the part. A very admirable soft poultice for parts that are excoriated, or that threaten to slough from pressure, during long illness, may be made by mixing equal parts of bread-crumbs and of mutton suet grated very fine, with a little boiling water, and stirring them in a saucepan over the fire till they are well incorporated. 154. Linseed Meal Poultice. The highest authority on poultices was Mr. Abernethy, who seemed to revel in the idea of them. 4i Scald your basin," he says, " by pouring a little hot water into it, then put a small quantity of finely-ground linseed meal into the basin, pour a little hot water on it, and stir it round briskly until you have well incorporated them; add a little more meal and a little more water, then stir it again. Do not let any lumps remain in the basin, but stir the poultice well, and do not be sparing of your trouble. If properly made, it is so well worked together, that you might throw it up to the ceiling, and it would come down again without falling in pieces; it is, in fact, like a pancake. What you do next is to take as much of it out of the basin as you may require, lay it on a piece of soft linen, let it be about a quarter of an inch thick, and so wide that it may cover the whole of the inflamed part." 155. Yeast Poultice. R. Farinae Ibj.; cerevisiae fermenti fgj. Misce, et calorem lenem adhibe donee intu- mescant. (Pharm. Lond.) 156. Mustard Poultice. R. Lini seminum, sinapis, singulorum contritorum libram dimidiam; aceti fervefacti, quantum satis sit; ut fiat cataplasmatis crassitudo. Misce. (Pharm. Lond.) A far better poultice is made by merely mixing flour of mustard with warm (not boiling) water. 157. Opiate Poultice. R> Micae panis, et lotionis opiatae suprapraescriptae (F. 120), singulorum, quantum satis sit. 158. Conium Poultice. B- Cataplasmatis panis quantum satis sit; extracti conii 3j. Misce. 159. Carrot Poultice. Boil carrots till they are quite soft, then mash them into a smooth pulp. § IX. Ointments. 160. Scott's Ointment. B- Unguenti hydrargyri fortioris, cerati saponis, aa, gj.; camphorae pulverizatae gj. Misce. 161. Tartar Emetic Ointment. R.. Antimonii potassio tartratis gj.; adipis gj. Misce. 162. Ointment for Piles. R. Pulveris gallse gj.; liquoris plumbi diacetatis Tn„xv.; adipis gj. Misce. R. Pulveris opii 9ss.; liquoris plumbi diacetatis guttas x.; adipis gss. Misce. 163. Creasote Ointment. R. Creasoti guttas viginti; unguenti resinae, adipis, singulorum unciam. Misce. These like the old elemi ointment, are good stimulating applications to indolent and sloughing ulcers; but the creasote is a good deodorizer as well. It is good also for piles. Peruvian Balsam Ointment. R.. Balsami Peruviani gj. ; unguenti cetacei gj. Misce. 682 APPENDIX OF FORMULAE. 164. Chalk Ointment. B- Cretso precipitatae gj.; olei olivae 3"j- '■> aJipis gss. Misce. For burns, excoria- tions with acrid discharge, §c. Bismuth Ointment. B- Bismuthi trisnitratis 3*0-! adipis 3vi- Misce. A capital ointment for excoriations and irritable sores. 165. Magnesia Ointment. B- Magnesiae carbonatis gj.; adipis gj. Misce. 166. Anodyne Bark Ointment. R.. Extracti vel pulveris opii gij.; camphorae gj.; pulveris cinchonae gijss.; adipis vel cerati cetacei, gv. • spiritus vini rect. q. s. misce fiat unguentum.—(Mr. Cole.) 167. Veratria Ointment. B- Veratrise gr. iv.; spiritus rectificati fgj.; adipis gj. Misce. In neuralgia. A bit the size of a bean to be rubbed on the painful part. 168. Ointment for the Eyelids.2 B- Unguenti citrini (hydrargyri nitratis) gss.; adipis fgss. Solve leni calore.2 R.. Unguenti citrini 3ss.; hydrargyri nitrico-oxydi in pulverem subtilissimum redacti gr. v.; adipis 3iy- Misce bene. R.. Liquoris plumbi diacetatis guttas x.; morphias acetatis gr iv.; calomelanos gr. x.; adipis gss. Misce 169. Ointment of Nitrate of Silver. B- Argenti nitratis gr. iv.; adipis bene loti 3ss. Misce 170. Calomel Ointment. R. Calomelanos gij.; adipis 3yij Misce. In chancre, and condylomata, §c. 171. Green, or Verdigris Ointment (Pharm. Ed). R.. Cupri acetatis gi.; cerati resinae gj. Misce. For flabby ulcers; warts; indolent eruptions, §c. 172. Goulard's, or Compound Lead Cerate. R.. Liquoris plumbi diacetatis f3bj- ; cerae giv. ; olei olivae. octarium dimidium ; cam- phorae gss. Melt the wax, and add gradually to it the oil, in which the .cairphor has been previously dissolved; as they cool, add the liquor plumbi, stirring continually till well mixed. 173. Red Precipitate Ointment. R.. Hydrargyri nitrico-oxydi, optime pulverizati gj.; adipis gj. Misce. § X. Miscellaneous Prescriptions for various Surgical Diseases. 174. Demulcent Mixtures for Gonorrhoea. R.. Pulveris acaciae 3'j- > sodae sesquicarbonatis gj.; tincturae opii ir^xx.; aquae fgvijss. Misce. Dosis fgjss. quater die. B- Liquoris potassae fgij. ; liquoris opii sedativi f3ss.; misturae amygdalae fgvj. Misce. Sumantur cochlearia duo quarta quaque hora,. ]£. Liquoris potassae ; tincturae hyoscyami, iiaf3ij.; aquae fgvi. Misce. Sumatur pars quarta ter die. 1 Singleton's Golden Ointment for the eyelids is said to be composed of equal parts of orpiment and lard. a The nitrate of mercury solidifies olive oil, and renders other oils green and rancid, so that it seems better to return to the old formula, and employ lard only, and not oil in the preparation of the unguen- tum eitrinum. Mr. Wilde speaks highly of a brown ointment of nitrate of mercury, prepared by the Dublin chemists, some of whom use rape oil, others fish oil. APPENDIX OF FORMULA 683 175. Copaiba Mixture. R.. Copaibse f3'ij.—iv.; mucilaginis acaciae f5'iv.; spiritus aetheris nitrici, spiritus lavandulae, aa f3-j.; olei cinnamomi guttas ii. ; aquae fgv. Misce. Dosis fgj, ter die. 176. Copaiba and Oil of Cubebs. R.. Copaibae fgiij.; olei cubebae n\xx.; liquoris potassae f3ij ; sp. myristicae f3iij-; misturae camphorae fgvij. Misce. Sumantur cochlearia duo magna ter die. Copaiba and Kino. R.. Copaibae fgss.; pulveris kino 3J-; mucilaginis acaciae f^iij.; spiritus lavandulae compositi 13iij-; aquae fgv. Misce. Sumantur cochlearia duo magna ter die. Copaiba and Catechu. R. Copaibae fgss.; tincturae catechu f3vj. ; olei juniperi guttas duas ; mucilaginis fgiij ; aquae fgv. Misce. Sumantur cochlearia duo ter die. Turpentine and Copaiba. R.. Olei terebinthinae fgij.; copaibae fgvj. Misce; sumantur guttae quadraginata ter die, ex cyatho aquae. 177. Copaiba and Magnesia Pills. R.. Copaibae fgss.; magnesiae carbonatis quantum satis sit ut fiat massa in pilulas di- videnda. 178. Cubebs and Soda. R.. Pulveris cubebse Qij. ; sodae sesquicarbonatis; potassae bitartratis, aa, k)ss. Misce; fiat pulvis, ter die sumendus. 179. Cantharides and Zinc. R.. Zinci sulphatis gr. xxiv.; pulveris cantharidis gr. vj.; pulveris rhei 3J- > terebin- thinae Venetiensis quantum satis sit, ut fiant pilulae viginti quatuor, quarum sumantur duae ter die. 180. Cantharides and Steel. R. Tincturae ferri sesquichloridi, tincturae cantharidis, aafgij. ; tincturae capsici f3J ; syrupi crocif3ij.; aquae pimentae fgvj. Misce; sumantur cochlearia duo ter die. 181. For Chronic Cystitis. R.. Foliorum buchu, et uvae ursi, aa, 3U. > aquae ferventis fgvj. Macera per horas duas; dein cola, et adde liquoris potassae 13J.; tincturae cinnamomi, tincturae hyoscyami, aa, f3iij. Misce; sumantur cochlearia duo ter die. R. Pareiraegj.; aquae destillatae octarium; decoque addimidium; dein adde decocti cinchonae flavae fgvj.; tincturae hyoscyami fgiij.; sodae sesquicarbonatis gss. Dosis lgiij. bis die. R.. Decocti chimaphilae fgj.; syrupi zinziberis f3j.; spiritus aetheris nitrici f3j. Misce, fiat haustus bis die sumendus. 182. Benzoic Acid. ty. Acidi benzoici, ammoniae sesquicarbonatis, aa gj.; syrupi tolutani fgij.; aquae destillatae fgvj. Misce. Dosis fgj. ter die. R.. Acidi benzoici, extracti papaveris, aa gss. Misce et divide in pilulas xij.; quarum sumantur duse ter die. R. Acidi benzoici, sacchari albi, aa, gr. viij. Fiat pulvis, ter die sumendus. In urinary disorders, chronic bronchitis and cystitis. 183. Antiodontalgic Remedies. R. Mastiches 3J. ; spiritus rectificati (vel Eaude Cologne) gjss. Solve. Cotton imbued with this forms a good temporary plug for a carious tooth. The same purpose is answered by a solution of gum copal in aether; or by collodion, or by a solution of guita percha in chloro- form. See Tomes's Lectures. G84 APPENDIX OF FORMULAE. ^Ethereal Tincture of Tannin. B- Tannin 5j-; mastiches 3J- • spiritus aetheris sulphurici gjss. Misce. For the same purpose. Tincture of Pellitory. B- Radicis pyrethri concisi gss.; spiritus rectificati giv. Macera per dies xiv., et cola. Half a teaspoonful mixed with a wine-glassful of water forms a very agreeable wash in nervous and atonic toothache. 184. Eye Snuff. B- Pulveris asari partes tres; pulveris florum lavandulae partes duas. Misce. Vel B- Pulveris euphorbii partem unam, pulveris amyli partes septem. Misce. Mercurial Eye Snuff. B- Hydrargyri sub-sulphatis flavi gss. ; pulveris glycyrrhizae gij. Misce intime. 185. Schmucker's Resolvent Pills. B- Sagapeni, galbani, saponis, aa 3J-; rhei gjss.; antimonii potassio-tartratis gr. xv. ; succi glycyrrhizae 3J- Misce. Dosis, gr. xv. bis die. Richter's Pills. R.. Ammoniaci, assafoetidse, saponis, Valerianae, arnicae, aa, gij.; antimonii potassio- tartaris gr. xviij.; syrupi quantum satis est ut fiat massa. Dosis, gr. xx.—xxx. ter die. 186. Gallic Acid Mixture. B- Acidi gallici 3'ij.; syrupi fgij. ; aquae destillatae fgviij. Misce. Dosis, pars sexta, tenia vel quarta quaque hora. In passive hemorrhage. 187. Alum Mixtures. B> Aluminis 3J-! acidi sulphurici diluti fgjss.; syrupi fgss.; infusi rosae fgvijss. Misce. Dosis, pars sexta quarta quaque hora,. In the same. B- Aluminis gj.; lactis Oj. ; corticis limonis 9j.; coque per quartam partem horse, et cola. To be drunk cold, ad libitum. 188. Resinous Lotion. ]^. Tincturae benzoes compositae gj.; aquae fgij. Misce. 189. Sir A. Cooper's Prescription for Cancer. R.. Ammoniae sesquicarbonatis gr. v.; sodae sesquicarbonatis gss.; tincturae calumba? fgj.; infusi gentianae compositi fgjss. Misce, fiat haustus bis die sumendus. 190. Arnica Montana. R.. Foliorum arnicae gij.; aquse ferventis Oss.; macera per horam, et cola. Dosis gj. B- Florum arnicae gjss.; spiritus rectificati Oj.; macera per dies xiv., et cola; vel R.. Foliorum arnicae gjss.; spiritus tenuoris Oj.; macera per dies xiv., et cola. Dose TTLxv.—xxx. In nervous headache, atonic amaurosis, tinnitus aurium, and as a local applica- tion for muscular stiffness after bruises. See Wilde's Contributions to Aural Surgery, Dublin, 1848. 191. Phosphorus Pills. B- Micae panis 3J > aquae destillatae quantum satis sit ut fiat massa idonese crassi- tudinis, dein adde phosphori granum unum. Misceantur bene et divide in pilulas xx. 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They may those of its leading predecessors and contemporaries, secure to him many a triumph and ter vent blessing.— that the best way for the reader to avail lumself of | Am. Journal Med. Sciences. ALLEN (J. M.), M. D., Professor of Anatomy in the Pennsylvania Medical College, &c. THE PRACTICAL ANATOMIST; or, The Student's Guide in the Disseqting- ROOM. With 266 illustrations. In one handsome royal 12mo. volume, of over 600 pages, lea- ther. $2 25. We believe it to be one of the most useful works notice, we feel confident that the work of Dr. Allen upon the subject ever written. It is handsomely is superior to any of them. We believe with the illustrated, well printed, and will be found of con- author, that none is so fully illustrated as this, and venient size for use in the dissecting-room.—Med. the arrangement of the work is such as to facilitate Examiner. the labors of the student. We most cordnlly re- However valuable may be the "Dissector's commend it to their attention.—Western Lanoet. Guides" which we, of late, have had occasion to ANATOMICAL ATLAS. By Professors H. H. Smith and W. E. Horner, of the University of Pennsyl- vania. 1 vol. 8vo., extra cloth, with nearly 650 illustrations. |3F" See Smith, p. 331. ABEL (F. A.), F.C.S. AND C. L. BLOXAM. HANDBOOK OF CHEMISTRY, Theoretical, Practical, and Technical; with a Recommendatory Preface by Dr. Hofmann. In one large octavo volume, extra cloth, of 662 pages, with illustrations. $3 25. _________________ • ASHWELL (SAMUEL), M.D., Obstetric Physician and Lecturer to Guy's Hospital, London. A PRACTICAL TttEATISE ON THE DISEASES PE0ULLAR TO WOMEN. Illustrated by Cases derived from Hospital and Private Practice. Third American, from the Third and revised London edition. In one octavo volume, extra cloth, of 528 pages. $3 00. The most useful practical work on the subject in I The most able, and certainly the most standard the English laneuaze. — Boston Med. and Surg, and practical, work on female diseases that we have Hie rjngubu iiii5u<»6 \yetseea.—Medico-Ckirurgtcal Review. ARNOTT (NEILL), M. D. ELEMENTS OF PHYSIOS; or Natural Philosophy, General and Medical. Written for universal use, in plain or non-technical language. A new edition, by Isaac Hays, M. D. Complete in one octavo volume, leather, of 484 pages, with about two hundred illustra- tions. $2 50.____________. BIRD (GOLDING), A. M., M. D., Ac. URINARY DEPOSITS: THEIR DIAGNOSIS, PATHOLOGY, AND THERAPEUTICAL INDICATIONS. Edited by Edmund Lloyd Birkett, M. D. A new American, from the fifth and enlarged London edition With eighty illustrations on wood. In one Some octavo volume, of a icut 400 pages, extra cloth. *2 00. (Just Issued.) The death of Dr. Bird has rendered it necessary to entrust the revision of the present edition to other hanus and in his performance of the duty thus devolving on him, Dr. Birkett Has sedulously ^Savored to carry out the author's plan by introducing such new matter and modifications of Uie text as the p ogress of science has called for. Notwithstanding the utmost care to keep the if,rl within a reasonable compass, these additions have resulted in a considerable enlargement. ht tEefore hoped that n will be found fully up to the present condition ot the subject, and that the reputation of^volume as a clear, complete, und compendious manual, will be fully maintained. BENNETT (J. HUGHES), M. D., F. R. S. E., Professor of Clinical Medicine in the University of Edinburgh, &c. TTT17 PATHOLOGY AND TREATMENT OP PULMONARY TUBERCU- LOSIS tnd on the Local Medication of Pharyngeal and Laryngeal Diseases frequently mistaken for or aJSciatedI with, Phthisis. One vol. 8vo.,extra cloth, with wood-cuts, pp.130. $125. BARLOW (GEORGE H.), M.D. Physician to Guy's Hospital, London, &c. A MANUAL OP THE PRACTICE OP MEDICINE. With Additions by D. F CowhVm. D., author of" A Practical Treatise on Diseases of Children," &c. In one hand- some octavo volume, leather, of over 600 pages. $2 75. „„h nr «»rlow'sManual in the warm- I found it clear, concise, practical, and sound.—Bos- J?£5^™^^^™>% ™ ton md-and Surg-Journai- uave had frequent occasion to consult it, and nave | 4 BLANCHARD & LEA'S MEDICAL BUDD (GEORGE), M. D., F. R. S., Professor of Medicine in King's College, London. ON DISEASES OF THE LIVER. Third American, from the third and enlarged London edition. In one very handsome octavo volume, extra cloth, with four beauti- fully colored plates, and numerous wood-cuts. pp. 500. $3 00. Has fairly established for itself a place among the classical medical literature of England.—British and Foreign Medieo-Chir. Review. Dr. Budd's Treatise on Diseases of the Liver is now a standard work in Medical literature, and dur- ing the intervals which have elapsed between the successive editions, the author has incorporated into the text the most striking novelties which have cha- racterized the recent progress of hepatic physiology and pathology; so that although the size of the book is not perceptibly changed, the history of liver dis- eases is made more complete, and is kept upon a level with the progress of modern science. It is the best work on Diseases of the Liver in any language.— London Med. Time* and Gazette. This work, now the standard book of reference on the diseases of which it treats, has been carefully revised, and many new illustrations of the views of the learned author added in the present edition.— Dublin Quarterly Journal. BY THE SAME AUTHOR. ON THE ORGANIC DISEASES AND FUNCTIONAL DISORDERS OF THE STOMACH. In one neat octavo volume, extra cloth. $1 50. BUCKNILLU. C), M.D., and DANIEL H. TUKE, M.D., Medical Superintendent of the Devon Lunatic Asylum. Visiting Medical Officer to the York Retreat, A MANUAL OF PSYCHOLOGICAL MEDICINE; containing the History, Nosology, Description, Statistics, Diagnosis, Pathology, and Treatment of INSANITY. With a Plate. In one handsome octavo volume, of 536 pages. $3 00. The increase of mental disease in its various forms, and tbe difficult questions to which it is constantly giving rise, render the subject one of daily enhanced interest, requiring on the part of the physician a constantly greater familiarity with this, the most perplexing branch of his profes- sion. At the same time there has been for some years no work accessible in this country, pre>ent- ing the results of recent investigations in the Diagnosis and Prognosis of Insanity, and the greatly improved methods of treatment which have done so much in alleviating the condition or restoring the health of the insane. To fill this vacancy the publishers present this volume, assured that the distinguished reputation and experience of the authors will entitle it at once to the confidence of both student and practitioner. Its scope may be gathered from the declaration of the authors that "their aim has heen to supply a text book which may serve as a guide in the acquisition of such knowledge, sufficiently elementary to be adapted to the wants of the student, and sufficiently modern in its views and explicit in its teaching to suffice for the demands of the practitioner." BENNETT (H EN RY), M . D. A PRACTICAL TREATISE ON INFLAMMATION OF THE UTERUS, ITS CERVIX AND APPENDAGES, and on its connection with Uterine Disease. To which is added, a Review of the present stale of Uterine Pathology. Fifth American, from the third English edition. In one octavo volume, of about 500 pages, extra cloth. $2 00. BROWN (ISAAC BAKER), Surgeon-Accoucheur to St. Mary's Hospital, &c. ON SOME DISEASES OF WOMEN ADMITTING OF SURGICAL TREAT MENT. With handsome illustrations. One vol. 8vo., extra cloth, pp. 276. $160. Mr. Brown has earned for himself a high reputa- tion in the operative treatment of sundry diseases and injuries to which females are peculiarly subject We can truly say of his work that it is an important addition to obstetrical literature. The operative suggestions and contrivances which Mr. Brown de- scribes, exhibit much practical sagacity and skill, and merit the careful attention of every surgeon- accoucheur.—Association Journal. We have no hesitation in recommending this book to tlie careful attention of all surgeons who make female complaints a part of their study and practice. —Dublin Quarterly Journal. BOWMAN (JOHN EJ, M.D. PRACTICAL HANDBOOK OF MEDICAL CHEMISTRY. Second Ame- rican, from the third and revised English Edition. In one neat volume, royal 12mo., extra cloth, with numerous illustrations, pp. 288. $1 25. BY THE SAME AUTHOR. INTRODUCTION TO PRACTICAL CHEMISTRY, INCLUDING ANA- LYSIS. Second American, from the second and revised London edition. With numerous illus- trations. In one neat vol., royal 12mo., extra cloth, pp.350. $125. BEALE ON THE LAWS OF HEALTH IN RE- LATION TO MIND AND BODY. A Series of Letters from an old Practitioner to a Patient. In one volume, royal 12mo., extra cloth, pp. 296. 80 cents. BUSHNAN'S PHYSIOLOGY OF ANIMAL AND VEGETABLE LIFE; a Popular Treatise on the Functions and Phenomena of Organic Life. In one handsome royal 12mo. volume, extra cloth, with over 100 illustrations, pp.234. 80 cents. BUCKLER ON THE ETIOLOGY, PATHOLOGY> AND TREATMENT OF FIBRO-BRONCHI- TIS AND RHEUMATIC PNEUMONIA. In one 8vo. volume, extra cloth, pp.150. $125. BLOOD AND URINE (MANUALS ON). BY JOHN WILLIAM GRIFFITH, G. OWEN REESE, AND ALFRED MARKWICK. One thick volume, royal 12mo., extra cloth, with plates, pp. 460. $1 25. BRODIE'S CLINICAL LECTURES ON SUR- GERY. 1 vol. 8vo. cloth. 350 pp. $125. AND SCIENTIFIC PUBLICATIONS. 5 BUMSTEAD (FREEMAN J.) M. D., Lecturer on Venereal Diseases at the College of Pnysicians and Surgeons, New York, &c. THE PATHOLOGY AND TREATMENT OF VENEREAL DISEASES, including the results of recent investigations upon the subject. With illustrations on wood. In one very handsome octavo volume, of nearly 700 pages, extra cloth; $3 75. {Now Ready.) By far the most valuable contribution to this par- ticular branch of practice that has seen the light within the last score of years. His clear and accu- rate descriptions of the various forms of venereal disease, and especially the methods of treatment he proposes, are worthy of the highest encomium. In these respects it is better adapted for the assistance of the every-day practitioner than any other with which we are acquainted. In variety of methods proposed, in minuteness of direction, guided by care- lul discrimination of varying forms and complica tions, we write down the book as unsurpassed. It is a work which should be in the possession of every practitioner.— Chicago Med. Journal. Nov. 1861. Tne foregoing admirable volume comes to us, em- bracing the whole subject of syphilology, resolving many a doubt, correcting and confirming many an entertained opinion, and in our estimation the best, completest, fullest monogiaph on this subject in our language. As far as the author's labors themselves are concerned, we feel it a duty to say that he has not only exhausted his subject, but he has presented to us, without the slightest hyperbole, the best di- gested treatise on these diseases in our language. He has carried its literature down to the present moment, and has achieved his task in a manner which cannot but redound to his credit.—British American Journal, Oct. 1861. We believe this treatise will come to be regarded as high authority in thi s branch of medical practice, and we cordially commend it to the favorable notice of our brethren in the profession. For our own part, we candidly confess that we have received n.any new ideas from its perusal, as well as modified many views which we have long, and, as we now think. erroneously entertained on the subject of syphilis. To sum up all in a few words, this book is one which no practising physician or medical student can very well afford to do without.—American Med. Times, Nov. 2, 1861. The whole work presents a complete history of venereal diseases, comprising much interesting and valuable material that has been spread through med- ical journals within the last twenty years—the pe- riod of many experiments and investigations on the subject—the whole carefully digested by the aid of the author's extensive personal experience, and offered to the profession in an admirable form. Its completeness is secured by good plates, which are especially full in the anatomy of the genital organs. We have examined it with great satisfaction, and congratulate the medical profession in America on the nationality of a work that may fairly be called original.—Berkshire Med. Journal, Dec. 1861. One thing, however, we are impelled to say, that we have met with no other book on syphilis, in the English language, which gave so full, clear, and impartial views of the important subjects on which it treats. We cannot, however, refrain from ex- pressing our satisfaction with the full and perspicu- ous manner in which the subject has been presented, and the careful attention to minute details, so use- ful—not to say indispensable—in a practical treatise. In conclusion, if we may be pardoned the use of a phrase now become stereotyped, but which we here employ in all seriousness and sincerity, we do not hesitate to express the opinion that Dr. Bumstead's Treatise on Venereal Diseases is a " work without which no medical library will hereafter be consi- dered complete."—Boston Med. and Surg. Journal, Sept. 5, 1861. BARCLAY (A. W.), M. D., Assistant Physician to St. George's Hospital, &c. A MANUAL OF MEDICAL DIAGNOSIS; being an Analysis of the Signs and Symptoms of Disease. Second American from the second and revised London edition. In one neat octavo volume, extra cloth, of 451 pages. $2 25. (Now ready.) The demand for a se-ond edition of this work shows that the vacancy which it attempts to sup- ply has been recognized by the profession, and that the efforts of the author to meet the want have been successful The revision which it has enjoyed will render it better adapted than before to afford assistance to the learner in the prosecution of his studies, and to the practitioner who requires a convenient and accessible manual for speedy reference in the exigencies of his daily duties. For this latter purpose its complete and extensive Index renders it especially valuable, offering facilities for immediately turning to any class of symptoms, or any variety of disease. The task of composing such a work is neither art easy nor a light one; but Dr. Barclay has performed it in a manner which meets our most unqualified approbation. He is no mere theorist; he knows his work thoroughly, and in attempting to perform it, has not exceeded his powera.—British Med. Journal, We venture to predict that the work will be de- servedly popular, and soon become, like Watson s Practice, an indispensable necessity to the practi- tioner.— N. A. Med. Journal. An inestimable work of reference for the young practitioner and student.—Nashville Med. Journal. We hope the volume will have an extensive cir- culation, not among students of medicine only, but practitioners also. They will never regret a faith- ful study of its pages.—Cincinnati Lancet. An important acquisition to medical literature. It is a work of high merit, both from the vast im- portance of the subject upon which it treats, and also from the real ability displayed in ;t» elabora- tion. In conclusion, let us bespeak for this volume that attention of every student of our art which it so richly deserves - that place in every medical library which it can so well adorn.- -Peninsular medical Journal. BARTLETT (ELiSHA), M. D. THE HISTORY, DIAGNOSIS, AND TREATMENT OF THE FEVERS of THF UNITED STATES. A new and revised edition. By Alonzo Clark , M. D , Prof. of pSogVand Practical Medicine in the N. Y. College of Physicians and Surgeons, &c. In one octavo volume, of six hundred pages, extra cloth. Price $3 00. It is a work of great practical value and interest containing much that is new relative to the seyera diseases o? which it treats, and, with the addition! of the editor, is fully up to the times. The distinct- ive features of the different forms of fever are plainly and forcibly portrayed, and the 1™*°™*™™*}™? carefully apd accurately drawn, and to the Ameri- can practitioner is a more valuable and safe guide than any work on fever extant.-Ofcto Med. and Surg Journal. This excellent monograph on febrile disease, has stood deservedly high since its first publication. It will be seen that it has now reached its fourth edi- tion under the supervision of Prof. A. Clark, a gen- tleman who, from the nature of his studies and pur- suits, is well calculated to appreciate and discuss the many intricate and difficult questions in patho- logy. His annotations add much to the interest of the work, and have brought it well up to the condi- tion of the science as it exists at the present day in regard to this class of diseases.—Southern Med. and Surg. Journal. 6 BLANCHARD & LEA'S MEDICAL BARWELL (RICHARD,) F- R. C. S., Assistant Surgeon Charing Cross Hospital, &c. A TREATISE ON DISEASES OF THE JOINTS. Illustrated with engrav- ings on wood. In one very handsome octavo volume, of about 500 pages, extra cloth; $5 00. (Now Ready.) "A treatise on Diseases of the Joints equal to, or rather beyond the current knowledge of the day, has long been required—my professional brethren must judge whether the ensuing pages may supply the deficiency No author is fit to estimate his own work at the moment of its completion, but it may be permitted me to say that the study of joint diseases has very much occupied my atten- tion, even from my studentship, and that for the last six or eight years my devotion to that subject has been almost unremitting.....The real weight of my work has been at the bedside, and the greatest labor devoted to interpreting symptoms and remedying their cause."—Author's Preface. At the outset we may state that the work is worthy of much praise, and bears evidence of much thoughtful and careful inquiry, and here and there of no slight originality. We have already carried this notice further thnn we intended to do, but not to the extent the work deserves. We can only add, that the perusal of it has afforded us great pleasure. The author has evidently worked very hard at his subject, and his investigations into the Physiology and Pathology of Joints have been carried on in a manner which entitles him to be listened to with attention and respect. We must not omit to men- tion the very admirable plates with which the vo- lume is enriched. We seldom meetwith such strik- ing and faithful delineations of disease.—London Med. Times and Gazette, Feb. 9, 1861. We cannot take leave, however, of Mr. Barwell, without congratulating him on the interesting amount of information which he has compressed into his book. The work appears to us calculated to be of much use to the practising surgeon who may be in want of a treatise on diseases of the joints, and at the same time one which contains the latest information on articular affections and the opera- tions for their cure.—Dublin Med. Press, Feb. 27, 1861. This volume will be welcomed, both by the pa- thologist and the surgeon, as being the record of much honest research and careful investigation into the nature and treatment of a most important class of disorders. We cannot conclude this notice of a valuable and useful book without calling attention to the amount of bond, fide work it contains. In the present day of universal book-making, it is no slight matter for a volume to show laborious investiga- tion, and at the same time original thought, on the part of its author, whom we may congratulate on the successful completion of his arduous task.— London Lancet, March 9, 1861. CARPENTER (WILLIAM B.), M. D., F. R. S., &.C., Examiner in Physiology and Comparative Anatomy in the University of London. PRINCIPLES OF HUMAN PHYSIOLOGY; with their chief applications to Psychology, Pathology, Therapeutics, Hygiene, and Forensic Medicine. A new American, from the last and revised London edition. With nearly three hundred illustrations. Edited, with addi- tions, by Francis Gtjrney Smith, M. D., Professor of the Institutes of Medicine in the Pennsyl- vania Medical College, &c. In one very large and beautiful octavo volume, of about nine hundred large pages, handsomely printed and strongly bound in leather, with raised bands. $4 25. In the preparation of this new edition, the author has spared no labor to render it, as heretofore, a complete and lucid exposition of the most advanced condition of its important subject. The amount of the additions required to effect this object thoroughly, joined to the former large size of the volume, presenting objections arising from the unwieldy bulk of the work, he has omitted all those portions not bearing directly upon Human Physiology, designing to incorporate them in his forthcoming Treatise on General Physiology. As a full and accurate text-book on the Phy- siology of Man, the work in its present condition therefore presents even greater claims upon the student and physician than those which have heretofore won for it the very wide and distin- guished favor which it has so long enjoyed. The additions of Prof. Smith will be found to supply whatever may have been wanting to the American student, while the introduction of many new illustrations, and the most careful mechanical execution, render the volume one of the most at- tractive as yet issued. For upwards of thirteen years Dr. Carpenter's work has been considered by the profession gene- rally, both in this country and England, as the most valuable compendium on the subject of physiology in our language. This distinction it owes to the high attainments and unwearied industry of its accom- plished author. The present edition (which, like the last American one, was prepared by the author him- self), is the result of such extensive revision, that it may almost be considered a new work. We need hardly say, in concluding this brief notice, that while the work is indispensable to every student of medi- cine in this country, it will amply repay the practi- tioner for its perusal by the interest and value of its contents.—Boston Med. and Surg. Journal. This is a standard work—the text-book used by all medical students who read the English language. It has passed through several editions in order to keep pace with the rapidly growing science of Phy- siology. Nothing need be said in its praise, for its merits are universally known; we have nothing to say of its defects, for they only appear where the science of which it treats is incomplete.—Western Lancet. The most complete exposition of physiology which any language can at present give.—Brit, and For. Med.-Chirurg. Review. The greatest, the most reliable, and the best book on the subject which we know of in the English language.—Stethoscopt To eulogize thisgreat work would be superfluous. We should observe, however, that in this edition the author has remodelled a large portion of the former, and the editor has added much matter of in- terest, especially in the form of illustrations. We may confidently recommend it as the most complete work on Human Physiology in our language.— Southern Med. and Surg. Journal. The most complete work on the science in our language—Am. Med. Journal. The most complete work now extant in our lan- guage.—N. O. Med. Register. The best text-book in the language on this ex- tensive subject.—London Med. Times. A complete cyclopaedia of this branch of science. —N. Y. Med. Times. The profession of this country, and perhaps also of Europe, have aaxiously and for some time awaited the announcement of this new edition of Carpenter's Human Physiology. His former editions have for many years been almost the only text-book on Phy- siology in all our medical schools, and its circula- tion among the profession has been unsurpassed by any work in any department of medical science. it is quite unnecessary for us to speak of this work as its merits would justify. The mere an- nouncement of its appearance will afford the highest pleasure to every student of Physiology, while its perusal will be of infinite service in advancing physiological science.—Ohio Med. and Surg. Journ. AND SCIENTIFIC PUBLICATIONS. 7 CARPENTER (WILLIAM B.), M. D., F. R. S., Examiner in Physiology and Comparative Anatomy in the University of London. THE MICROSCOPE AND ITS REVELATIONS. With an Appendix con- taming the Applications of the Microscope to Clinical Medicine, &c. By F. G. Smith, M. D. Illustrated by four hundred and thirty-four beautiful engravings on wood. In one large and very handsome octavo volume, of 724 pages, extra cloth, $4 00 ; leather, $4 50. Dr. Carpenter's position as a microscopist and physiologist, and his great experience as a teacher. eminently qualify him to produce what has long been wanted—a good text-book on the practical use of the microscope. In the present volume his object has been, as stated in his Preface, « to combine, within a moderate compass, that information with regard to the use of his 'tools,' which is most essential to the working microscopist, with such an account of the objects best fitted for his study, as might qualify him to comprehend what he observes, and might thus prepare him to benefit science, whilst expanding and refreshing his own mind " That he has succeeded in accom- plishing this, no one acquainted with his previous labors can doubt. The great importance of the microscope as a means of diagnosis, and the number of microsco- pists who are also physicians, have induced the American publishers, with the author's approval, to add an Appendix, carefully prepared by Professor Smith, on the applications of the instrument' to clinical medicine, together with an account of American Microscopes, their modifications and accessories. This portion of the work is illustrated with nearly one hundred wood-cuts, and, it is hoped, will adapt the volume more particularly to the use of the American student. Those who are acquainted with Dr. Carpenter's previous writings on Animal and Vegetable Physio- logy , will fully understand how vast a store of know- ledge he is able to bring to bear upon so comprehen- sive a subject as the revelations of the microscope j and even those who have no previous acquaintance with the construction or uses of this instrument, will find abundance of information conveyed in clear and simple language.—Med. Times and Gazette. Although originally not intended as a strictly medical work, the additions by Prof. Smith give it a positive claim upon the profession, for which we doubt not he will receive their sincere thanks. In- deed, we know not where the student of medicine will find such a complete and satisfactory collection of microscopic facts bearing upon physiology and practical medicine as is contained in Prof. Smith's appendix; and this of itself, it seems to us, is fully worth the cost of the volume.—Louisville Medical Review. BY THE SAME AUTHOR. ELEMENTS (OR MANUAL) OF PHYSIOLOGY, INCLUDING PHYSIO- LOGICAL ANATOMY. Second American, from a new and revised London edition. With one hundred and ninety illustrations. In one very handsome octavo volume, leather, pp. 566. $3 00. In publishing the first edition of this work, its title was altered from that of the London volume, by the substitution of the word " Elements" for that of " Manual," and with the author's sanction the title of " Elements" is still retained as being more expressive of the scope of the treatise. To say that it is the best manual of Physiology now before the public, would not do sufficient justice to the author.—Buffalo Medical Journal. In his former works it would seem that he had exhausted the subjectof Physiology. In the present, he gives the essence, as it were, of the whole.—N. Y. Journal of Medicine. Those who have occasion for an elementary trea- tise on Physiology, cannot do better than to possess themselves of the manual of Dr. Carpenter.—Medical Examiner. The best and most complete expose1 of modern Physiology, in one volume, extant in the English language.—St. Louis Medical Journal. BY THE SAME AUTHOR. PRINCIPLES OF COMPARATIVE PHYSIOLOGY. New American, from the Fourth and Revised London edition. In one large and handsome octavo volume, with over three hundred beautiful illustrations, pp. 752. Extra cloth, $4 80; leather, raised bands, $5 25. This book should not only be read but thoroughly studied by every member of the profession. None are too wise or old, to be benefited thereby. But especially to the younger class would we cordially commend it as best fitted of any work in the English language to qualify them for the reception and com- prehension of those truths which are daily being de- veloped in physiology.—Medical Counsellor. Without pretending to it, it is an encyclopedia of the subject, accurate and complete in all respects— a truthful reflection of the advanced state at which the science has now arrived.—Dublin Quarterly Journal of Medical Science. A truly magnificent work—in itself a perfect phy- siological study.—Ranking's Abstract. This work stands without its fellow. It is one few men in Europe could have undertaken; it is one no man, we believe, could have brought to so suc- cessful an issue as Dr. Carpenter, ft required for its production a physiologist at once deeply read in the labors of others, capable of taking a general, critical,and unprejudiced view of those labors, and of combining the varied, heterogeneous materials at his disposal, so as to form an harmonious whole. We feel that this abstract can give the reader a very imperfect idea of the fulness of this work, and no idea of its unity, of the admirable marner in which material has been brought, from the most various sources, to conduce to its completeness, of the lucid- ity of the reasoning it contains, or of the clearness of language in which the whole is clothed. Not the profession only, but the scientific world at large, must feel deeply indebted to Dr. Carpenter for this great work. It must, indeed, add largely even to his high reputation.—Medical Times. by the same author. (Preparing.) PRINCIPLES OF GENERAL PHYSIOLOGY, INCLUDING ORGANIC CHEMISTRY AND HISTOLOGY. With a General Sketch of the Vegetable and Animal Kingdom. In one large and very handsome octavo volume, with several hundred illustrations. BY THE SAME AUTHOR. A PRIZE ESSAY ON THE USE OF ALCOHOLIC LIQUORS IN HEALTH AND DISEASE. New edition, with a Preface by D. F. Condie, M. D., and explanations of scientific words. In one neat 12mo. volume, extra cloth, pp. 178. 50 cents. BLANCHARD & LEA'S MEDICAL CONDIE (D. F.), M. D., «tc. A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. Fifth edition, revised and augmented. In one large volume, 8vo., leather, of over 750 pages. $3 25. (Just Issued, 1859.) In presenting a new and revised edition of this favorite work, the publishers have only to state that the author has endeavored to render it in every respect " a complete and faithful exposition of the pathology and therapeutics of the maladies incident to the earlier stages of existence—a full and exact account of the diseases of infancy and childhood." To accomplish this he has subjected the whole work to a careful and thorough revision, rewriting a considerable portion, and adding several new chapters. In this manner it is hoped that any deficiencies which may have previously existed have been supplied, that the recent labors of practitioners and observers have been tho- roughly incorporated, and that in every point the work will be found to maintain the high reputation it has enjoyed as a complete and thoroughly practical book of reference in infantile affections. A few notices of previous editions are subjoined. Dr. Condie's scholarship, acumen, industry, and practical sense are manifested in this, as in all his numerous contributions to science.—Dr. Holmes's Report to the American Medical Association. Taken as a whole, in our judgment. Dr. Condie's Treatise is the one from the perusal of which the practitioner in this country will rise with the great- est satisfaction.—Western Journal of Medicine and Surgery. One of the best works upon the Diseases of Chil- dren in the English language.—Western Lancet. We feel assured from actual experience that no physician's library can be complete without a copy of this work.—N. Y. Journal of Medicine. A veritable paediatric encyclopaedia, and an honor to American medical literature.—Ohio Medical and Surgical Journal. We feel persuaded that the American medical pro- fession will soon regard it not only as a very good We pronounced the first edition to be the beat work,on the diseases of children in the English language, and, notwithstanding all that has been published, we still regard it in that light.—Medical Examiner. The value of works by native authors on the dis- eases which the physician is called upon to combat, will be appreciated by all; and the work of Dr. Con- die has gained for itself the character of a safe guide for students, and a useful work for consultation by those engaged in practice.—N. Y. Med. Times. This is the fourth edition of this deservedly popu- lar treatise. During the interval since the last edi- tion, it has been subjected to a thorough revision by the author; and all new observations in the pathology and therapeutics of children have been included in the present volume. As we said btfore, we do not know of a better book on diseases of chil- dren, and to a large part of its recommendations we yield an unhesitating concurrence.—Buffalo Med. but as the vert best "Practical Treatise on the Journal. Diseases of Children."—American Medical Journal Perhaps the most full and complete work now be- In the department of infantile therapeutics, the fore the profession of the United States; indeed, we work of Dr. Condie is considered one of the best may say in the English language. It is vastly supe- which has been published in the English language, rior to most of its predecessors.—Transylvania Med. —The Stethoscope. [journal. CHRISTISON (ROBERT), M, D., V. P. R. S. E., «tc. A DISPENSATORY; or, Commentary on the Pharmacopoeias of Great Britain and the United States; comprising the Natural History, Description, Chemistry, Pharmacy, Ac- tions, Uses, and Doses of the Articles of the Materia Medica. Second edition, revised and im- proved, with a Supplement containing the most important New Remedies. With copious Addi- tions, and two hundred and thirteen large wood-engravings. By R. Eglesfeld Griffith, M. D. In one very large and handsome octavo volume, leather, raised bands, of over 1000 pages. $3 50. COOPER (BRANSBY B.), F. R. S. LECTURES ON THE PRINCIPLES AND PRACTICE OF SURGERY. In one very large octavo volume, extra cloth, of 750 pages. $3 00. COOPER ON DISLOCATIONS AND FRAC- TURES OF THE JOINTS—Edited by Bransby B. Cooper, F. R. S., &c. With additional Ob- servations by Prof. J. C. Warren. A new Ame- rican edition. In one handsome octavo volume, extra cloth, of about 500 pages, with numerous illustrations on wood. $3 25. COOPER ON THE ANATOMY AND DISEASES OF THE BREAST, with twenty-five Miscellane- ous and Surgical Papers. One large volume, im- perial 8vo., extra cloth, with 252 figures, on 36 plates. $2 50. COOPER ON THE STRUCTURE AND DIS- EASES OF THE TESTIS, AND ON THE THYMUS GLAND. One vol. imperial 8vo., ex- tra cloth, with 177 figures on 29 plates. $2 00. COPLAND ON THE CAUSES, NATURE, AND TREATMENT OF PALSY AND APOPLEXY. In one volume, royal 12mo., extra cloth, pp. 326. 80 cents. CLYMER ON FEVERS; THEIR DIAGNOSIS, PATHOLOGY, AND TREATMENT In one octavo volume, leather, of 600 pages. $1 50. COLOMBAT DE L'ISERE ON THE DISEASES OF FEMALES, and on the special Hygiene of their Sex. Translated, with many Notes and Ad- ditions, by C. D. Meigs, M. D. Second edition, revised and improved. In one large volume, oc- tavo, leather, with numerous wood-cuts. pp. 720. 83 50. CARSON (JOSEPH), M. D., Professor of Materia Medica and Pharmacy in the University of Pennsylvania. SYNOPSIS OF THE COURSE OF LECTURES ON MATERIA MEDICA AND PHARMACY, delivered in the University of Pennsylvania. Second and revised edi- tion. In one very neat octavo volume, extra cloth, of 208 pages. $1 50. CURLING (T. B.), F. R.S., Surgeon to the London Hospital, President of the Hunterian Society, &c. A PRACTICAL TREATISE ON DISEASES OF THE TESTIS, SPERMA- TIC CORD, AND SCROTUM. Second American, from the second and enlarged English edi- tion. In one handsome octavo volume, extra cloth, with numerous illustrations, pp. 420. $2 00, AND SCIENTIFIC PUBLICATIONS. 9 CHURCHILL (FLEETWOOD), M. D., M. R. I. A. ON THE THEORY AND PRACTICE OF MIDWIFERY. A new American from the fourth revised and enlarged London edition. With Notes and Additions, by D. Francis Condie, M. D., author of a "Practical Treatise on the Diseases of Children," &c. With 194 illustrations In one very handsome octavo volume, leather, of nearly 700 large pages. $3 50. (Just Issued.) This work has been so long an established favorite, both as a text-book for the learner and as a reliable aid in consultation for the practitioner, that in presenting a new edition it is only necessary to call attention to the very extended improvements which it has received. Having had the benefit of two revisions by the author since the last American reprint, it has been materially enlarged, and Dr. Churchill's well-known conscientious industry is a guarantee that every portion has been tho- roughly brought up with the latest results of European investigation in all departments of the sci- ence and art of obstetrics. The recent date of the last Dublin edition has not left much of novelty for the American editor to introduce, but he has endeavored to insert whatever has since appeared, together with such matters as his experience has shown him would be desirable for the American student, including a large number of illustrations. With the sanction of the author he has added in the form of an appendix, some chapters from a little "Manual for Midwives and Nurses," re- cently issued by Dr. Churchill, believing that the details there presented can hardly fail to prove of advantage to the junior practitioner. The result of all these additions is that the work now con- tains fully one-half more matter than the last American edition, with nearly one-half more illus- trations, so that notwithstanding the use of a smaller type, the volume contains almost two hundred pages more than before. No effort has been spared to secure an improvement in the mechanical execution of the work equal to that which the text has received, and the volume is confidently presented as one of the handsomest that has thus far been laid before the American profession; while the very low price at which it is offered should secure for it a place in every lecture-room and on every office table. The most popular work on midwifery ever issued 'rom the American press.—Charleston Med. Journal. Were we reduced to the necessity of having but me work on midwifery, and permitted to choose, A better book in which to learn these important points we have not met than Dr. Churchill's. Every page of it is full of instruction; the opinion of all writers of authority is given on questions of diffi- culty, as well as the directions and advice of the learned autftor himself, to which he adds the result of statistical inquiry, putting statistics in their pro per place and giving them their due weight, and no more. We have never read a book more free from professional jealousy than Dr. Churchill's. It ap- pears to be written with the true design of a book on medicine, viz: to give all that is known on the sub- ject of which he treats, both theoretically and prac- tically, and to advance such opinions of his own as he believes will benefit medical science, and insure the safety of the patient. We have said enough to convey to the profession that this book of Dr. Chur- chill's is admirably suited for a book of reference for the practitioner, as well as a text-book for the student, and we hope it may be extensively pur- chased amongst our readers. To them we most strongly recommend it. — Dublin Medical Press, June 20, 1860. To bestow praise on a book that has received such marked approbation would be superfluous. We need only say, therefore, that if the first edition was thought worthy of a favorable reception by the medical public, we can confidently affirm that this will be found much more so. The lecturer, the practitioner, and the student, may all have recourse to its pages, and derive from their perusal much in- terest and instruction in everything relating to theo- retical and practical midwifery.—Dublin Quarterly Journal of Medical Science. A work of very great merit, and such as we can confidently recommend to the study of every obste- tric practitioner.—London Medical Gazette. This is certainly the most perfect system extant. It is the best adapted for the purposes of a text- book, and that which he whose necessities confine him to one book, should select in preference to all others.—Southern Medical and Surgical Journal. BY THE SAME AUTHOR we would unhesitatingly take Churchill.—Western Med. and Surg. Journal. It is impossible to conceive a more useful and ilegant manual than Dr. Churchill's Practice of Midwifery.—Provincial Medical Journal. Certainly, in our opinion, the very best work on he subject which exists.—N. Y. Annalist. No work holds a higher position, or is more de- serving of being placed in the hands of the tyro, the advanced student, or the practitioner.—Medical Examiner. Previous editions, under the editorial supervision of Prof. R. M. Huston, have been received with marked favor, and they deserved it; but this, re- printed from a very late Dublin edition, carefully revised and brought up by the author to the present time, does present an unusually accurate and able exposition of every important particular embraced in the department of midwifery. * * The clearness, directness, and precision of its teachings, together with the great amount of statistical research which its text exhibits, have served to place it already in the foremost rank of works in this department of re medial science.—N. O. Med. and Surg. Journal. In our opinion, it forms one of the best if not th. very best text-book and epitome of obstetric science which we at r/resent possess in the English lan- guage.—Monthly Journal of Medical Science. The clearness and precision of style in which it ia written, and the great amount of statistical research which it contains, have served to place it in the first rank of works in this departmentof medical science. —N. Y. Journal of Medicine. Few treatises will be found better adapted as a text-book for the student, or as a manual for tha frequent consultation of the young practitioner.— American Medical Journal. (Lately Published.) ON THE DISEASES OF INFANTS AND CHILDREN. Second American FHition revised and enlarged by the author. Edited, with Notes, by W. V. Keating, M. D. In SeI largeand harXome vdume, extra cloth, of over 700 pages. $3 00, or in leather, $3 25. In DreDarine this work a second time for the American profession, the author has spared no labor in eivinl it a very thorough revision, introducing several new chapters, and rewriting others, while eTOre portion of the volume has been subjected to a severe scrutiny. The efforts of the Americln editor have been directed to supplying such information relative to matters peculiar to this country as might have escaped the attention of the author and the whole may, there- fore b^sSy pronounced one of the most complete works on the subject accessible to the Ame- rican ProKoni By an alteration in the size of the page, these very extensive additions have been accommodated without unduly increasing the size of the work. BY THE SAME AUTHOR. ESSAYS ON THE PUERPERAL FEVER, AND OTHER DISEASES PE- CULIAR TO WOMEN. Selected from the writings of British Authors previous to the close of the Eighteenth Century. In one neat octavo volume, extra cloth, of about 450 pages. $2 50. 10 BLANCHARD & LEA'S MEDICAL CHURCHILL (FLEETWOOD), M. D., M. R. I. A., Sec. ON THE DISEASES OF WOMEN; including those of Pregnancy and Child- bed. A new American edition, revised by the Author. With Notes and Additions, by D Fran Cis Condie, M.D., author ot "A Practical Treatise on the Diseases of Children." With nume rous illustrations. In one large and handsome octavo volume, leather, of 768 pages. $3 00. This edition of Dr. Churchill's very popular treatise may almost be termed a new work, so thoroughly has he revised it in every portion. It will be found greatly enlarged, and completely brought up to the most recent condition of the subject, while the very handsome series of illustra- tions introduced, representing such pathological conditions as can be accurately portrayed, present a novel feature, and afford valuable assistance to the young practitioner. Such additions as ap- peared desirable for the American student have been made by the editor, Dr. Condie, while a marked improvement in the mechanical execution keeps pace with the advance in all other respects which the volume has undergone, while the price has been kept at the former very moderate rate. It comprises, unquestionably, one of the most ex- act and comprehensive expositions of the present state of medical knowledge in respect to the diseases of women that has yet been published.—Am. Journ. Med. Sciences. This work is the most reliable which we possess on this subject; and is deservedly popular with the profession.—Charleston Med. Journal, July, 1857. We know of no author who deserves that appro- bation, on "the diseases of females," to the same extent that Dr. Churchill does. His, indeed, is the only thorough treatise we know of on the subject j and it may be commended to practitioners and stu- dents as a masterpiece in its particular department, —Tht Western Journal of Medicine and Surgery. As a comprehensive manual for students, or a work of reference for practitioners, it surpasses any other that has ever issued on the same subject from the British press.—Dublin Quart. Journal. DICKSON (S. H.), M. D., Professor of Practice of Medicine in the Jefferson Medical College, Philadelphia ELEMENTS OF MEDICINE; a Compendious View of Pathology and Thera- peutics, or the History and Treatment of Diseases. Second edition, revised. In one large and handsome octavo volume of 750 pages, leather. $3 75. (Just Issued.) The steady demand which has so soon exhausted the first edition of this work, sufficiently shows that the author was not mistaken in supposing that a volume of this character was needed—an elementary manual of practice, which should present the leading principles of medicine with the practical results, in a condensed and perspicuous manner. Disencumbered of unnecessary detail and fruitless speculations, it embodies what is most requisite for the student to learn, and at the same time what the active practitioner wants when obliged, in the daily calls of his profession, to refresh his memory on special points. The clear and attractive style of the author renders the whole easy of comprehension, while his long experience gives to his teachings an authority every- where acknowledged. Few physicians, indeed, have had wider opportunities for observation and experience, and few, perhaps, have used them to better purpose. As the result of a long life de- voted to study and practice, the present edition, revised and brought up to the date of publication, will doubtless maintain the reputation already acquired as a condensed and convenient American text-book on the Practice of Medicine. DRUITT (ROBERT), M.R. C.S., file. THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. A new and revised American from the eighth enlarged and improved London edition. Illustrated with four hundred and thirty-two wood-engravings. In one very handsomely printed octavo volume, leather, of nearly 700 large pages. $3 50. (Just Issued.) A work which like Damn's Surgery has for so many years maintained the position of a lead- ing favorite with all classes of the profession, needs no special recommendation to attract attention to a revised edition. It is only necessary to state that the author has spared no pains to keep the work up to its well earned reputation of presenting in a small and convenient compass the latest condition of every department of surgery, considered both as a science and as an art; and that the services of a competent American editor have been employed to introduce whatever novelties may have escaped the author's attention, or may prove of service to the American practitioner. As several editions have appeared in London since the issue of the last Americao reprint, the volume has had the benefit of repeated revisions by the author, resulting in a very thorough alteration and improvement. The extent of these additions may be estimated from the fact that it now contains about one-third more matter than the previous American edition, and that notwithstanding the adoption of a smaller type, the pages have been increased by about one hundred, while nearly two hundred and fifty wood-cuts have been added to the former list of illustrations. A marked improvement will also be perceived in the mechanical and artistical execution of the work, which, printed in the best style, on new type, and fine paper, leaves little to be desired as regards external finish; while at the very low price affixed it will be found one of the cheapest volumes accessible to the profession. This popular volume, now a most comprehensive work on surgery, has undergone many corrections, improvements, and additions, and the principles and the practice of the art have been brought down to the latest record and observation. Of the operations in surgery it is impossible to speak too highly. The descriptions are so clear and concise, and the illus- trations so accurate and numerous, that the student can have no difficulty, With instrument in hand, and book by his side, over the dead body, in obtaining a proper knowledge and sufficient tact in this much neglected department of medical education.—British and Foreign Medico-Chirurg. Review, Jan. 1S60. In the present edition the author has entirely re- written many of the chapters, and has incorporated the various improvements and additions in modern surgery. On carefully going over it, we find that | Journal of Med. Sciences, Nov. 1859. nothing of real practical importance has been omit- ted ; it presents a faithful epitome of everything re- lating t > surgery up to the present hour. It is de- servedly a popular manual, both with the student and practitioner.—London Lancet, Nov. 19, 1859. In closing this brief notice, we recommend as cor- dially as ever this most useful and comprehensive hand-book. It must prove a vast assistance, not only to the student of surgery, but also to the busy practitioner who may not have the leisure to devote himself to the study of more lengthy volumes.— London Med. Times and Gazette, Oct. 22,1859. In a word, this eighth edition of Dr Druitt's Manual of Surgery is all that the surgical student or practitioner could desire. — Dublin Quarterly AND SCIENTIFIC PUBLICATIONS. 11 DALTON, JR. (J. C), M. D. Professor of Physiology in the College of Physicians, New York. A TREATISE ON HUMAN PHYSIOLOGY, designed for the use of Students and Practitioners of Medicine. Second edition, revised and enlarged, with two hundred and seventy-one illustrations on wood. In one very beautiful octavo volume, of 700 pages, extra cloth, §4 00; leather, raised bands, $4 50. (Just Issued, 1861.) The general favor which has so soon exhausted an edition of this work has afforded the author an opportunity in its revision of supplying the deficiencies which existed in the former volume. This has caused the insertion of two new chapters—one on the Special Senses, the other on Im- bibition, Exhalation, and the Functions of the Lymphatic System—besides numerous additions of smaller amount scattered through the work, and a general revision designed to bring it thoroughly up to the present condition of the science with regard to all points which may be considered as definitely settled. A number of new illustrations has been introduced, and the Work, it is hoped, in its improved form, may continue to command the confidence of those for whose use it is in- tended. It will be seen, therefore, that Dr. Dalton's best I own original views and experiments, together with efforts have been directed towards perfecting his a desire to supply what he considered some deficien- work. The additions are marked by the same fea- cies in the first edition, have already made the pre tures which characterize the remainder of the vol uine, and render it by far the most desirable text- book on physiology to place in the hands of the student which, so far as we are aware, exists in the English language, or perhaps in any other. We therefore have no hesitation in recommending Dr. Dalton's book for the classes for which it is intend- ed, satisfied as we are that it is better adapted to their use than any other work of the kind to which they have access.—American Journal of the Med. Sciences, April, 1861. It is, therefore, no disparagement to the many books upon physiology, most excellent in their day, to say that Dalton's is the only one that gives us the science as it was known to the best philosophers throughout the world, at the beginning of the cur- rent year. It states in comprehensive but concise diction, the facts established by experiment, or other method of demonstration, and details, in an understandable manner, how it is done, but abstains from the discussion of unsettled or theoretical points. Herein it is unique; and these characteristics ren der it a text-book without a rival, for those who desire to study physiological science as it is known to its most successful cultivators. And it is physi- ology thus presented that lies at the foundation of correct pathological knowledge; and this in turn is the basis of rational therapeutics; so that pathalo- gy, in fact, becomes of prime importance in the proper discharge of our every-day practical duties. —Cincinnati Lancet, May, 1861. Dr. Dalton needs no word of praise from us. He is universally recognized as among the first, if not the very first, of American physiologists now living. The first edition of his admirable work appeared but two years since, and the advance of science, his Bent one a necessity, and it will no doubt be even more eagerly sought for than the first. That it is not mereTy a reprint, will be seen from the author's statement of the following principal additions and alterations which he has made. The present, like the first edition, is printed in the highest style of the printer's art, and the illustrations are truly admira- ble tor their clearness in expressing exactly what their author intended.—Boston Medical and Surgi- cal Journal, March 28, 1861. It is unnecessary to give a detail of the additions j suffice it to say, that they are numerous and import- ant, and such as will render the work still more valuable and acceptable to the profession as a learn- ed and original treatise on this all-important branch of medicine. All that was said in commendation of the getting up of the first edition, and the superior style of the illustrations, apply with equal force to this. No better work on physiology can be placed in the hand of the student.—St. Louis Medical and Surgical Journal, May, 1861. These additions, while testifying to the learning and industry of the author, render the book exceed- ingly useful, as the most complete expose of a sci- ence, of which Dr. Dalton is doubtless the ablest representative on this side of the Atlantic.—New Orleans Med. Times, May, 1861. A second edition of this deservedly popular work having been called for in the short space of two years, the author has supplied deficiencies, which existed in the former volume, and has thus more completely fulfilled his design of presenting to the profession a reliable and precise text-book, and one which we consider the best outline on the subject of which it treats, in any language— N. American Medico-Chirurg. Review, May, 1861. DUNGLISON, FORBES, TWEEDIE, AND CONOLLY. THE CYCLOPAEDIA OF PRACTICAL MEDICINE: comprising Treatises on the Nature and Treatment of Diseases, Materia Medica, and Therapeutics, Diseases of Women and Children, Medical Jurisprudence, &c &c. In four large super-royal octavo volumes, of 3254 double-columned pages, strongly and handsomely bound, with raised bands. $12 00. * * This work contains no less than four hundred and eighteen distinct treatises, contributed by t*tfeigi^Su2ed?hySiCmns,veadevmgit a complete library of reference for the country practitioner The most complete work on Practical Medicine •xtant; or, at least, in our language—Buffalo Medical and Surgical Journal. For reference, it is above all price to every prac- titioner.— Western Lancet. One of the most valuable medical publications of the day—as a work of reference it is invaluable— Western Journal of Medicine and Surgery. It has been to us, both as learner and teacher, a work for ready and frequent reference, one in which modern English medicine is exhibited in the most advantageous light—Medical Examiner. The editors are practitioners of established repu- tation, and the list of contributors embraces many of the most eminent professors and teachers of Lon- don, Edinburgh, Dublin, and Glasgow. It is, in- deed, the great merit ol this work that theprincipal articles have been furnished by practitioners who have not only devoted especial attention to the dis- eases about which they have written, but have also enjoyed opportunities for an extensive practi- cal acquaintance with them and whose reputation carries the assurance of their competency justly to appreciate the opinions of others, while it stamps their own doctrines with high and just authority— American Medical Journal. DEWEES'S COMPREHENSIVE SYSTEM OF MIDWIFERY. Illustrated by occasional cases and many engravings. Twelfth edition, with the author's'last improvements and corrections^ In one octavo volume, extracloth.of 600pages. $320. DEWEES'S TREATISE ON THE PHYSICAL AND MEDICAL TREATMENT OF CHILD REN. The last edition. In one volume, octavo, extra cloth, 548 pages. $2 80 DEWEES'S TREATISE ON THE DISEASES OF FEMALES. Tenth edition. In one volume, octavo extra cloth, 532 pages, with plates. $3 00 12 BLANCHARD & LEA'S MEDICAL DUNGLISON (ROBLEY), M.D., Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia. NEW AND ENLARGED EDITION. MEDICAL LEXICON; a Dictionary of Medical Science, containing a concise Explanation of the various Subjects and Terms of Anatomy, Physiology, Pathology, Hygiene, Therapeutics, Pharmacology, Pharmacy, Surgery, Obstetrics, Medical Jurisprudence, Dentistry, &c. Notices of Climate and of Mineral Waters; Formulae for Officinal, Empirical, and Dietetic Preparations, &c. With French and other Synonymes. Revised and very greatly enlarged. In one very large and handsome octavo volume, of 992 double-columned pages, in small type ; strongly bound in leather, with raised bands. Price $4 00. Especial care has been devoted in the preparation of this edition to render it in every respect worthy a continuance of the very remarkable favor which it has hitherto enjoyed. The rapid sale of Fifteen large editions, and the constantly increasing demand, show that it is regarded by the profession as the standard authority. Stimulated by this fact, the author has endeavored in the present revision to introduce whatever might be necessary " to make it a satisfactory and desira- ble—if not indispensable—lexicon, in which the student may search without disappointment for every term that has been legitimated in the nomenclature of the science." To accomplish this, large additions have been found requisite, and the extent of the author's labors may be estimated from the fact that about Six Thousand subjects and terms have been introduced throughout, ren- dering the whole number of definitions about Sixty Thousand, to accommodate which, the num- ber of pages has been increased by nearly a hundred, notwithstanding an enlargement in the size of the page. The medical press, both in this country and in England, has pronounced the work in- dispensable to all medical students and practitioners, and the present improved edition will not lose that enviable reputation. The publishers have endeavored to render the mechanical execution worthy of a volume of such universal use in daily reference. The greatest care hns been exercised to obtain the typographical accuracy so necessary in a work of the kind. By the small but exceedingly clear type employed, an immense amount of matter is condensed in its thousand ample pages, while the binding will be found strong and durable. With all these improvements and enlargements, the price has been kept at the former very moderate rate, placing it within the reach of all. This work, the appearance of the fifteenth edition of 'which, it has become our duty and pleasure to announce, is perhaps the most stupendous monument of labor and erudition in medical literature. One would hardly suppose after constant use of the pre- ceding editions, where we have never failed to find a sufficiently full explanation of everj medical term, that in this edition "about six thousand subjects and terms have been added," with a careful revision and correction of the entire work. It is only neces- sary to announce the advent of this edition to make it occupy the place of the preceding one on the table of every medical man, as it is without doubt the best and most comprehensive work of the kind which has ever appeared.—Buffalo Med. Journ., Jan. 1858. The work is a monument of patient research, skilful judgment, and vast physical labor, that will perpetuate the name of the author more effectually than any possible device of stone or metal. Dr. Dunglison deserves the thanks not only of the Ame- rican profession, but of the whole medical world.— North Am. Medico-Chir. Review, Jan. 1858. A Medical Dictionary better adapted for the wants of the profession than any other with which we are acquainted, and of a character which places it far above comparison and competition.—Am. Journ. Med. Sciences, Jan. 1858. We need only say, that the addition of 6,000 new terms, with their accompanying definitions, may be said to constitute a new work, by itself. We have examined the Dictionary attentively, and are most happy to pronounce it unrivalled of its kind. The erudition displayed, and the extraordinary industry which must have been demanded, in its preparation and perfection, redound to the lasting credit of its author, and have furnished us with a volume indis- pensable at the present day, to all who would find themselves au niveau with the highest standards of medical information.—Boston Medical and Surgical Journal, Dec. 31, 1857. Good lexicons and encyclopedic works generally, aTe the most labor-saving contrivances which lite- rary men enjoy; and the labor which is required to produce them in the perfect manner of this example is something appalling to contemplate. The author tells us in his preface that he has added about six thousand terms and subjects to this edition, which, before, was considered universally as the best work of the kind in any language.—Silliman's Journal, March, 1858. He has razed his gigantic structure to the founda- tions, and remodelled and reconstructed the entire pile. No less than six thousand additional subjects and terms are illustrated and analyzed in this new edition, swelling the grand aggregate to beyond sixty thousand ! Thus is placed before the profes- sion a complete and thorough exponent of medical terminology, without rival or possibility of rivalry. —Nashville Journ. of Med. and Surg., Jan. 1858. It is universally acknowledged, we believe, that this work is incomparably the best and moBt com- plete Medical Lexicon in the English language. The amount of labor which the distinguished authoT has bestowed upon it is truly wonderful, and the learning and research displayed in its preparation are equally remarkable. Comment and commenda- tion are unnecessary, as no one at the present day thinks of purchasing any other Medical Dictionary than this.—St. Louis Med. and Surg. Journ., Jan. 1858. It is the foundation stone of a good medical libra- ry, and should always be included in the first list of books purchased by the medical student.—Am. Med. Monthly, Jan. 1858. A very perfect work of the kind, undoubtedly the most perfect in the English language.—Med. and Surg. Reporter, Jan. 1868. It is now emphatically the Medical Dictionary of the English language, and for it there is no substi- tute.— N. H. Med. Journ., Jan. 1858. It is scarcely necessary to remark that any medi- cal library wanting a copy of Dunglison's Lexicon must be imperfect.—Cin. Lancet, Jan. 1858. We have ever considered it the best authority pub- lished, and the present edition we may safely say haa no equal in the world.—Peninsular Med. Journal, Jan.1858. The most complete authority on the subject to b« found in any language.—Va.Med. Journal, Feb. '58. BY THE SAME AUTHOR. THE PRACTICE OF MEDICINE. A Treatise on Special Pathology and The- rapeutics. Third Edition. In two large octavo volumes, leather, of 1,500 pages. 56 25. AND SCIENTIFIC PUBLICATIONS. 13 DUNGLISON (ROBLEY), M.D., Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia. HUMAN PHYSIOLOGY. Eighth edition. Thoroughly revised and exten- sively modified and enlarged, with five hundred and thirty-two illustrations. In two large and handsomely printed octavo volumes, leather, of about 1500 pages. $7 00. In revising this work for its eighth appearance, the author has spared no labor to render it worthy a continuance of the very great favor which has been extended to it by the profession. The whole contents have been rearranged, and to a great extent remodelled; the investigations which of late years have been so numerous and so important, have been carefully examined and incorporated, and the work in every respect has been brought up to a level with the present state of the subject. The object of the author has been to render it a concise but comprehensive treatise, containing the whole body of physiological science, to which the student and man of science can at all times refer with the certainty of finding whatever they are in search of, fully presented in all its aspects; and on no former edition has the author bestowed more labor to secure this result. We believe that it can truly be said, no more com- plete repertory of facts upon the subject treated, can anywhere be found. The author has, moreover, that enviable tact at description and that facility and ease of expression which render him peculiarly acceptable to the casual, or the studious reader. This faculty, so requisite in setting forth many graver and less attractive subjects, lends additional chaTms to one always fascinating.—Boston Med. and Surg. Journal. The most complete and satisfactory system of Physiology in the English language.—Amer. Med Journal. The best work of the kind in the English lan- guage.—Silliman's Journal. The present edition the author has made a perfect mirror of the science as it is at the present hour. As a work upon physiology proper, the science of the functions performed by the body, the student will find it all he wishes.—Nashville Journ. of Med. That he has succeeded, most admirably succeeded in his purpose, is apparent from the appearance of an eighth edition. It is now the great encyclopaedia on the subject, and worthy of a place in every phy- sician's library.—Western Lancet. BY THE same author. (A new edition.) GENERAL THERAPEUTICS AND MATERIA MEDICA; adapted for a Medical Text-book. With Indexes of Remedies and of Diseases and their Remedies. Sixth Edition, revised and improved. With one hundred and ninety-three illustrations. In two large and handsomely printed octavo vols., leather, of about 1100 pages. $6 00. In announcing a new edition of Dr. Dunglison's General Therapeutics and Materia Medica, we have no words of commendation to bestow upon a work whose merits have been heretofore so often and so justly extolled. It must not be supposed, however, that the present is a mere reprint of the previous edition: the character of the author for laborious research, judicious analysis, and clearness of ex- pression, is fully sustained by the numerous addi- tions he has made to the work, and the careful re- vision to which he has subjected the whole.—JV. A. Medico-Chir. Review, Jan. 1858. The work will, we have little doubt, be bought and read by the majority of medical students; its size, arrangement, and reliability recommend it to all; no one, we venture to predict, will study it without profit, and there are few to whom it will not be in some measure useful as a work of refer- ence. The young practitioner, more especially, will find the copious indexes appended to this edition of great assistance in the selection and preparation of suitable formulae.—Charleston Med. Journ. and Re- view, Jan. 1858. by the same author. (A new Edition.) NEW REMEDIES, WITH FORMULAE FOR THEIR PREPARATION AND ADMINISTRATION. Seventh edition, with extensive Additions. In one very large octavo volume, leather, of 770 pages. $3 75. Another edition of the "New Remedies" having been called for, the author has endeavored to add everything of moment that has appeared since the publication of the last edition. The articles treated of in the former editions will be found to have undergone considerable ex- pansion in this, in order that the author might be enabled to introduce, as far as practicable, the re*ults of the subsequent experience of others, as well as of his own observation and reflection ; and to make the work still more deserving of the extended circulation with which the preceding edition* have been favored by the profession. By an enlargement of the page, the numerous addi- tions have been incorporated without greatly increasing the bulk of the volume.—Preface. The great learning of the author, and his remark- able industry in pushing his researches into every source whence information is derivable,have enabled him to throw together an extensive mass of facts and statements, accompanied by full reference to authorities; which last feature renders the work practically valuable to investigators who desire te examine the original papers.—The American Journal of Pharmacy. One of the most useful of the author's works— Southern Medical and Surgical Journal. This elaborate and useful volume should be found in every medical library, for as a book of re- ference, for physicians, it is unsurpassed by any other work in existence, and the double index for diseases and for remedies, will be found greatly to enhance its value.—New York Med. Gazette. ELLIS (BENJAMIN), M.D. THE MEDICAL FORMULARY: being a Collection of Prescriptions, derived from the writings and practice of many of the most eminent physicians of America and Europe. To?e her w th the usual Dietetic Preparations and Antidotes for Poisons. To which is added anSenatorl the Endermic use of Medicines, and on the use of Ether and Chloroform. The w^hole accompanied1 with a few brief Pharmaceutic and Medical Observations. Eleventh editior, «v?'ed and much expended by Robert P. Thomas, M. D., Professor of Materia Medica in the Philadelphia College of Pharmacy. (Preparing.) 14 BLANCHARD & LEA'S MEDICAL ERICHSEN (JOHN), Professor of Surgery in University College, London, &C. THE SCIENCE AND ART OF SURGERY; being a Treatise on Surgical Injuries, Diseases, and Operations. New and improved American, from the second enlarged and carefully revised London edition. Illustrated with over four hundred engravings on wood. In one large and handsome octavo volume, of one thousand closely printed pages, leather, raised bands. $4 50. (Just Issued.) The very distinguished favor with which this work has been received on both sides of the Atlan- tic has stimulated the author to render it even more worthy of the position which it has so rapidly attained as a standard authority. Every portion has been carefully revised, numerous additions have been made, and the most watchful care has been exercised to render it a complete exponent of the most advanced condition of surgical science. In this manner the work has been enlarged by about a hundred pages, while the series of engravings has been increased by more than a hundred, rendering it one of the most thoroughly illustrated volumes before the profession. The additions of the author having rendered unnecessary most of the notes of the former American editor, but little has been added in this country; some few notes and occasional illustrations have, however, been introduced to elucidate American modes of practice. It is, in our humble judgment, decidedly the best book of the kind in the English language. Strange that just such books are notoftener produced by put) lie teachers of surgery in this country and Great Britain Indeed, it is a matter of great astonishment. but no less true than astonishing, that of the many works on surgery republished in this country within the last fifteen or twenty years as text-books for medical students, this is the only one that even ap- proximates to Ihe fulfilment of the peculiar wants of youngmen just entenngupon the study of this branch of the profession.— Western Jour .of Med. ami Surgery. Its value is greatly enhanced by a very copious well-arranged index. We regard this as one of the most valuable contributions to modern surgery. To one entering his novitiate of practice, we regard it the most serviceable guide which he canconsult. He will find a fulness of detailleadinghim throLgh every step of the operation, and not desertine him until the final issue of" the case is decided —Sethoscope. Embracing, as will be perceived, the whole surgi- cal domain, and each division of itself almost com- plete and perfect, each chapterfull and explicit, each subject faithfully exhibited, we can only express oui estimate of it in the aggregate. We consider it an excellent contribution to surgery, as probably the best single volume now extant on the. subject, and with great pleasure we add it to our text-books.— Nashville. Journal of Medicine and Surgery. Prof. Erichsen's work, for its size, has not been surpassed; his nine hundred and eight pages, pro- fusely illustrated, are rich in physiological, patholo- gical, and operative suggestions, doctrines, details, and processes ; and will prove a reliable resource for information, both to physician and surgeon, in the hour of peril.—N. 0. Med. and Surg. Journal. FLINT (AUSTIN), M. D., Professor of the Theory and Practice of Medicine in the University of Louisville, &c. PHYSICAL EXPLORATION AND DIAGNOSIS OF DISEASES AFFECT- ING THE RESPIRATORY ORGANS. In one large and handsome octavo volume, extra cloth, 636 pages. $3 00. We regard it, in point both of arrangement and of the marked ability of its treatment of the subjects, as destined to take the first rank in works of this class. So far as our information extends, it has at present no equal. To the practitioner, as well as the student, it will be invaluable in clearing up the diagnosis of doubtful cases, and in shedding light upon difficult phenomena.—Buffalo Med. Journal. A work of original observation of the highest merit. Werecommend the treatise to every one who wishes to become a correct auscultator. Based to a very large extent upon cases numerically examined, it carries the evidence of careful study and discrimina- tion upon every page. It does credit to the autnor, and, through him, to the profession in this country. It is, what we cannot call every book upon auscul- tation, a readable book.—Am. Jour. Med. Sciences. BY THE same author. (Now Ready.) A PRACTICAL TREATISE ON THE DIAGNOSIS, PATHOLOGY, AND TREATMENT OF DISEASES OF THE HEART. In one neat octavo volume, of about 500 pages, extra cloth. $2 75. We do no* know that Dr. Flint has written any- thing which is not. first rate; but this, his latest con- tribution to medical literature, in our opinion, sur- passes all the others. The work is most comprehen- sive in its scope, and most sound in the views it enun- ciatits. The descriptions are clear and methodical; the statements are substantiated by facts, and are made with such simplicity and sincerity, that with- out them they would carry conviction. The style is admirably clear, direct, and free from dryness With Dr. Walshe's excellent treatise before us, we have no hesitation in saying that Dr. Flint's book is the best work on the heart in the English language —Boston Med. and Surg. Journal. We have thus endeavored to present our readers with a fair analysis of this remarkable work. Pre- ferring to employ the very words of thedistinguished author, wherever it was possible, we have essayed to condense into the briefest spacea general view of his observations and suggestions, and to direct the attention of our brethren to the abounding stores of valuable matter here collected and arranged for their use and instruction. No medical library will here after be considered complete without this volume j and we trust it will promptly find its way into the hands of every American student and physician.— N Am. Med. Chir. Review. This last work of Prof. Flint will add much to his previous well-earned celebrity, as a writer oi great forceand beauty, and, with his previous work, places him at. the head of American writers upon diseases of the chest. We have adopted his work upon the heart as a text-book, believing it to be more valuable for that purpose than any work of the kind that has yet appeared.—Nashville Med. Journ. With more than pleasure do we hail the advent of this work, for it fills a wide gap on the list < f text- books for our schools, and is, tor the practitioner, then.ost valuable practical work of its kind.—iV. O. Med. News. In regard to the merits of the work, we have no hesitation in pronouncing it full, accurate, and ju- dicious. Considering the pres-nt state of science, such a work was much needed. It should be in the hands of every practitioner.—Chicago Med. Journal. But these are very trivial spots, and in no wise prevent us from declaring our most hearty approval of the author's nbility, industry, and conscientious- ness.—Dublin Quarterly Journal of Med. Sciences, He has labored on with the same industry and care, and his place, among theirs* authors of our country is becoming fully established. To this end, the work whose title is given above, contributes in no small degree. Our spa e will not admit of »n extended analysis, and we will close this brief notice by commending it without reserve to every class of readers in the profession.—Peninsular Med. Journ. AND SCIENTIFIC PUBLICATIONS. 15 FOWNES (GEORGE), PH. D., «tc. A MANUAL OF ELEMENTARY CHEMISTRY; Theoretical and Practical. From the seventh revised and corrected London edition. With one hundred and ninety-seven illustrations. Edited by Robert Bridges, M. D. In one large royal 12mo volume, of 600 pages. In leather, $1 65; extra cloth, $1 50. (Just Issued.) The death of the author having placed the editorial care of this work in the practised hands of Drs. Bence Jones and A. W. Hoffman, everything has been done in its revision which experience could suggest to keep it on a level with the rapid advance of chemical science. The additions requisite to this purpose have Heces:-itated an enlargement of the page, notwithstanding which the work has been increased bv about fifty pages. At the same time every care has been used to maintain its distinctive character as a condensed manual for the student, divested of all unnecessary detail or mere theoretical speculation. The additions have, of course, been mainly in the depart- ment of Organic Chemistry, which has made such rapid progress within the last few years, but yet equal attention has been bestowed on the other branches of the subject—Chemical Physics and Inorganic Chemistry—to present all investigations and discoveries of importance, and to keep up the reputation of the volume as a complete manual of the whole science, admirably adapted for the learner. By the use of a small but exceedinglv clear type the matter of a large octavo is compressed within the convenient and portable limits of a moderate sized duodecimo, and at the very low price affixed, it is offered as one of the cheapest volumes before the profession. Dr. Fownes' excellent work has been universally recognized everywhere in his own and this country, as the best elementary treatise on chemistry in the English tongue, and is very generally adopted, we believe, as the standard text- book in all < ur colleges, both literary and scientific—Charleston Med. Journ. and Review. A standard manual, which has long enjoyed the reputation of embodying much knowledge in a small space. The author has achieved the difficult task of condensation with masterly tact. His book is con- cise without being dry, and brief without being too dogmatical or general.— Virginia Med. and Surgical Journal. The work of Dr. Fownes has long been before the public, and its merits have been fully appreci- ated as the best text-book on chemistry now in existence. We do not, of course, place it in a rank superior to the works of Brande, Graham, Turner, Gregory, or Gmelin, but we say that, as a work for students, it is preferable to any of them.—Lon- don Journal of Medicine. A work well adapted to the wants of the student It is an excellent exposition of the chief doctrines and facts of modern chemistry. The size of the wor k, and still more the condensed yet perspicuous style in which it is written, absolve it from the charges very properly urged against most manuals termed popular.—Edinburgh Journal of Medical Science FISKE FUND PRIZE ESSAYS —THE EF- FECTS OF CLIMATE ON TUBERCULOUS DISEASE. By Edwin Lee, M. R. C. S , London, and THE INFLUENCE OF PREGNANCY ON THE DEVELOPMENT OF TUBERCLES By Edward Warren, M. D , of Edenton, N C. To- gether in one neat 8vo volume, extra cloth. 81 UU. FRICK ON RENAL AFFECTIONS; their Diag- nosis and Pathology. With illustrations. One volume, royal 12mo., extra cloth. 75 cents FERGUSSON (WILLIAM), F. R. S., Professor of Surgery in King's College, London, &c. . A SYSTEM OF PRACTICAL SURGERY. Fourth American, from the third and enlarged London edition. In one large and beautifully printed octavo volume, of about 700 pages, with 393 handsome illustrations, leather. $3 00. GRAHAM (THOMAS), F. R. S. THE ELEMENTS OF INORGANIC CHEMISTRY, including the Apphca- 7~ « «f«h7 With Griffith's " Medical Formulary" and this, the practising physician would be supplied with nearly or quite all the most useful information on the sub- ject.—Charleston Med. Jour, and Review, Jan. 1860 PEASLEE (E. R.), M. D., Professor of Physiology and General Pathology in the New York Medical College. HUMAN HISTOLOGY, in its relations to Anatomy, Physiology, and Pathology; for the use of Medical Students. With four hundred and thirty-four illustrations. In one hand- some octavo volume, of over 600 pages. (Lately Published.) $3 75. It embraces a library upon the topics discussed within itself, and is just what the teacher and learner need. Another advantage, by no means to be over- looked, everything of real value in the wide range which it embraces, is with great skill compressed into an octavo volume of but little more than six hundred pages. We have not only the whole sub- ject of Histology, interesting in itself, ably and fully discussed, but what is of infinitely greater interest to the student, because of greater practical value, are its relations to Anatomy, Physiology, and Pa- thology, which are here fully and satisfactorily set forth.—Nashville Journ. of Med. and Surgery. We would recommend it to the medical student and practitioner, as containing a summary of all that is known of the important subjects which it treats; of all that is contained in the great works of Simon and Lehmann, and the organic chemists in general. Master this one volume, we would say to the medical student and practitioner—master this book and you know all that is known of the great fundamental principles of medicine, and we have no hesitation in saying that it is an honor to the American medi- cal profession that one of its members should have produced it.—St. Louis Med. and Surg. Journal. PEREIRA (JONATHAN), M. D., F. R. S., AND L. S. THE ELEMENTS OF MATERIA MEDICA AND THERAPEUTICS. Third American edition, enlarged and improved by the author; including Notices of most of the Medicinal Substances in use in the civilized world, and forming an Encyclopaedia of Materia Eca EdS with Additions, by Joseph Carson, M. D, Professor of Materia Medica and Pharmacy in the University of Pennsylvania. In two very large octavo volumes o 2100 pages on small type, with about 500 illustrations on stone and wood, strongly bound in leather, with raised bands. $y 00. *** Vol. II. will no longer be sold separate. PARKER (LANGSTON), Surgeon to the Queen's Hospital, Birmingham. THE MODERN TREATMENT OF SYPHILITIC DISEASES, BOTH PRI- MARY AND SECONDARY; comprising the Treatment of Constitutional and ConfirmedSyphi- Ksbva safe and successful methoS. With numerous Cases, Formulae, and Clinical Observa- tions From the Third and entirely rewritten London edition. In one neat octavo volume, extra cloth, of 316 pages. $175.__________________ BOVLE'S MATERIA MEDICA-AND~THERAPETJTICSj including the » tSn, if the Pharmacopoeias of London, Edinburgh, Dublin, and of the United States. wie^^ In one large octavo volume, extra cloth, of about 700 pages. $ J 00. 26 BLANCHARD & LEA'S MEDICAL RAMSBOTHAM (FRANCIS H.), M.D. THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDICINE AND SURGERY, in reference to the Process of Parturition. A new and enlarged edition, thoroughly revised by the Author. With Additions by W.V. Keating, M. D., Professor of Obstetrics, &c, in the Jefferson Medical College, Philadelphia. In one large and handsome imperial octavo volume, of 650 pages, strongly bound in leather, with raised bands; with sixty-four beautiful Plates, and numerous Wood-cuts in the text, containing in all nearly 200 large and beautiful figures. $5 00. From Prof. Hodge, of the University of Pa. To the American public, it is most valuable, from its intrinsic undoubted excellence, and as being the best authorized exponent of British Midwifery. Its circulation will, I trust, be extensive throughout our country. It is unnecessary to say anything in regard to the i truly elegant style in which they have brought it utility of this work. It is already appreciated in our country for the value of the matter, the clearness of its style, and the fulness of its illustrations. To the physician's library it is indispensable, while to the student as a text-book, from which to extract the material for laying the foundation of an education on obstetrical science, it has no superior.—Ohio Med and Surg. Journal. The publishers have secured its success by the out, excelling themselves in its production, espe- cially in its plates. It is dedicated to Prof. Meigs, and has the emphatic endorsement of Prof. Hodge, as the best exponent of British Midwifery. We know of no text-book which deserves in all respects to be more highly recommended to students, and we could wish to see it in the handsof every practitioner, for they will find it invaluable for reference.—Med. Gazette. RICORD (P.), M. D. A TREATISE ON THE VENEREAL DISEASE. By John Hunter, F. R. S. With copious Additions, by Ph Ricord, M.D. Translated and Edited, with Notes, by Freeman J. Bumstead. M. D., Lecturer on Venereal at the College of Physicians and Surgeons, New York. Second edition, revised, containing a resume of Ricord's Recent Lectures on Chancre. In one handsome octavo volume, extra cloth, of 550 pages, with eight plates. $3 25. (Just Issued.) In revising this work, the editor has endeavored to introduce whatever matter of interest the re- cent investigations of syphilographers have added to our knowledge of the subject. The principal source from which this has been derived is the volume of "Lectures on Chancre," published a few months since by M. Ricord, which affijrds a large amount of new and instructive material on many controverted points. In the previous edition, M. Ricord's additions amounted to nearly one-third of the whole, and with the matter now introduced, the work may be considered to present his views and experience more thoroughly and completely than any other. secretaries, sometimes accredited and sometimes not. In the notes to Hunter, the master substitutes him- Every one will recognize the attractiveness ana value which this work derives from thus presenting the opinions of these two masters side by side. But, it must be admitted, what has made the fortune of the book, is the fact that it contains the "most com- plete embodiment of the veritable doctrines of the Hopital du Midi," which has ever been made public. The doctrinal ideas of M. Ricord, ideas which, if not universally adopted, are incomestabiy dominant, have heretofore only been interpreted by more or less skilful self for his interpreters, and gives hisoriginal thoughts to the world in a lucid and perfectly intelligible man- ner. In conclusion we can say that this is incon- testably the best treatise on syphilis with which we are acquainted, and, as we do not often employ the phrase, we may be excused for expressing the hope that it may find a place in the library of every phy- sician.— Virginia Med. and Surg. Journal. BY THE SAME AUTHOR. RICORD'S LETTERS ON SYPHILIS. Translated by W. P. Lattimore, M.D. In one neat octavo volume, of 270 pages, extra cloth. $2 00. A ROKITANSKY (CARL), M.D., Curator of the Imperial Pathological Museum, and Professor at the University of Vienna, Sec. MANUAL OF PATHOLOGICAL ANATOMY. Four volumes, octavo, bound in two, extra cloth, of about 1200 pages. king, C. H. Moore, and G. E. Day. $5 50. The profession is too well acquainted with the re- putation of Rokitansky's work to need our assur- ance that this is one of the most profound, thorough. and valuable books ever issued from the medical press. It is sui generis, and has no standard of com- parison. It is only necessary to announce that it is issued in a form as cheap as is compatible with its size and preservation, and its sale follows as a matter of course. No library can be called com- plete without it.—Buffalo Med. Journal. An attempt to give our readers any adequate idea of the vast amount of instruction accumulated in these volumes, would be feeble and hopeless. The effort of the distinguished author to concentrate in a small space his great fund of knowledge, has Translated by W. E. Swaine, Edward Sieve- so charged his text with valuable truths, that any attempt of a reviewer to epitomize is at once para- lyzed, and must end in a failure.—Western Lancet. As this is the highest source of knowledge upon the important subject of which it treats, no real student can afford to be without it. The American publishers have entitled themselves to the thanks of the profession of their country, for this timeousand beautiful edition.—Nashville Journal of Medicine. As a book of reference, therefore, this work must prove of inestimable value, and we cannot too highly recommend it to the profession.—Charleston Med. Journal and Review. This book is a necessity to every practitioner.— Am. Med. Monthly. RIGBY (EDWARD), M.D., Senior Physician to the General Lying-in Hospital, Sec. A SYSTEM OF MIDWIFERY. With Notes and Additional Illustrations. Second American Edition. One volume octavo, extra cloth, 422 pages. $2 50. by the same author. (Lately Published.) ON THE CONSTITUTIONAL TREATMENT OF FEMALE DISEASES. In one neat royal 12mo. volume, extra cloth, of about 250 pages. $1 00. AND SCIENTIFIC PUBLICATIONS. 27 STILLE (ALFRED), M. D. THERAPEUTICS AND MATERIA MEDICA; a Systematic Treatise on the Action and Uses of Medicinal Agents, including their Description and History. In two large and handsome octavo volumes, of 1789 pages. (Just Issued.) $8 00. This work is designed especially for the student and practitioner of medicine, and treats the various articles of the Materia Medica from the point of view of the bedside, and not of the shop or of the lecture-room. While thus endeavoring to give all practical information likely to be useful with respect to the employment of special remedies in special affections, and the results to be anticipated from their administration, a copious Index of Diseases and their Remedies renders the work emi- nently fitted for reference by showing at a glance ihe different means which have been employed, and enabling the practitioner to extend his resources in difficult ca.-es with all that the experience of the profession has suggested. Rarely, indeed, have we had submitted to us a work on medicine so ponderous in its dimensions as that now before us, and yet so fascinating in its contents. It is, therefore, with a peculiar gratifi- cation that we recognize in Dr. Stille the posses- sion of many of those more distinguished qualifica- tions which entitle him to approbation, and which justify him in coming before his medical brethren as an instructor. A comprehensive knowledge, tested by a sound and penetrating judgment, joined to a love of progress -which a discriminating spirit of inquiry has tempered so as to accept nothing new because it is new, and abandon nothing old because it is old, but which estimates either accoroing to its relations to a just logic and experience—manifests itself everywhere, and gives to the guidance of the author all the assurance of safety which the diffi- culties of his subject can allow. In conclusion, we earnestly advise our readers to ascertain for them- selves, by a study of Dr. Stille's vulumes, the great value and interest of the stores of knowledge they present. We have pleasure in referring rather to the ample treasury of undoubted truths, the real and assured conquest of medicine, accumulated by Dr. Stille in his pages; and commend the sum of his la- bors to the attention of our readers, as alike honor- able to our science, and creditable to the zeal, the candor, and the judgment of him who has garnered the whole so carefully.—Edinburgh Med. Journal. Our expectations of the value of this work were based on the well-known reputation and character of the author as a man of scholarly attainments, an elegant writer, a candid inquirer after truth, and a philosophical thinker ; we knew that the task would be conscientiously performed, and that few, if any, among the distinguished medical teachers in this country are better qualified than he to prepare a systematic treatise on therapeutics in accordance with the present requirements of medical science. Our preliminary examination of the work has satis- fied us that we were not mistaken in our anticipa- tions—New Orleans Medical News, March, I860. The most recent authority is the one last men- tioned, Stille. His great work on " Materia Medi- ca and Therapeutics," published last year, in two octavo volumes, of some sixteen hundred pages, while it embodies the results of the labor of others up to the time of publication, is enriched with a great amount of original observation and research. We would draw attention, by the way, to the very convenient mode in which the Index is arranged in this work. There is first an " Index of Remedies;" next an "Index of Diseases and their Remedies." Such an arrangement of the Indices, in our opinion, greatly enhances the practical value of books of this kind. In tedious, obstinate cases of disease, where we have to try one remedy after another until our stock is pretty nearly exhausted, and we are almost driven to our wit's end, such an index as the second of the two just mentioned, is precisely what we want.—London Med. Times and Gazette, April, 1861. We think this work will do much to obviate the reluctance to a thorough investigation of this branch of scientific study, for in the wide range of medical literature treasured in the English tongue, we shall hardly find a work written in a style more clear and simple, conveying forcibly the facts taught, and yet free from turgidity and redundancy. There is a fas- cination in its pages that will insure to it a wide popularity and attentive perusal, and a degree of usefulness not often attained through the influence of a single work. The author has much enhanced the practical utility of his book by passing briefly over the physical, botanisal, and commercial history of medicines, and directing attention chiefly to their physiological action, and their application for the amelioration or cure of disease. He ignores hypothe- sis and theory wh ich are so allu ring to many medical writers, and so liable to lead them astray, and con- fines himself to such facts as have been tried in the crucible of experience.—Chicago Medical Journal. SMITH (HENRY H.), M. D. AND HORNER (WILLIAM E.), M. D. AN ANATOMICAL ATLAS, illustrative of the Structure of the Human Body. In one volume, large imperial octavo, extra cloth, with about six hundred and fifty beautiful figures. $3 00. These figures are well selected, and present a complete and accurate representation of that won- derful fabric, the human body. The plan of this Atlas, which renders it so peculiarly convenient for the student, and its superb artistical execution, have been already pointed out. We must congratu- late the student upon the completion of this Atlas as it is the most convenientwork of the kind that has yet appeared ; and we must add, the very beau- tiful manner in which it is " got up" is so creditable to the country as to be flattering to our national pride.__American Medical Journal. SHARPEY (WILLIAM), M. D., JONES QUAIN, M.D., AND RICHARD QUAIN, F. R. S., &c. HUMAN ANATOMY. Revised, with Notes and Additions, by Joseph Leidy, M. D., Professor of Anatomy in the University of Pennsylvania Complete in two large octavo volumes, leather, of about thirteen hundred pages. Beautifully illustrated with over five hundred engravings on wood. $6 00._________________ SIMPSON (J. Y. , M. D., Professor of Midwifery, Sec, in the University of Edinburgh, &c. CLINICAL LECTURES ON THE DISEASES OF FEMALES. With nume- rous illustrations. ..,„«■ ™ This valuable series of practical Lectures is now appearing in the "Medical News and Library'' for I860, 1861, and 1862, and can thus be had without cost by subscribers to the « American Journal of the Medical Sciences." See p. 2. SOLLY ON THE HUMAN BRAIN; its Structure, Physiology, and Diseases. From the Second and much enlaiged London edition, la om octavo volume, extra cloth, of 500 pages, with 120 wood- cuts. $2 00. SKEY'S OPERATIVE SURGERY. In one very handsome octavo volume, extra cloth, of over 650 pages, with about one hundred wood-cuts. $3 25. SIMONS GENERAL PATHOLOGY, as conduc- ive to the Establishment of Rational Principles for the prevention and Cure of Disease. In one octavo volume, extra cloth, of 212 pages. $1 25. 28 BLANCHARD & LEA'S MEDICAL SARGENT (F. W.), M. D. ON BANDAGING AND OTHER OPERATIONS OF MINOR SURGERY. New edition, with an additional chapter on Military Surgery. One handsome royal 12mo. vol of nearly 400 pages, with 184 wood cuts. Leather, $1 50. (Now Ready.) The value of this work as a handy and convenient manual for surgeons engaged in active duty in the field and hospital, has induced the publishers to render it more complete for those purposes by the addition of a chapter on gun-shot wounds and other matters peculiar to military surgery. In its present form, therefore, with no increase in price, it will be found a very cheap and convenient vade-mecum for consultation and reference in the daily exigencies of military as well as civil practice. The instruction given upon the subject of Ban- daging, is alone of great value, and while the author modestly proposes to instruct the students of medi- cine, and the younger physicians, we will say that experienced physicians will obtain many exceed- ingly valuable suggestions by its perusal. With- out attempting to particularize further, we will conclude our brief notice by saying, that it will be found one of the most satisfactory manuals for refer- ence in the field, or hospital yet published; thor- oughly adapted to the wants of Military surgeons, and at the same time equally useful for ready and convenient reference by surgeons everywhere.__ Buffalo Med. and Surg. Journal, June, 1862. We have read Bourgerie's Minor Surgery with pleasure and profit, but in many respects the volume now before us immeasurably transcends it. We consider that no better book could be placed in the hanus of an hospital dresser, or the young surgeon, whose education in this respect has not been per- fected. We most cordially commend this volume as one which the medical student should most close- ly study, to perfect himself in these minor surgical operations in which neatness and dexterity are so much required, and on which a great portion of his reputation as a future surgeon must evidently rest. And to the surgeon in practice it must prove itself a valuable volume, as instructive on many points which he may have forgotten.—British American Journal, May, 1862. SMITH (W. TYLER), M. D., Physician Accoucheur to St. Mary's Hospital, Sec. ON PARTURITION, AND THE PRINCIPLES AND PRACTICE OP OBSTETRICS. In one royal 12mo. volume, extra cloth, of 400 pages, f 1 25. BY THE SAME AUTHOR. A PRACTICAL TREATISE ON THE PATHOLOGY AND TREATMENT OF LEUCORRHGSA. With numerous illustrations. In one very handsome octavo volume, extra cloth, of about 250 pages. $1 50. TANNER (T. H.), M. D., Physician to the Hospital for Women, &c. A MANUAL OF CLINICAL MEDICINE AND PHYSICAL DIAGNOSIS. To which is added The Code of Ethics of the American Medical Association. Second American Edition. In one neat volume, small 12mo., extra cloth, 87j cents. TAYLOR (ALFRED S.), M. D., F. R. S., Lecturer on Medical Jurisprudence and Chemistry in Guy's Hospital. MEDICAL JURISPRUDENCE. Fifth American, from the seventh improved and enlarged London edition. With Notes and References to American Decisions, by Edward Hartshokne,M. D. In one large 8vo. volume, leather, of over 700 pages. (NowReady.) $3 25. This standard work having had the advantage of two revisions at the hands of the author since the appearance of the last American edition, will be found thoroughly revised and brought up com- pletely to the present state of the science. As a work of authority, it must therefore maintain its position, both as a text-book for the student, and a compendious treatise to which the practitioner can at all times refer in ca»es of doubt or difficulty. No work upon the subject can be put into the hands of students either of law or medicine which will engage them more closely or profitably; and none could be offered to the busy practitioner of either calling, for the purpose of casual or hasty reference, that would be more likely toafford the aid desired. We therefore recommend it as the best and safest manual for daily use.—American Journal of Medical Sciences. It is not excess of praise to say that the volume before us is the very best treatise extant on Medical Jurisprudence. In saying this, we do not wish to be understood as detracting from the merits of the excellent works of Beck, Ryan, Traill, Guy, and others; but in interest and value we think it must be conceded that Taylor is superior to anything that has preceded it.—N. W. Medical and Surg. Journal It is at once comprehensive and eminently prac- tical, and by universal consent stands at the head of American and British legal medicine. It should he in the possession of every physician, as the subject is one of great and increasing importance to the public as well as to the profession.—St. Louis Med. and Surg. Journal. This work of Dr. Taylor's is generally acknow- ledged to be one of the ablest extant on the subject of medical jurisprudence. It is certainly one of the most attractive books that we have met with; sup- plying so much both to interest and instruct, that we do not hesitate to affirm that after having once commenced its perusal, few could be prevailed upon to desist before completing it. In ihe last London edition, all the newly observed and accurately re- corded facts have been inserted, including much that is recent of Chemical, Microscopical, and Pa- thological research, besides papers on numerous subjects never before published__Charleston Med. Journal and Review. BY THE SAME AUTHOR. ON POISONS, IN RELATION TO MEDICAL JURISPRUDENCE AND MEDICINE. Second American, from a second and revised London edition. In one large octavo volume, ol 755 pages, leather. $3 50. Mr. Taylor's position as the leading medical jurist of England, has conferred on him extraordi- nary advantages in acquiring experience on these subjects, nearly all cases of moment being referred to him for examination, as an expert whose testimony is generally accepted as final. The results of his labors, therefore, as gathered together in this volume, carefully weighed and sifted, and presented in the clear and intelligible style for which he is noted, may be received as an acknowledged authority, and as a guide to be followed with implicit confidence. AND SCIENTIFIC PUBLICATIONS. 29 TODD (ROBERT BENTLEY), M. D., F. R. S., Professor of Physiology in King's College, London; and WILLIAM BOWMAN, F. R. S., Demonstrator of Anatomy in King's College, London. THE PHYSIOLOGICAL ANATOMY AND PHYSIOLOGY OF MAN. With about three hundred large and beautiful illustrations on wood. Complete in one large octavo volume, of 950 pages, leather. Price $4 50. I3P Gentlemen who have received portions of this work, as published in the " Medical News and Library," can now complete their copies, if immediate application be made. It will be fur- nished as follows, free by mail, in paper covers, with cloth backs. Parts I., IL, III. (pp. 25 to 552), $2 50. Part IV. (pp. 553 to end, with Title, Preface, Contents,